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);
1-24 (F) pervasive developmental disorders;
2-1 (G) obsessive-compulsive disorders; and
2-2 (H) depression in childhood and adolescence.
2-3 (2) "Group health benefit plan" means a plan described
2-4 by Section 2 of this article.
2-5 (3) "Small employer" has the meaning assigned by
2-6 Article 26.02 of this code.
2-7 Sec. 2. SCOPE OF ARTICLE [MANDATORY COVERAGE; EXEMPTION].
2-8 (a) This article applies only to a group health benefit plan that
2-9 provides benefits for medical or surgical expenses incurred as a
2-10 result of a health condition, accident, or sickness, including:
2-11 (1) a group insurance policy or insurance agreement, a
2-12 group hospital service contract, or a group evidence of coverage
2-13 that is offered by:
2-14 (A) an insurance company;
2-15 (B) a group [Each insurer, nonprofit] hospital
2-16 service [plan] corporation operating under [subject to] Chapter 20
2-17 of this code;
2-18 (C) a[,] health maintenance organization
2-19 operating under [subject to] the Texas Health Maintenance
2-20 Organization Act (Chapter 20A, Vernon's Texas Insurance Code);
2-21 (D) a fraternal benefit society operating under
2-22 Chapter 10 of this code; or
2-23 (E) a stipulated premium insurance company
2-24 operating under Chapter 22 of this code; and
2-25 (2) to the extent permitted by the Employee Retirement
2-26 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
2-27 group health benefit plan that is offered under:
3-1 (A) a multiple employer welfare arrangement as
3-2 defined by Section 3, Employee Retirement Income Security Act of
3-3 1974 (29 U.S.C. Section 1002); or
3-4 (B) another analogous benefit arrangement [,
3-5 employer, multiple employer, union, association, trustee, or other
3-6 self-funded or self-insured welfare or benefit plan, program, or
3-7 arrangement that issues group health insurance policies, enters
3-8 into health care service contracts or plans, or provides for group
3-9 health benefits, coverage, or services in this state for hospital,
3-10 medical, or surgical expenses incurred as a result of accident or
3-11 sickness shall offer and make available to each group policyholder,
3-12 contract holder, employer, multiple employer, union, association,
3-13 or trustee under a group policy, contract, plan, program, or
3-14 arrangement that provides hospital, surgical, and medical benefits,
3-15 coverage for services and benefits on an expense-incurred, service,
3-16 or prepaid basis for expenses incurred for the necessary care,
3-17 diagnosis, and treatment of serious mental illnesses].
3-18 (b) This article [section] does not apply to coverage under:
3-19 (1) a blanket accident and health insurance policy as
3-20 that term is defined under Section 2, Article 3.51-6 of this code;
3-21 (2) a short-term travel policy;
3-22 (3) an accident-only policy;
3-23 (4) a limited or specified-disease policy; or
3-24 (5) a medicare supplement policy, as that term is
3-25 defined under Section 1(3), Article 3.74 of this code.
3-26 Sec. 3. REQUIRED [LEVEL OF] COVERAGE FOR SERIOUS MENTAL
3-27 ILLNESSES. (a) Except as provided by Section 4 of this article, a
4-1 group health benefit plan:
4-2 (1) must provide coverage for the following treatment
4-3 of serious mental illness in each calendar year:
4-4 (A) 45 days of inpatient treatment; and
4-5 (B) 60 visits for outpatient treatment,
4-6 including group and individual outpatient treatment;
4-7 (2) may not include a lifetime limit on the number of
4-8 days of inpatient treatment or the number of outpatient visits
4-9 covered under the plan; and
4-10 (3) [The coverage offered under this article for
4-11 services and benefits for the condition of serious mental illness
4-12 must be at least as favorable as the coverage made available for
4-13 services and benefits provided by the insuring entity for other
4-14 major illnesses and] must include the same [durational limits,]
4-15 amount limits, deductibles, and coinsurance factors for serious
4-16 mental illness as for physical illness.
4-17 (b) An issuer of a group health benefit plan may not count
4-18 toward the number of outpatient visits required to be covered under
4-19 Subsection (a)(1) of this section an outpatient visit for the
4-20 purpose of medication management and must cover that outpatient
4-21 visit under the same terms and conditions as it covers outpatient
4-22 visits for treatment of physical illness.
4-23 (c) An issuer of a group health benefit plan may provide or
4-24 offer coverage required under this section through a managed care
4-25 plan.
4-26 Sec. 4. SMALL EMPLOYER COVERAGE. An issuer of a group
4-27 health benefit plan to a small employer must offer the coverage
5-1 described in Section 3 of this article but is not required to
5-2 provide the coverage if the small employer rejects the coverage.
5-3 Sec. 5. CERTAIN BENEFITS PROHIBITED. (a) This article may
5-4 not be interpreted to require a group health benefit plan to
5-5 provide coverage for treatment of:
5-6 (1) addiction to a controlled substance or marihuana
5-7 that is used in violation of law; or
5-8 (2) mental illness resulting from the use of a
5-9 controlled substance or marihuana in violation of law.
5-10 (b) In this section, "controlled substance" and "marihuana"
5-11 have the meanings assigned by Section 481.002, Health and Safety
5-12 Code.
5-13 SECTION 2. This Act takes effect September 1, 1997, and
5-14 applies only to a group health benefit plan that is delivered,
5-15 issued for delivery, or renewed on or after January 1, 1998. A
5-16 group health benefit plan that is delivered, issued for delivery,
5-17 or renewed before January 1, 1998, is governed by the law as it
5-18 existed immediately before the effective date of this Act, and that
5-19 law is continued in effect for that purpose.
5-20 SECTION 3. The importance of this legislation and the
5-21 crowded condition of the calendars in both houses create an
5-22 emergency and an imperative public necessity that the
5-23 constitutional rule requiring bills to be read on three several
5-24 days in each house be suspended, and this rule is hereby suspended.
_______________________________ _______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 1173 was passed by the House on May
2, 1997, by a non-record vote; and that the House concurred in
Senate amendments to H.B. No. 1173 on May 24, 1997, by a non-record
vote.
_______________________________
Chief Clerk of the House
I certify that H.B. No. 1173 was passed by the Senate, with
amendments, on May 22, 1997, by a viva-voce vote.
_______________________________
Secretary of the Senate
APPROVED: _____________________
Date
_____________________
Governor