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.