1-1 By: Hamric, Gray, et al. (Senate Sponsor - Shapiro) H.B. No. 349 1-2 (In the Senate - Received from the House May 6, 1997; 1-3 May 7, 1997, read first time and referred to Committee on Economic 1-4 Development; May 17, 1997, reported favorably by the following 1-5 vote: Yeas 7, Nays 0; May 17, 1997, sent to printer.) 1-6 A BILL TO BE ENTITLED 1-7 AN ACT 1-8 relating to coverage under certain health benefit plans for care 1-9 after the performance of a mastectomy and certain related 1-10 procedures. 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 21.52G to read as follows: 1-14 Art. 21.52G. COVERAGE FOR HOSPITAL STAYS FOLLOWING 1-15 PERFORMANCE OF A MASTECTOMY AND CERTAIN RELATED PROCEDURES 1-16 Sec. 1. DEFINITIONS. In this article: 1-17 (1) "Enrollee" means a person entitled to coverage 1-18 under a health benefit plan. 1-19 (2) "Health benefit plan" means a plan described by 1-20 Section 2 of this article. 1-21 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to 1-22 a health benefit plan that: 1-23 (1) provides benefits for medical or surgical expenses 1-24 incurred as a result of a health condition, accident, or sickness, 1-25 including: 1-26 (A) an individual, group, blanket, or franchise 1-27 insurance policy or insurance agreement, a group hospital service 1-28 contract, or an individual or group evidence of coverage that is 1-29 offered by: 1-30 (i) an insurance company; 1-31 (ii) a group hospital service corporation 1-32 operating under Chapter 20 of this code; 1-33 (iii) a fraternal benefit society 1-34 operating under Chapter 10 of this code; 1-35 (iv) a stipulated premium insurance 1-36 company operating under Chapter 22 of this code; or 1-37 (v) a health maintenance organization 1-38 operating under the Texas Health Maintenance Organization Act 1-39 (Chapter 20A, Vernon's Texas Insurance Code); or 1-40 (B) to the extent permitted by the Employee 1-41 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 1-42 seq.), a health benefit plan that is offered by: 1-43 (i) a multiple employer welfare 1-44 arrangement as defined by Section 3, Employee Retirement Income 1-45 Security Act of 1974 (29 U.S.C. Section 1002); or 1-46 (ii) another analogous benefit 1-47 arrangement; or 1-48 (2) is offered by an approved nonprofit health 1-49 corporation that is certified under Section 5.01(a), Medical 1-50 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 1-51 that holds a certificate of authority issued by the commissioner 1-52 under Article 21.52F of this code. 1-53 (b) This article applies to a health benefit plan that 1-54 provides coverage only for a specific disease or condition or for 1-55 hospitalization. 1-56 (c) This article does not apply to: 1-57 (1) a plan that provides coverage: 1-58 (A) only for accidental death or dismemberment; 1-59 (B) for wages or payments in lieu of wages for a 1-60 period during which an employee is absent from work because of 1-61 sickness or injury; or 1-62 (C) as a supplement to liability insurance; 1-63 (2) a plan written under Chapter 26 of this code; 1-64 (3) a Medicare supplemental policy as defined by 2-1 Section 1882(g)(1), Social Security Act (42 U.S.C. 1395ss); 2-2 (4) workers' compensation insurance coverage; 2-3 (5) medical payment insurance issued as part of a 2-4 motor vehicle insurance policy; or 2-5 (6) a long-term care policy, including a nursing home 2-6 fixed indemnity policy, unless the commissioner determines that the 2-7 policy provides benefit coverage so comprehensive that the policy 2-8 is a health benefit plan as described by Subsection (a) of this 2-9 section. 2-10 Sec. 3. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY 2-11 FOLLOWING MASTECTOMY OR RELATED PROCEDURE; EXCEPTION. (a) A 2-12 health benefit plan that provides benefits for the treatment of 2-13 breast cancer must include coverage for inpatient care for an 2-14 enrollee for a minimum of: 2-15 (1) 48 hours following a mastectomy; and 2-16 (2) 24 hours following a lymph node dissection for the 2-17 treatment of breast cancer. 2-18 (b) A health benefit plan is not required to provide the 2-19 minimum hours of coverage of inpatient care required under 2-20 Subsection (a) of this section if the enrollee and the enrollee's 2-21 attending physician determine that a shorter period of inpatient 2-22 care is appropriate. 2-23 Sec. 4. PROHIBITIONS. The issuer of a health benefit plan 2-24 may not: 2-25 (1) deny to an enrollee eligibility or continued 2-26 eligibility to enroll or renew coverage under the terms of the plan 2-27 solely to avoid the requirements of this article; 2-28 (2) provide money payments or rebates to an enrollee 2-29 to encourage the enrollee to accept less than the minimum coverage 2-30 required under Section 3(a) of this article; 2-31 (3) reduce or limit the amount paid to an attending 2-32 physician, or otherwise penalize the physician, because the 2-33 physician provided care to an enrollee in accordance with this 2-34 article; or 2-35 (4) provide financial or other incentives to an 2-36 attending physician to encourage the physician to provide care to 2-37 an enrollee in a manner inconsistent with this article. 2-38 Sec. 5. NOTICE. Each health benefit plan shall provide 2-39 written notice to each enrollee under the plan regarding the 2-40 coverage required by this article. The notice must be provided in 2-41 accordance with rules adopted by the commissioner. 2-42 Sec. 6. RULES. The commissioner shall adopt rules as 2-43 necessary to administer this article. 2-44 SECTION 2. This Act takes effect September 1, 1997, and 2-45 applies only to a health benefit plan that is delivered, issued for 2-46 delivery, or renewed on or after January 1, 1998. A health benefit 2-47 plan that is delivered, issued for delivery, or renewed before 2-48 January 1, 1998, is governed by the law as it existed immediately 2-49 before the effective date of this Act, and that law is continued in 2-50 effect for this purpose. 2-51 SECTION 3. The importance of this legislation and the 2-52 crowded condition of the calendars in both houses create an 2-53 emergency and an imperative public necessity that the 2-54 constitutional rule requiring bills to be read on three several 2-55 days in each house be suspended, and this rule is hereby suspended. 2-56 * * * * *