75R6372 DLF-F By Hamric, Gray H.B. No. 349 Substitute the following for H.B. No. 349: By Averitt C.S.H.B. No. 349 A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to coverage under certain health benefit plans for care 1-3 after the performance of a mastectomy and certain related 1-4 procedures. 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 21.52G to read as follows: 1-8 Art. 21.52G. COVERAGE FOR HOSPITAL STAYS FOLLOWING 1-9 PERFORMANCE OF A MASTECTOMY AND CERTAIN RELATED PROCEDURES 1-10 Sec. 1. DEFINITIONS. In this article: 1-11 (1) "Enrollee" means a person entitled to coverage 1-12 under a health benefit plan. 1-13 (2) "Health benefit plan" means a plan described by 1-14 Section 2 of this article. 1-15 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to 1-16 a health benefit plan that: 1-17 (1) provides benefits for medical or surgical expenses 1-18 incurred as a result of a health condition, accident, or sickness, 1-19 including: 1-20 (A) an individual, group, blanket, or franchise 1-21 insurance policy or insurance agreement, a group hospital service 1-22 contract, or an individual or group evidence of coverage that is 1-23 offered by: 1-24 (i) an insurance company; 2-1 (ii) a group hospital service corporation 2-2 operating under Chapter 20 of this code; 2-3 (iii) a fraternal benefit society 2-4 operating under Chapter 10 of this code; 2-5 (iv) a stipulated premium insurance 2-6 company operating under Chapter 22 of this code; or 2-7 (v) a health maintenance organization 2-8 operating under the Texas Health Maintenance Organization Act 2-9 (Chapter 20A, Vernon's Texas Insurance Code); or 2-10 (B) to the extent permitted by the Employee 2-11 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 2-12 seq.), a health benefit plan that is offered by: 2-13 (i) a multiple employer welfare 2-14 arrangement as defined by Section 3, Employee Retirement Income 2-15 Security Act of 1974 (29 U.S.C. Section 1002); or 2-16 (ii) another analogous benefit 2-17 arrangement; or 2-18 (2) is offered by an approved nonprofit health 2-19 corporation that is certified under Section 5.01(a), Medical 2-20 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 2-21 that holds a certificate of authority issued by the commissioner 2-22 under Article 21.52F of this code; or 2-23 (3) is offered by any other entity not licensed under 2-24 this code or another insurance law of this state that contracts 2-25 directly for health care services on a risk-sharing basis, 2-26 including an entity that contracts for health care services on a 2-27 capitation basis. 3-1 (b) This article applies to a health benefit plan that 3-2 provides coverage only for a specific disease or condition or for 3-3 hospitalization. 3-4 (c) This article does not apply to: 3-5 (1) a plan that provides coverage: 3-6 (A) only for accidental death or dismemberment; 3-7 (B) for wages or payments in lieu of wages for a 3-8 period during which an employee is absent from work because of 3-9 sickness or injury; or 3-10 (C) as a supplement to liability insurance; 3-11 (2) a plan written under Chapter 26 of this code; 3-12 (3) a Medicare supplemental policy as defined by 3-13 Section 1882(g)(1), Social Security Act (42 U.S.C. 1395ss); 3-14 (4) workers' compensation insurance coverage; 3-15 (5) medical payment insurance issued as part of a 3-16 motor vehicle insurance policy; or 3-17 (6) a long-term care policy, including a nursing home 3-18 fixed indemnity policy, unless the commissioner determines that the 3-19 policy provides benefit coverage so comprehensive that the policy 3-20 is a health benefit plan as described by Subsection (a) of this 3-21 section. 3-22 Sec. 3. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY 3-23 FOLLOWING MASTECTOMY OR RELATED PROCEDURE; EXCEPTION. (a) A 3-24 health benefit plan that provides benefits for the treatment of 3-25 breast cancer must include coverage for inpatient care for an 3-26 enrollee for a minimum of: 3-27 (1) 48 hours following a mastectomy; and 4-1 (2) 24 hours following a lymph node dissection for the 4-2 treatment of breast cancer. 4-3 (b) A health benefit plan is not required to provide the 4-4 minimum hours of coverage of inpatient care required under 4-5 Subsection (a) of this section if the enrollee and the enrollee's 4-6 attending physician determine that a shorter period of inpatient 4-7 care is appropriate. 4-8 Sec. 4. PROHIBITIONS. The issuer of a health benefit plan 4-9 may not: 4-10 (1) deny to an enrollee eligibility or continued 4-11 eligibility to enroll or renew coverage under the terms of the plan 4-12 solely to avoid the requirements of this article; 4-13 (2) provide money payments or rebates to an enrollee 4-14 to encourage the enrollee to accept less than the minimum coverage 4-15 required under Section 3(a) of this article; 4-16 (3) reduce or limit the amount paid to an attending 4-17 physician, or otherwise penalize the physician, because the 4-18 physician provided care to an enrollee in accordance with this 4-19 article; or 4-20 (4) provide financial or other incentives to an 4-21 attending physician to encourage the physician to provide care to 4-22 an enrollee in a manner inconsistent with this article. 4-23 Sec. 5. NOTICE. (a) Each health benefit plan shall provide 4-24 written notice to each enrollee under the plan regarding the 4-25 coverage required by this article. The notice must be provided in 4-26 accordance with rules adopted by the commissioner. 4-27 (b) The notice required under this section must be 5-1 prominently positioned in any literature or correspondence made 5-2 available or distributed by the health benefit plan. 5-3 Sec. 6. RULES. The commissioner shall adopt rules as 5-4 necessary to administer this article. 5-5 SECTION 2. This Act takes effect September 1, 1997, and 5-6 applies only to a health benefit plan that is delivered, issued for 5-7 delivery, or renewed on or after January 1, 1998. A health benefit 5-8 plan that is delivered, issued for delivery, or renewed before 5-9 January 1, 1998, is governed by the law as it existed immediately 5-10 before the effective date of this Act, and that law is continued in 5-11 effect for this purpose. 5-12 SECTION 3. The importance of this legislation and the 5-13 crowded condition of the calendars in both houses create an 5-14 emergency and an imperative public necessity that the 5-15 constitutional rule requiring bills to be read on three several 5-16 days in each house be suspended, and this rule is hereby suspended.