75R5716 SAW-D By Van de Putte, Kuempel, Maxey, et al. H.B. No. 262 Substitute the following for H.B. No. 262: By Averitt C.S.H.B. No. 262 A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to coverage under certain health benefit plans for 1-3 reconstructive surgery incident to mastectomy. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is 1-6 amended by adding Article 21.53D to read as follows: 1-7 Art. 21.53D. COVERAGE FOR RECONSTRUCTIVE SURGERY AFTER 1-8 MASTECTOMY 1-9 Sec. 1. DEFINITIONS. In this article: 1-10 (1) "Health benefit plan" means a plan described by 1-11 Section 2 of this article. 1-12 (2) "Breast reconstruction" means reconstruction of a 1-13 breast incident to mastectomy to restore or achieve breast 1-14 symmetry. The term includes surgical reconstruction of a breast on 1-15 which mastectomy surgery has been performed and surgical 1-16 reconstruction of a breast on which mastectomy surgery has not 1-17 been performed. 1-18 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a 1-19 health benefit plan that: 1-20 (1) provides benefits for medical or surgical expenses 1-21 incurred as a result of a health condition, accident, or sickness, 1-22 including: 1-23 (A) an individual, group, blanket, or franchise 1-24 insurance policy or insurance agreement, a group hospital service 2-1 contract, or an individual or group evidence of coverage that is 2-2 offered by: 2-3 (i) an insurance company; 2-4 (ii) a group hospital service corporation 2-5 operating under Chapter 20 of this code; 2-6 (iii) a fraternal benefit society 2-7 operating under Chapter 10 of this code; 2-8 (iv) a stipulated premium insurance 2-9 company operating under Chapter 22 of this code; or 2-10 (v) a health maintenance organization 2-11 operating under the Texas Health Maintenance Organization Act 2-12 (Chapter 20A, Vernon's Texas Insurance Code); or 2-13 (B) to the extent permitted by the Employee 2-14 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 2-15 seq.), a health benefit plan that is offered by: 2-16 (i) a multiple employer welfare 2-17 arrangement as defined by Section 3, Employee Retirement Income 2-18 Security Act of 1974 (29 U.S.C. Section 1002); or 2-19 (ii) another analogous benefit 2-20 arrangement; or 2-21 (2) is offered by an approved nonprofit health 2-22 corporation that is certified under Section 5.01(a), Medical 2-23 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 2-24 that holds a certificate of authority issued by the commissioner 2-25 under Article 21.52F of this code. 2-26 (b) This article does not apply to: 2-27 (1) a plan that provides coverage: 3-1 (A) only for a specified disease; 3-2 (B) only for accidental death or dismemberment; 3-3 (C) for wages or payments in lieu of wages for a 3-4 period during which an employee is absent from work because of 3-5 sickness or injury; or 3-6 (D) as a supplement to liability insurance; 3-7 (2) a plan written under Chapter 26 of this code; 3-8 (3) a Medicare supplemental policy as defined by 3-9 Section 1882(g)(1), Social Security Act (42 U.S.C. 1395ss); 3-10 (4) workers' compensation insurance coverage; 3-11 (5) medical payment insurance issued as part of a 3-12 motor vehicle insurance policy; or 3-13 (6) a long-term care policy, including a nursing home 3-14 fixed indemnity policy, unless the commissioner determines that the 3-15 policy provides benefit coverage so comprehensive that the policy 3-16 is a health benefit plan as described by Subsection (a) of this 3-17 section. 3-18 Sec. 3. COVERAGE REQUIRED. A health benefit plan that 3-19 provides coverage for mastectomy must provide coverage for breast 3-20 reconstruction. The coverage may be subject to the same deductible 3-21 or copayment applicable to mastectomy. 3-22 Sec. 4. PROHIBITION. A health benefit plan may not offer a 3-23 financial incentive for a patient to forego breast reconstruction 3-24 or to waive the coverage required by Section 3 of this article. 3-25 Sec. 5. RULES. The commissioner may adopt rules to 3-26 implement this article. 3-27 SECTION 2. This Act takes effect September 1, 1997, and 4-1 applies only to a health benefit plan that is delivered, issued for 4-2 delivery, or renewed on or after January 1, 1998. A health benefit 4-3 plan that is delivered, issued for delivery, or renewed before 4-4 January 1, 1998, is governed by the law as it existed immediately 4-5 before the effective date of this Act, and that law is continued in 4-6 effect for this purpose. 4-7 SECTION 3. The importance of this legislation and the 4-8 crowded condition of the calendars in both houses create an 4-9 emergency and an imperative public necessity that the 4-10 constitutional rule requiring bills to be read on three several 4-11 days in each house be suspended, and this rule is hereby suspended.