By Coleman, Uher, Maxey, Averitt, H.B. No. 1173
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage by certain health benefit plans for certain
1-3 serious mental illnesses.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 3.51-14, Insurance Code, is amended to
1-6 read as follows:
1-7 Art. 3.51-14. COVERAGE [MANDATORY PROVISION OF BENEFITS] FOR
1-8 CERTAIN SERIOUS MENTAL ILLNESSES
1-9 Sec. 1. DEFINITIONS [DEFINITION]. For purposes of this
1-10 article:[,]
1-11 (1) "Serious [serious] mental illness" means the
1-12 following psychiatric illnesses as defined by the American
1-13 Psychiatric Association in the Diagnostic and Statistical Manual
1-14 (DSM) [III-R]:
1-15 (A) [(1)] schizophrenia;
1-16 (B) [(2)] paranoid and other psychotic
1-17 disorders;
1-18 (C) [(3)] bipolar disorders (hypomanic [mixed],
1-19 manic, [and] depressive, and mixed);
1-20 (D) [(4)] major depressive disorders (single
1-21 episode or recurrent); [and]
1-22 (E) [(5)] schizo-affective disorders (bipolar or
1-23 depressive); and
1-24 (F) a psychiatric illness that is experienced in
1-25 the period beginning a year before the date of treatment by a
2-1 person younger than 18 years of age and that substantially
2-2 interferes with or limits the person's ability to function in the
2-3 person's community, family, or school.
2-4 (2) "Group health benefit plan" means a plan described
2-5 by Section 2 of this article.
2-6 (3) "Small employer" has the meaning assigned by
2-7 Article 26.02 of this code.
2-8 Sec. 2. SCOPE OF ARTICLE [MANDATORY COVERAGE; EXEMPTION].
2-9 (a) This article applies only to a group health benefit plan that
2-10 provides benefits for medical or surgical expenses incurred as a
2-11 result of a health condition, accident, or sickness, including:
2-12 (1) a group insurance policy or insurance agreement, a
2-13 group hospital service contract, or a group evidence of coverage
2-14 that is offered by:
2-15 (A) an insurance company;
2-16 (B) a group [Each insurer, nonprofit] hospital
2-17 service [plan] corporation operating under [subject to] Chapter 20
2-18 of this code;
2-19 (C) a[,] health maintenance organization
2-20 operating under [subject to] the Texas Health Maintenance
2-21 Organization Act (Chapter 20A, Vernon's Texas Insurance Code);
2-22 (D) a fraternal benefit society operating under
2-23 Chapter 10 of this code; or
2-24 (E) a stipulated premium insurance company
2-25 operating under Chapter 22 of this code; and
2-26 (2) to the extent permitted by the Employee Retirement
2-27 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
3-1 group health benefit plan that is offered under:
3-2 (A) a multiple employer welfare arrangement as
3-3 defined by Section 3, Employee Retirement Income Security Act of
3-4 1974 (29 U.S.C. Section 1002); or
3-5 (B) another analogous benefit arrangement [,
3-6 employer, multiple employer, union, association, trustee, or other
3-7 self-funded or self-insured welfare or benefit plan, program, or
3-8 arrangement that issues group health insurance policies, enters
3-9 into health care service contracts or plans, or provides for group
3-10 health benefits, coverage, or services in this state for hospital,
3-11 medical, or surgical expenses incurred as a result of accident or
3-12 sickness shall offer and make available to each group policyholder,
3-13 contract holder, employer, multiple employer, union, association,
3-14 or trustee under a group policy, contract, plan, program, or
3-15 arrangement that provides hospital, surgical, and medical benefits,
3-16 coverage for services and benefits on an expense-incurred, service,
3-17 or prepaid basis for expenses incurred for the necessary care,
3-18 diagnosis, and treatment of serious mental illnesses].
3-19 (b) This article [section] does not apply to coverage under:
3-20 (1) a blanket accident and health insurance policy as
3-21 that term is defined under Section 2, Article 3.51-6 of this code;
3-22 (2) a short-term travel policy;
3-23 (3) an accident-only policy;
3-24 (4) a limited or specified-disease policy; or
3-25 (5) a medicare supplement policy, as that term is
3-26 defined under Section 1(3), Article 3.74 of this code.
3-27 (c) Notwithstanding Section 172.014, Local Government Code,
4-1 or any other law, this article applies to health and accident
4-2 coverage provided by a risk pool created under Chapter 172, Local
4-3 Government Code.
4-4 Sec. 3. REQUIRED [LEVEL OF] COVERAGE FOR SERIOUS MENTAL
4-5 ILLNESSES. (a) Except as provided by Section 4 of this article, a
4-6 group health benefit plan:
4-7 (1) must provide coverage for the following treatment
4-8 of serious mental illness in each calendar year:
4-9 (A) 45 days of inpatient treatment; and
4-10 (B) 60 visits for outpatient treatment,
4-11 including group and individual outpatient treatment;
4-12 (2) may not include a lifetime limit on the number of
4-13 days of inpatient treatment or the number of outpatient visits
4-14 covered under the plan; and
4-15 (3) [The coverage offered under this article for
4-16 services and benefits for the condition of serious mental illness
4-17 must be at least as favorable as the coverage made available for
4-18 services and benefits provided by the insuring entity for other
4-19 major illnesses and] must include the same [durational limits,]
4-20 amount limits, deductibles, and coinsurance factors for serious
4-21 mental illness as for physical illness.
4-22 (b) An issuer of a group health benefit plan may not count
4-23 toward the number of outpatient visits required to be covered under
4-24 Subsection (a)(1) of this section an outpatient visit for the
4-25 purpose of medication management and must cover that outpatient
4-26 visit under the same terms and conditions as it covers outpatient
4-27 visits for treatment of physical illness.
5-1 (c) An issuer of a group health benefit plan may provide or
5-2 offer coverage required under this section through a managed care
5-3 plan.
5-4 Sec. 4. SMALL EMPLOYER COVERAGE. An issuer of a group
5-5 health benefit plan to a small employer must offer the coverage
5-6 described in Section 3 of this article but is not required to
5-7 provide the coverage if the small employer rejects the coverage.
5-8 Sec. 5. CERTAIN BENEFITS PROHIBITED. (a) This article may
5-9 not be interpreted to require a group health benefit plan to
5-10 provide coverage for treatment of:
5-11 (1) addiction to a controlled substance or marihuana
5-12 that is used in violation of law; or
5-13 (2) mental illness resulting from the use of a
5-14 controlled substance or marihuana in violation of law.
5-15 (b) In this section, "controlled substance" and "marihuana"
5-16 have the meanings assigned by Section 481.002, Health and Safety
5-17 Code.
5-18 SECTION 2. This Act takes effect September 1, 1997, and
5-19 applies only to a group health benefit plan that is delivered,
5-20 issued for delivery, or renewed on or after January 1, 1998. A
5-21 group health benefit plan that is delivered, issued for delivery,
5-22 or renewed before January 1, 1998, is governed by the law as it
5-23 existed immediately before the effective date of this Act, and that
5-24 law is continued in effect for that purpose.
5-25 SECTION 3. The importance of this legislation and the
5-26 crowded condition of the calendars in both houses create an
5-27 emergency and an imperative public necessity that the
6-1 constitutional rule requiring bills to be read on three several
6-2 days in each house be suspended, and this rule is hereby suspended.