1-1 By: Gray, et al. (Senate Sponsor - Shapiro) H.B. No. 102 1-2 (In the Senate - Received from the House May 15, 1997; 1-3 May 16, 1997, read first time and referred to Committee on Economic 1-4 Development; May 18, 1997, reported favorably by the following 1-5 vote: Yeas 11, Nays 0; May 18, 1997, sent to printer.) 1-6 A BILL TO BE ENTITLED 1-7 AN ACT 1-8 relating to minimum coverage under certain health benefit plans for 1-9 inpatient stays and postdelivery care following the birth of a 1-10 child. 1-11 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-12 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is 1-13 amended by adding Article 21.53F to read as follows: 1-14 Art. 21.53F. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH 1-15 CARE FACILITY AND POSTDELIVERY CARE FOLLOWING BIRTH OF CHILD 1-16 Sec. 1. SHORT TITLE. This article may be cited as the Lee 1-17 Alexandria Hanley Act. 1-18 Sec. 2. DEFINITIONS. In this article: 1-19 (1) "Attending physician" means an obstetrician, 1-20 pediatrician, or other physician who attends a woman who has given 1-21 birth or who attends the newborn child. 1-22 (2) "Enrollee" means an individual enrolled in a 1-23 health benefit plan. 1-24 (3) "Health benefit plan" means a plan described by 1-25 Section 3 of this article. 1-26 Sec. 3. SCOPE OF ARTICLE. (a) This article applies to a 1-27 health benefit plan that: 1-28 (1) provides benefits for medical or surgical expenses 1-29 incurred as a result of a health condition, accident, or sickness, 1-30 including: 1-31 (A) an individual, group, blanket, or franchise 1-32 insurance policy or insurance agreement, a group hospital service 1-33 contract, or an individual or group evidence of coverage that is 1-34 offered by: 1-35 (i) an insurance company; 1-36 (ii) a group hospital service corporation 1-37 operating under Chapter 20 of this code; 1-38 (iii) a fraternal benefit society 1-39 operating under Chapter 10 of this code; 1-40 (iv) a stipulated premium insurance 1-41 company operating under Chapter 22 of this code; or 1-42 (v) a health maintenance organization 1-43 operating under the Texas Health Maintenance Organization Act 1-44 (Chapter 20A, Vernon's Texas Insurance Code); or 1-45 (B) to the extent permitted by the Employee 1-46 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 1-47 seq.), a health benefit plan that is offered by: 1-48 (i) a multiple employer welfare 1-49 arrangement as defined by Section 3, Employee Retirement Income 1-50 Security Act of 1974 (29 U.S.C. Section 1002); 1-51 (ii) any other entity not licensed under 1-52 this code or another insurance law of this state that contracts 1-53 directly for health care services on a risk-sharing basis, 1-54 including an entity that contracts for health care services on a 1-55 capitation basis; or 1-56 (iii) another analogous benefit 1-57 arrangement; or 1-58 (2) is offered by an approved nonprofit health 1-59 corporation that is certified under Section 5.01(a), Medical 1-60 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 1-61 that holds a certificate of authority issued by the commissioner 1-62 under Article 21.52F of this code. 1-63 (b) This article does not apply to: 1-64 (1) a plan that provides coverage: 2-1 (A) only for a specified disease or other 2-2 limited benefit; 2-3 (B) only for accidental death or dismemberment; 2-4 (C) for wages or payments in lieu of wages for a 2-5 period during which an employee is absent from work because of 2-6 sickness or injury; 2-7 (D) as a supplement to liability insurance; 2-8 (E) for credit insurance; 2-9 (F) only for dental or vision care; or 2-10 (G) only for indemnity for hospital confinement; 2-11 (2) a small employer health benefit plan written under 2-12 Chapter 26 of this code; 2-13 (3) a Medicare supplemental policy as defined by 2-14 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 2-15 (4) workers' compensation insurance coverage; 2-16 (5) medical payment insurance issued as part of a 2-17 motor vehicle insurance policy; or 2-18 (6) a long-term care policy, including a nursing home 2-19 fixed indemnity policy, unless the commissioner determines that the 2-20 policy provides benefit coverage so comprehensive that the policy 2-21 is a health benefit plan as described by Subsection (a) of this 2-22 section. 2-23 Sec. 4. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY 2-24 FOLLOWING BIRTH; EXCEPTIONS. (a) A health benefit plan that 2-25 provides maternity benefits, including benefits for childbirth, 2-26 must include coverage for inpatient care for a mother and her 2-27 newborn child in a health care facility for a minimum of: 2-28 (1) 48 hours following an uncomplicated vaginal 2-29 delivery; and 2-30 (2) 96 hours following an uncomplicated delivery by 2-31 caesarean section. 2-32 (b) Notwithstanding Subsection (a) of this section, a health 2-33 benefit plan that provides coverage for in-home postdelivery care 2-34 to a mother and her newborn child is not required to provide the 2-35 minimum hours of coverage of inpatient care required under 2-36 Subsection (a) of this section unless that inpatient care is 2-37 determined to be medically necessary by an attending physician or 2-38 is requested by the mother. 2-39 (c) For purposes of Subsection (a) of this section, the 2-40 determination as to whether a delivery is complicated shall be made 2-41 by the attending physician. 2-42 (d) This article does not require a mother who is eligible 2-43 for coverage under a health benefit plan to: 2-44 (1) give birth in a hospital or other health care 2-45 facility; or 2-46 (2) remain under inpatient care in a hospital or other 2-47 health care facility for any fixed term following the birth of a 2-48 child. 2-49 Sec. 5. POSTDELIVERY CARE. (a) If a decision is made to 2-50 discharge a mother or newborn child from inpatient care before the 2-51 expiration of the minimum hours of coverage of inpatient care 2-52 required under Section 4(a) of this article, the health benefit 2-53 plan must provide coverage for timely postdelivery care. That care 2-54 may be provided to the mother and child by a physician, registered 2-55 nurse, or other appropriate licensed health care provider and may 2-56 be provided at: 2-57 (1) the mother's home, a health care provider's 2-58 office, or a health care facility; or 2-59 (2) another location determined to be appropriate 2-60 under rules adopted by the commissioner. 2-61 (b) The coverage required under Subsection (a) of this 2-62 section must allow the mother the option to have the care provided 2-63 in the mother's home. 2-64 (c) For purposes of this section, "postdelivery care" means 2-65 postpartum health care services provided in accordance with 2-66 accepted maternal and neonatal physical assessments. The term 2-67 includes parent education, assistance and training in 2-68 breast-feeding and bottle-feeding, and the performance of any 2-69 necessary and appropriate clinical tests. The timeliness of the 3-1 care shall be determined in accordance with recognized medical 3-2 standards for that care. 3-3 Sec. 6. PROHIBITIONS. A health benefit plan may not: 3-4 (1) modify the terms and conditions of coverage based 3-5 on the determination by a person enrolled in the health benefit 3-6 plan to request less than the minimum coverage required under 3-7 Section 4(a) of this article; 3-8 (2) offer to the mother of a newborn child financial 3-9 incentives or other compensation the receipt of which is contingent 3-10 on the waiver by the mother of the minimum hours of coverage of 3-11 inpatient care required under Section 4(a) of this article; 3-12 (3) refuse to accept a physician's recommendation for 3-13 a specified period of inpatient care made in consultation with the 3-14 mother of the newborn child if the period recommended by the 3-15 physician does not exceed the minimum periods recommended in 3-16 guidelines for perinatal care developed by the American College of 3-17 Obstetricians and Gynecologists, the American Academy of 3-18 Pediatrics, or another nationally recognized professional 3-19 association of obstetricians and gynecologists or of pediatricians; 3-20 (4) reduce payments or other forms of reimbursement 3-21 for inpatient care below the usual and customary rate of 3-22 reimbursement for that care; or 3-23 (5) penalize a physician for recommending inpatient 3-24 care for a mother or her newborn child by: 3-25 (A) refusing to allow the physician to 3-26 participate as a provider within the health benefit plan; 3-27 (B) reducing payments made to the physician; 3-28 (C) requiring the physician to provide 3-29 additional documentation or undergo additional utilization review; 3-30 or 3-31 (D) imposing other analogous sanctions or 3-32 disincentives. 3-33 Sec. 7. NOTICE. In accordance with rules adopted by the 3-34 commissioner, each health benefit plan must provide to each 3-35 enrollee under the plan written notice regarding the coverage 3-36 required by this article. 3-37 Sec. 8. RULES. The commissioner shall adopt rules as 3-38 necessary to administer this article. 3-39 SECTION 2. This Act takes effect September 1, 1997, and 3-40 applies only to a health benefit plan that is delivered, issued for 3-41 delivery, or renewed on or after January 1, 1998. A health benefit 3-42 plan that is delivered, issued for delivery, or renewed before 3-43 January 1, 1998, is governed by the law as it existed immediately 3-44 before the effective date of this Act, and that law is continued in 3-45 effect for that purpose. 3-46 SECTION 3. The importance of this legislation and the 3-47 crowded condition of the calendars in both houses create an 3-48 emergency and an imperative public necessity that the 3-49 constitutional rule requiring bills to be read on three several 3-50 days in each house be suspended, and this rule is hereby suspended. 3-51 * * * * *