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.