By Gray H.B. No. 102
75R326 PB-F
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 21.53D to read as follows:
1-8 Art. 21.53D. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
1-9 CARE FACILITY AND POSTDELIVERY CARE FOLLOWING BIRTH OF CHILD
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Attending physician" means an obstetrician,
1-12 pediatrician, or other physician who attends a woman who has given
1-13 birth or who attends the newborn child.
1-14 (2) "Health benefit plan" means a plan that provides
1-15 benefits for medical or surgical expenses incurred as a result of a
1-16 health condition, accident, or sickness and that is offered by any
1-17 insurance company, group hospital service corporation, or health
1-18 maintenance organization that delivers or issues for delivery an
1-19 individual, group, blanket, or franchise insurance policy or
1-20 insurance agreement, a group hospital service contract, or an
1-21 evidence of coverage, by a multiple employer welfare arrangement as
1-22 defined by Section 3, Employee Retirement Income Security Act of
1-23 1974 (29 U.S.C. Section 1002), or by any other analogous benefit
1-24 arrangement to the extent permitted by the Employee Retirement
2-1 Income Security Act of 1974 (29 U.S.C. Section 1002). The term
2-2 does not include:
2-3 (A) a plan that provides coverage:
2-4 (i) only for accidental death or
2-5 dismemberment;
2-6 (ii) for wages or payments in lieu of
2-7 wages for a period during which an employee is absent from work
2-8 because of sickness or injury; or
2-9 (iii) as a supplement to liability
2-10 insurance;
2-11 (B) a medicare supplemental policy as defined by
2-12 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
2-13 (C) worker's compensation insurance coverage;
2-14 (D) medical payment insurance issued as part of
2-15 a motor vehicle insurance policy; or
2-16 (E) a long-term care policy, including a nursing
2-17 home fixed indemnity policy, unless the commissioner determines
2-18 that the policy provides benefit coverage so comprehensive that the
2-19 policy meets the definition of a health benefit plan.
2-20 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
2-21 FOLLOWING BIRTH; EXCEPTION. (a) A health benefit plan that
2-22 provides maternity benefits, including benefits for childbirth,
2-23 must include coverage for inpatient care for a mother and her
2-24 newborn child in a health care facility for a minimum of:
2-25 (1) 48 hours following a vaginal delivery; and
2-26 (2) 96 hours following a delivery by caesarean
2-27 section.
3-1 (b) Notwithstanding Subsection (a) of this section, a health
3-2 benefit plan that provides coverage for in-home postdelivery care
3-3 to a mother and her newborn child is not required to provide the
3-4 minimum hours of coverage of inpatient care required under
3-5 Subsection (a) of this section unless that inpatient care is
3-6 determined to be medically necessary by an attending physician or
3-7 is requested by the mother.
3-8 Sec. 3. POSTDELIVERY CARE. (a) If a decision is made to
3-9 discharge a mother and newborn child from inpatient care before the
3-10 expiration of the minimum hours of coverage of inpatient care
3-11 required under Section 2(a) of this article, the health benefit
3-12 plan shall provide coverage for timely postdelivery care. That
3-13 care may be provided to the mother and child by a physician,
3-14 registered nurse, or other appropriate licensed health care
3-15 provider and may be provided at:
3-16 (1) the mother's home, a health care provider's
3-17 office, or a health care facility; or
3-18 (2) another location determined to be appropriate
3-19 under rules adopted by the commissioner.
3-20 (b) The coverage required under Subsection (a) of this
3-21 section must allow the mother the option to have the care provided
3-22 in the mother's home.
3-23 (c) For purposes of this section, "postdelivery care" means
3-24 postpartum health care services provided in accordance with
3-25 accepted maternal and neonatal physical assessments. The term
3-26 includes parent education, assistance and training in breast
3-27 feeding and bottle feeding, and the performance of any necessary
4-1 and appropriate clinical tests. The timeliness of the care shall
4-2 be determined in accordance with recognized medical standards for
4-3 that care.
4-4 Sec. 4. PROHIBITIONS. A health benefit plan may not:
4-5 (1) modify the terms and conditions of coverage based
4-6 on the determination by a person enrolled in the health benefit
4-7 plan to request less than the minimum coverage required under
4-8 Section 2(a) of this article;
4-9 (2) offer to the mother of a newborn child financial
4-10 incentives or other compensation the receipt of which is contingent
4-11 on the waiver by the mother of the minimum hours of coverage of
4-12 inpatient care required under Section 2(a) of this article;
4-13 (3) refuse to accept a physician's recommendation for
4-14 a specified period of inpatient care made in consultation with the
4-15 mother of the newborn child if the period recommended by the
4-16 physician does not exceed the minimum periods recommended in
4-17 guidelines for perinatal care developed by nationally recognized
4-18 professional associations of obstetricians and gynecologists and of
4-19 pediatricians;
4-20 (4) reduce payments or other forms of reimbursement
4-21 for inpatient care below the usual and customary rate of
4-22 reimbursement for that care; or
4-23 (5) penalize a physician for recommending inpatient
4-24 care for a mother or her newborn child by:
4-25 (A) refusing to allow the physician to
4-26 participate as a provider within the health benefit plan;
4-27 (B) reducing payments made to the physician;
5-1 (C) requiring the physician to provide
5-2 additional documentation or undergo additional utilization review;
5-3 or
5-4 (D) imposing other analogous sanctions or
5-5 disincentives.
5-6 Sec. 5. NOTICE. (a) Each health benefit plan shall provide
5-7 written notice to each enrollee under the plan regarding the
5-8 coverage required by this article. The health benefit plan shall
5-9 provide the notice in accordance with rules adopted by the
5-10 commissioner.
5-11 (b) The notice required under this section must be
5-12 prominently positioned in any literature or correspondence made
5-13 available or distributed by the health benefit plan.
5-14 Sec. 6. RULES. The commissioner shall adopt rules as
5-15 necessary to administer this article.
5-16 SECTION 2. The notice required under Section 5(a), Article
5-17 21.53D, Insurance Code, as added by this Act, must be transmitted
5-18 to each person enrolled in a health benefit plan subject to that
5-19 article not later than the earlier of:
5-20 (1) the date of the next mailing scheduled to be made
5-21 by the plan to the enrollee after January 1, 1998;
5-22 (2) the next yearly informational packet scheduled to
5-23 be sent to the enrollee after January 1, 1998; or
5-24 (3) February 1, 1998.
5-25 SECTION 3. This Act takes effect September 1, 1997, and
5-26 applies only to an insurance policy or evidence of coverage that is
5-27 delivered, issued for delivery, or renewed on or after January 1,
6-1 1998. A policy or evidence of coverage that is delivered, issued
6-2 for delivery, or renewed before January 1, 1998, is governed by the
6-3 law as it existed immediately before the effective date of this
6-4 Act, and that law is continued in effect for that purpose.
6-5 SECTION 4. The importance of this legislation and the
6-6 crowded condition of the calendars in both houses create an
6-7 emergency and an imperative public necessity that the
6-8 constitutional rule requiring bills to be read on three several
6-9 days in each house be suspended, and this rule is hereby suspended.