By Gray H.B. No. 831 75R2500 PB-D A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to minimum coverage under certain health benefit plans for 1-3 inpatient stays after a 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 21.53E to read as follows: 1-7 Art. 21.53E. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH 1-8 CARE FACILITY FOLLOWING MASTECTOMY 1-9 Sec. 1. DEFINITIONS. In this article: 1-10 (1) "Attending physician" means a physician who 1-11 attends a woman after the performance of a mastectomy on the woman. 1-12 (2) "Health benefit plan" means a plan that provides 1-13 benefits for medical or surgical expenses incurred as a result of a 1-14 health condition, accident, or sickness and that is offered by any 1-15 insurance company, group hospital service corporation, or health 1-16 maintenance organization that delivers or issues for delivery an 1-17 individual, group, blanket, or franchise insurance policy or 1-18 insurance agreement, a group hospital service contract, or an 1-19 evidence of coverage, by a multiple employer welfare arrangement as 1-20 defined by Section 3, Employee Retirement Income Security Act of 1-21 1974 (29 U.S.C. Section 1002), or by any other analogous benefit 1-22 arrangement to the extent permitted by the Employee Retirement 1-23 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.). The 1-24 term does not include: 2-1 (A) a plan that provides coverage: 2-2 (i) only for accidental death or 2-3 dismemberment; 2-4 (ii) for wages or payments in lieu of 2-5 wages for a period during which an employee is absent from work 2-6 because of sickness or injury; or 2-7 (iii) as a supplement to liability 2-8 insurance; 2-9 (B) a medicare supplemental policy as defined by 2-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 2-11 (C) workers' compensation insurance coverage; 2-12 (D) medical payment insurance issued as part of 2-13 a motor vehicle insurance policy; 2-14 (E) a plan written under Chapter 26 of this 2-15 code; or 2-16 (F) a long-term care policy, including a nursing 2-17 home fixed indemnity policy, unless the commissioner determines 2-18 that the policy provides benefit coverage so comprehensive that the 2-19 policy meets the definition of a health benefit plan. 2-20 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY 2-21 FOLLOWING MASTECTOMY; EXCEPTION. (a) A health benefit plan that 2-22 provides benefits for surgical procedures must include coverage of 2-23 inpatient care in a health care facility for a woman enrolled in 2-24 the plan and on whom a mastectomy is performed for a minimum of 48 2-25 hours following the performance of the mastectomy. 2-26 (b) Notwithstanding Subsection (a) of this section, a health 2-27 benefit plan that provides benefits for surgical procedures is not 3-1 required to provide the minimum hours of coverage of inpatient care 3-2 required under Subsection (a) of this section if: 3-3 (1) the attending physician determines, in accordance 3-4 with protocols and guidelines adopted by the American College of 3-5 Surgeons or another analogous nationally recognized organization of 3-6 surgeons, that the patient meets the appropriate guidelines for a 3-7 shorter length of inpatient care based on an evaluation of the 3-8 patient by the attending physician; and 3-9 (2) coverage is provided under the plan for 3-10 post-discharge physician office visits or in-home nurse visits as 3-11 necessary to monitor the condition of the patient during the first 3-12 48 hours after discharge from the health care facility. 3-13 Sec. 3. PROHIBITIONS. A health benefit plan may not: 3-14 (1) modify the terms and conditions of coverage based 3-15 on the determination by a person enrolled in the health benefit 3-16 plan to request less than the minimum coverage required under 3-17 Section 2(a) of this article; 3-18 (2) offer to a mastectomy patient financial incentives 3-19 or other compensation the receipt of which is contingent on the 3-20 waiver by the patient of the minimum hours of coverage of inpatient 3-21 care required under Section 2(a) of this article; 3-22 (3) refuse to accept a physician's recommendation for 3-23 a specified period of inpatient care made in consultation with the 3-24 patient if the period recommended by the physician does not exceed 3-25 the minimum periods recommended in guidelines for postsurgical care 3-26 adopted by the American College of Surgeons or another analogous 3-27 nationally recognized organization of surgeons; 4-1 (4) reduce payments or other forms of reimbursement 4-2 for inpatient care below the usual and customary rate of 4-3 reimbursement for that care; or 4-4 (5) penalize a physician for recommending inpatient 4-5 care for a mastectomy patient by: 4-6 (A) refusing to allow the physician to 4-7 participate as a provider within the health benefit plan; 4-8 (B) reducing payments made to the physician; 4-9 (C) requiring the physician to provide 4-10 additional documentation or undergo additional utilization review; 4-11 or 4-12 (D) imposing other analogous sanctions or 4-13 disincentives. 4-14 Sec. 4. NOTICE. (a) Each health benefit plan shall provide 4-15 to each person enrolled in the plan written notice regarding the 4-16 coverage required by this article. The notice must be provided in 4-17 accordance with rules adopted by the commissioner. 4-18 (b) The notice required under this section must be 4-19 prominently positioned in any literature or correspondence made 4-20 available or distributed by the health benefit plan. 4-21 Sec. 5. RULES. The commissioner shall adopt rules as 4-22 necessary to administer this article. 4-23 SECTION 2. This Act takes effect September 1, 1997, and 4-24 applies only to a health benefit plan that is delivered, issued for 4-25 delivery, or renewed on or after January 1, 1998. A plan that is 4-26 delivered, issued for delivery, or renewed before January 1, 1998, 4-27 is governed by the law as it existed immediately before the 5-1 effective date of this Act, and that law is continued in effect for 5-2 that purpose. 5-3 SECTION 3. The importance of this legislation and the 5-4 crowded condition of the calendars in both houses create an 5-5 emergency and an imperative public necessity that the 5-6 constitutional rule requiring bills to be read on three several 5-7 days in each house be suspended, and this rule is hereby suspended.