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.

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