75R10389 SAW-D
By Coleman, Maxey, et al. H.B. No. 1173
Substitute the following for H.B. No. 1173:
By Lewis of Tarrant C.S.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
2-1 the period beginning a year before the date of treatment by a
2-2 person younger than 18 years of age and that substantially
2-3 interferes with or limits the person's ability to function in the
2-4 person's community, family, or school.
2-5 (2) "Group health benefit plan" means a plan described
2-6 by Section 2 of this article.
2-7 (3) "Small employer" has the meaning assigned by
2-8 Article 26.02 of this code.
2-9 Sec. 2. SCOPE OF ARTICLE [MANDATORY COVERAGE; EXEMPTION].
2-10 (a) This article applies only to a group health benefit plan that
2-11 provides benefits for medical or surgical expenses incurred as a
2-12 result of a health condition, accident, or sickness, including:
2-13 (1) a group insurance policy or insurance agreement, a
2-14 group hospital service contract, or a group evidence of coverage
2-15 that is offered by:
2-16 (A) an insurance company;
2-17 (B) a group [Each insurer, nonprofit] hospital
2-18 service [plan] corporation operating under [subject to] Chapter 20
2-19 of this code;
2-20 (C) a[,] health maintenance organization
2-21 operating under [subject to] the Texas Health Maintenance
2-22 Organization Act (Chapter 20A, Vernon's Texas Insurance Code);
2-23 (D) a fraternal benefit society operating under
2-24 Chapter 10 of this code; or
2-25 (E) a stipulated premium insurance company
2-26 operating under Chapter 22 of this code; and
2-27 (2) to the extent permitted by the Employee Retirement
3-1 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
3-2 group health benefit plan that is offered under:
3-3 (A) a multiple employer welfare arrangement as
3-4 defined by Section 3, Employee Retirement Income Security Act of
3-5 1974 (29 U.S.C. Section 1002); or
3-6 (B) another analogous benefit arrangement [,
3-7 employer, multiple employer, union, association, trustee, or other
3-8 self-funded or self-insured welfare or benefit plan, program, or
3-9 arrangement that issues group health insurance policies, enters
3-10 into health care service contracts or plans, or provides for group
3-11 health benefits, coverage, or services in this state for hospital,
3-12 medical, or surgical expenses incurred as a result of accident or
3-13 sickness shall offer and make available to each group policyholder,
3-14 contract holder, employer, multiple employer, union, association,
3-15 or trustee under a group policy, contract, plan, program, or
3-16 arrangement that provides hospital, surgical, and medical benefits,
3-17 coverage for services and benefits on an expense-incurred, service,
3-18 or prepaid basis for expenses incurred for the necessary care,
3-19 diagnosis, and treatment of serious mental illnesses].
3-20 (b) This article [section] does not apply to coverage under:
3-21 (1) a blanket accident and health insurance policy as
3-22 that term is defined under Section 2, Article 3.51-6 of this code;
3-23 (2) a short-term travel policy;
3-24 (3) an accident-only policy;
3-25 (4) a limited or specified-disease policy; or
3-26 (5) a medicare supplement policy, as that term is
3-27 defined under Section 1(3), Article 3.74 of this code.
4-1 Sec. 3. REQUIRED [LEVEL OF] COVERAGE FOR SERIOUS MENTAL
4-2 ILLNESSES. (a) Except as provided by Section 4 of this article, a
4-3 group health benefit plan:
4-4 (1) must provide coverage for the following treatment
4-5 of serious mental illness in each calendar year:
4-6 (A) 45 days of inpatient treatment; and
4-7 (B) 60 visits for outpatient treatment,
4-8 including group and individual outpatient treatment;
4-9 (2) may not include a lifetime limit on the number of
4-10 days of inpatient treatment or the number of outpatient visits
4-11 covered under the plan; and
4-12 (3) [The coverage offered under this article for
4-13 services and benefits for the condition of serious mental illness
4-14 must be at least as favorable as the coverage made available for
4-15 services and benefits provided by the insuring entity for other
4-16 major illnesses and] must include the same [durational limits,]
4-17 amount limits, deductibles, and coinsurance factors for serious
4-18 mental illness as for physical illness.
4-19 (b) An issuer of a group health benefit plan may not count
4-20 toward the number of outpatient visits required to be covered under
4-21 Subsection (a)(1) of this section an outpatient visit for the
4-22 purpose of medication management and must cover that outpatient
4-23 visit under the same terms and conditions as it covers outpatient
4-24 visits for treatment of physical illness.
4-25 (c) An issuer of a group health benefit plan may provide or
4-26 offer coverage required under this section through a managed care
4-27 plan.
5-1 Sec. 4. SMALL EMPLOYER COVERAGE. An issuer of a group
5-2 health benefit plan to a small employer must offer the coverage
5-3 described in Section 3 of this article but is not required to
5-4 provide the coverage if the small employer rejects the coverage.
5-5 SECTION 2. This Act takes effect September 1, 1997, and
5-6 applies only to a group health benefit plan that is delivered,
5-7 issued for delivery, or renewed on or after January 1, 1998. A
5-8 group health benefit plan that is delivered, issued for delivery,
5-9 or renewed before January 1, 1998, is governed by the law as it
5-10 existed immediately before the effective date of this Act, and that
5-11 law is continued in effect for that purpose.
5-12 SECTION 3. The importance of this legislation and the
5-13 crowded condition of the calendars in both houses create an
5-14 emergency and an imperative public necessity that the
5-15 constitutional rule requiring bills to be read on three several
5-16 days in each house be suspended, and this rule is hereby suspended.