By Gray, Greenberg, Van de Putte, McCall, H.B. No. 102 75R8032 PB-D A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to minimum coverage under certain health benefit plans for 1-3 inpatient stays and postdelivery care following the birth of a 1-4 child. 1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is 1-7 amended by adding Article 21.53F to read as follows: 1-8 Art. 21.53F. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH 1-9 CARE FACILITY AND POSTDELIVERY CARE FOLLOWING BIRTH OF CHILD 1-10 Sec. 1. SHORT TITLE. This article may be cited as the Lee 1-11 Alexandria Hanley Act. 1-12 Sec. 2. DEFINITIONS. In this article: 1-13 (1) "Attending physician" means an obstetrician, 1-14 pediatrician, or other physician who attends a woman who has given 1-15 birth or who attends the newborn child. 1-16 (2) "Enrollee" means an individual enrolled in a 1-17 health benefit plan. 1-18 (3) "Health benefit plan" means a plan described by 1-19 Section 3 of this article. 1-20 Sec. 3. SCOPE OF ARTICLE. (a) This article applies to a 1-21 health benefit plan that: 1-22 (1) provides benefits for medical or surgical expenses 1-23 incurred as a result of a health condition, accident, or sickness, 1-24 including: 1-25 (A) an individual, group, blanket, or franchise 2-1 insurance policy or insurance agreement, a group hospital service 2-2 contract, or an individual or group evidence of coverage that is 2-3 offered by: 2-4 (i) an insurance company; 2-5 (ii) a group hospital service corporation 2-6 operating under Chapter 20 of this code; 2-7 (iii) a fraternal benefit society 2-8 operating under Chapter 10 of this code; 2-9 (iv) a stipulated premium insurance 2-10 company operating under Chapter 22 of this code; or 2-11 (v) a health maintenance organization 2-12 operating under the Texas Health Maintenance Organization Act 2-13 (Chapter 20A, Vernon's Texas Insurance Code); or 2-14 (B) to the extent permitted by the Employee 2-15 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 2-16 seq.), a health benefit plan that is offered by: 2-17 (i) a multiple employer welfare 2-18 arrangement as defined by Section 3, Employee Retirement Income 2-19 Security Act of 1974 (29 U.S.C. Section 1002); 2-20 (ii) any other entity not licensed under 2-21 this code or another insurance law of this state that contracts 2-22 directly for health care services on a risk-sharing basis, 2-23 including an entity that contracts for health care services on a 2-24 capitation basis; or 2-25 (iii) another analogous benefit 2-26 arrangement; or 2-27 (2) is offered by an approved nonprofit health 3-1 corporation that is certified under Section 5.01(a), Medical 3-2 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 3-3 that holds a certificate of authority issued by the commissioner 3-4 under Article 21.52F of this code. 3-5 (b) This article does not apply to: 3-6 (1) a plan that provides coverage: 3-7 (A) only for a specified disease or other 3-8 limited benefit; 3-9 (B) only for accidental death or dismemberment; 3-10 (C) for wages or payments in lieu of wages for a 3-11 period during which an employee is absent from work because of 3-12 sickness or injury; 3-13 (D) as a supplement to liability insurance; 3-14 (E) for credit insurance; 3-15 (F) only for dental or vision care; or 3-16 (G) only for indemnity for hospital confinement; 3-17 (2) a small employer health benefit plan written under 3-18 Chapter 26 of this code; 3-19 (3) a Medicare supplemental policy as defined by 3-20 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 3-21 (4) workers' compensation insurance coverage; 3-22 (5) medical payment insurance issued as part of a 3-23 motor vehicle insurance policy; or 3-24 (6) a long-term care policy, including a nursing home 3-25 fixed indemnity policy, unless the commissioner determines that the 3-26 policy provides benefit coverage so comprehensive that the policy 3-27 is a health benefit plan as described by Subsection (a) of this 4-1 section. 4-2 Sec. 4. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY 4-3 FOLLOWING BIRTH; EXCEPTIONS. (a) A health benefit plan that 4-4 provides maternity benefits, including benefits for childbirth, 4-5 must include coverage for inpatient care for a mother and her 4-6 newborn child in a health care facility for a minimum of: 4-7 (1) 48 hours following an uncomplicated vaginal 4-8 delivery; and 4-9 (2) 96 hours following an uncomplicated delivery by 4-10 caesarean section. 4-11 (b) Notwithstanding Subsection (a) of this section, a health 4-12 benefit plan that provides coverage for in-home postdelivery care 4-13 to a mother and her newborn child is not required to provide the 4-14 minimum hours of coverage of inpatient care required under 4-15 Subsection (a) of this section unless that inpatient care is 4-16 determined to be medically necessary by an attending physician or 4-17 is requested by the mother. 4-18 (c) For purposes of Subsection (a) of this section, the 4-19 determination as to whether a delivery is complicated shall be made 4-20 by the attending physician. 4-21 (d) This article does not require a mother who is eligible 4-22 for coverage under a health benefit plan to: 4-23 (1) give birth in a hospital or other health care 4-24 facility; or 4-25 (2) remain under inpatient care in a hospital or other 4-26 health care facility for any fixed term following the birth of a 4-27 child. 5-1 Sec. 5. POSTDELIVERY CARE. (a) If a decision is made to 5-2 discharge a mother or newborn child from inpatient care before the 5-3 expiration of the minimum hours of coverage of inpatient care 5-4 required under Section 4(a) of this article, the health benefit 5-5 plan must provide coverage for timely postdelivery care. That care 5-6 may be provided to the mother and child by a physician, registered 5-7 nurse, or other appropriate licensed health care provider and may 5-8 be provided at: 5-9 (1) the mother's home, a health care provider's 5-10 office, or a health care facility; or 5-11 (2) another location determined to be appropriate 5-12 under rules adopted by the commissioner. 5-13 (b) The coverage required under Subsection (a) of this 5-14 section must allow the mother the option to have the care provided 5-15 in the mother's home. 5-16 (c) For purposes of this section, "postdelivery care" means 5-17 postpartum health care services provided in accordance with 5-18 accepted maternal and neonatal physical assessments. The term 5-19 includes parent education, assistance and training in 5-20 breast-feeding and bottle-feeding, and the performance of any 5-21 necessary and appropriate clinical tests. The timeliness of the 5-22 care shall be determined in accordance with recognized medical 5-23 standards for that care. 5-24 Sec. 6. PROHIBITIONS. A health benefit plan may not: 5-25 (1) modify the terms and conditions of coverage based 5-26 on the determination by a person enrolled in the health benefit 5-27 plan to request less than the minimum coverage required under 6-1 Section 4(a) of this article; 6-2 (2) offer to the mother of a newborn child financial 6-3 incentives or other compensation the receipt of which is contingent 6-4 on the waiver by the mother of the minimum hours of coverage of 6-5 inpatient care required under Section 4(a) of this article; 6-6 (3) refuse to accept a physician's recommendation for 6-7 a specified period of inpatient care made in consultation with the 6-8 mother of the newborn child if the period recommended by the 6-9 physician does not exceed the minimum periods recommended in 6-10 guidelines for perinatal care developed by the American College of 6-11 Obstetricians and Gynecologists, the American Academy of 6-12 Pediatrics, or another nationally recognized professional 6-13 association of obstetricians and gynecologists or of pediatricians; 6-14 (4) reduce payments or other forms of reimbursement 6-15 for inpatient care below the usual and customary rate of 6-16 reimbursement for that care; or 6-17 (5) penalize a physician for recommending inpatient 6-18 care for a mother or her newborn child by: 6-19 (A) refusing to allow the physician to 6-20 participate as a provider within the health benefit plan; 6-21 (B) reducing payments made to the physician; 6-22 (C) requiring the physician to provide 6-23 additional documentation or undergo additional utilization review; 6-24 or 6-25 (D) imposing other analogous sanctions or 6-26 disincentives. 6-27 Sec. 7. NOTICE. In accordance with rules adopted by the 7-1 commissioner, each health benefit plan must provide to each 7-2 enrollee under the plan written notice regarding the coverage 7-3 required by this article. 7-4 Sec. 8. RULES. The commissioner shall adopt rules as 7-5 necessary to administer this article. 7-6 SECTION 2. This Act takes effect September 1, 1997, and 7-7 applies only to a health benefit plan that is delivered, issued for 7-8 delivery, or renewed on or after January 1, 1998. A health benefit 7-9 plan that is delivered, issued for delivery, or renewed before 7-10 January 1, 1998, is governed by the law as it existed immediately 7-11 before the effective date of this Act, and that law is continued in 7-12 effect for that purpose. 7-13 SECTION 3. The importance of this legislation and the 7-14 crowded condition of the calendars in both houses create an 7-15 emergency and an imperative public necessity that the 7-16 constitutional rule requiring bills to be read on three several 7-17 days in each house be suspended, and this rule is hereby suspended.