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:
2-1 (A) an individual, group, blanket, or franchise
2-2 insurance policy or insurance agreement, a group hospital service
2-3 contract, or an individual or group evidence of coverage that is
2-4 offered by:
2-5 (i) an insurance company;
2-6 (ii) a group hospital service corporation
2-7 operating under Chapter 20 of this code;
2-8 (iii) a fraternal benefit society
2-9 operating under Chapter 10 of this code;
2-10 (iv) a stipulated premium insurance
2-11 company operating under Chapter 22 of this code; or
2-12 (v) a health maintenance organization
2-13 operating under the Texas Health Maintenance Organization Act
2-14 (Chapter 20A, Vernon's Texas Insurance Code); or
2-15 (B) to the extent permitted by the Employee
2-16 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-17 seq.), a health benefit plan that is offered by:
2-18 (i) a multiple employer welfare
2-19 arrangement as defined by Section 3, Employee Retirement Income
2-20 Security Act of 1974 (29 U.S.C. Section 1002);
2-21 (ii) any other entity not licensed under
2-22 this code or another insurance law of this state that contracts
2-23 directly for health care services on a risk-sharing basis,
2-24 including an entity that contracts for health care services on a
2-25 capitation basis; or
2-26 (iii) another analogous benefit
2-27 arrangement; or
3-1 (2) is offered by an approved nonprofit health
3-2 corporation that is certified under Section 5.01(a), Medical
3-3 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-4 that holds a certificate of authority issued by the commissioner
3-5 under Article 21.52F of this code.
3-6 (b) This article does not apply to:
3-7 (1) a plan that provides coverage:
3-8 (A) only for a specified disease or other
3-9 limited benefit;
3-10 (B) only for accidental death or dismemberment;
3-11 (C) for wages or payments in lieu of wages for a
3-12 period during which an employee is absent from work because of
3-13 sickness or injury;
3-14 (D) as a supplement to liability insurance;
3-15 (E) for credit insurance;
3-16 (F) only for dental or vision care; or
3-17 (G) only for indemnity for hospital confinement;
3-18 (2) a small employer health benefit plan written under
3-19 Chapter 26 of this code;
3-20 (3) a Medicare supplemental policy as defined by
3-21 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-22 (4) workers' compensation insurance coverage;
3-23 (5) medical payment insurance issued as part of a
3-24 motor vehicle insurance policy; or
3-25 (6) a long-term care policy, including a nursing home
3-26 fixed indemnity policy, unless the commissioner determines that the
3-27 policy provides benefit coverage so comprehensive that the policy
4-1 is a health benefit plan as described by Subsection (a) of this
4-2 section.
4-3 Sec. 4. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
4-4 FOLLOWING BIRTH; EXCEPTIONS. (a) A health benefit plan that
4-5 provides maternity benefits, including benefits for childbirth,
4-6 must include coverage for inpatient care for a mother and her
4-7 newborn child in a health care facility for a minimum of:
4-8 (1) 48 hours following an uncomplicated vaginal
4-9 delivery; and
4-10 (2) 96 hours following an uncomplicated delivery by
4-11 caesarean section.
4-12 (b) Notwithstanding Subsection (a) of this section, a health
4-13 benefit plan that provides coverage for in-home postdelivery care
4-14 to a mother and her newborn child is not required to provide the
4-15 minimum hours of coverage of inpatient care required under
4-16 Subsection (a) of this section unless that inpatient care is
4-17 determined to be medically necessary by an attending physician or
4-18 is requested by the mother.
4-19 (c) For purposes of Subsection (a) of this section, the
4-20 determination as to whether a delivery is complicated shall be made
4-21 by the attending physician.
4-22 (d) This article does not require a mother who is eligible
4-23 for coverage under a health benefit plan to:
4-24 (1) give birth in a hospital or other health care
4-25 facility; or
4-26 (2) remain under inpatient care in a hospital or other
4-27 health care facility for any fixed term following the birth of a
5-1 child.
5-2 Sec. 5. POSTDELIVERY CARE. (a) If a decision is made to
5-3 discharge a mother or newborn child from inpatient care before the
5-4 expiration of the minimum hours of coverage of inpatient care
5-5 required under Section 4(a) of this article, the health benefit
5-6 plan must provide coverage for timely postdelivery care. That care
5-7 may be provided to the mother and child by a physician, registered
5-8 nurse, or other appropriate licensed health care provider and may
5-9 be provided at:
5-10 (1) the mother's home, a health care provider's
5-11 office, or a health care facility; or
5-12 (2) another location determined to be appropriate
5-13 under rules adopted by the commissioner.
5-14 (b) The coverage required under Subsection (a) of this
5-15 section must allow the mother the option to have the care provided
5-16 in the mother's home.
5-17 (c) For purposes of this section, "postdelivery care" means
5-18 postpartum health care services provided in accordance with
5-19 accepted maternal and neonatal physical assessments. The term
5-20 includes parent education, assistance and training in
5-21 breast-feeding and bottle-feeding, and the performance of any
5-22 necessary and appropriate clinical tests. The timeliness of the
5-23 care shall be determined in accordance with recognized medical
5-24 standards for that care.
5-25 Sec. 6. PROHIBITIONS. A health benefit plan may not:
5-26 (1) modify the terms and conditions of coverage based
5-27 on the determination by a person enrolled in the health benefit
6-1 plan to request less than the minimum coverage required under
6-2 Section 4(a) of this article;
6-3 (2) offer to the mother of a newborn child financial
6-4 incentives or other compensation the receipt of which is contingent
6-5 on the waiver by the mother of the minimum hours of coverage of
6-6 inpatient care required under Section 4(a) of this article;
6-7 (3) refuse to accept a physician's recommendation for
6-8 a specified period of inpatient care made in consultation with the
6-9 mother of the newborn child if the period recommended by the
6-10 physician does not exceed the minimum periods recommended in
6-11 guidelines for perinatal care developed by the American College of
6-12 Obstetricians and Gynecologists, the American Academy of
6-13 Pediatrics, or another nationally recognized professional
6-14 association of obstetricians and gynecologists or of pediatricians;
6-15 (4) reduce payments or other forms of reimbursement
6-16 for inpatient care below the usual and customary rate of
6-17 reimbursement for that care; or
6-18 (5) penalize a physician for recommending inpatient
6-19 care for a mother or her newborn child by:
6-20 (A) refusing to allow the physician to
6-21 participate as a provider within the health benefit plan;
6-22 (B) reducing payments made to the physician;
6-23 (C) requiring the physician to provide
6-24 additional documentation or undergo additional utilization review;
6-25 or
6-26 (D) imposing other analogous sanctions or
6-27 disincentives.
7-1 Sec. 7. NOTICE. In accordance with rules adopted by the
7-2 commissioner, each health benefit plan must provide to each
7-3 enrollee under the plan written notice regarding the coverage
7-4 required by this article.
7-5 Sec. 8. RULES. The commissioner shall adopt rules as
7-6 necessary to administer this article.
7-7 SECTION 2. This Act takes effect September 1, 1997, and
7-8 applies only to a health benefit plan that is delivered, issued for
7-9 delivery, or renewed on or after January 1, 1998. A health benefit
7-10 plan that is delivered, issued for delivery, or renewed before
7-11 January 1, 1998, is governed by the law as it existed immediately
7-12 before the effective date of this Act, and that law is continued in
7-13 effect for that purpose.
7-14 SECTION 3. The importance of this legislation and the
7-15 crowded condition of the calendars in both houses create an
7-16 emergency and an imperative public necessity that the
7-17 constitutional rule requiring bills to be read on three several
7-18 days in each house be suspended, and this rule is hereby suspended.
_______________________________ _______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 102 was passed by the House on May
14, 1997, by a non-record vote.
_______________________________
Chief Clerk of the House
I certify that H.B. No. 102 was passed by the Senate on May
26, 1997, by the following vote: Yeas 31, Nays 0.
_______________________________
Secretary of the Senate
APPROVED: _____________________
Date
_____________________
Governor