1-1 By: Coleman, et al. (Senate Sponsor - Ellis) H.B. No. 1173
1-2 (In the Senate - Received from the House May 5, 1997;
1-3 May 6, 1997, read first time and referred to Committee on Economic
1-4 Development; May 18, 1997, reported adversely, with favorable
1-5 Committee Substitute by the following vote: Yeas 11, Nays 0;
1-6 May 18, 1997, sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR H.B. No. 1173 By: Lucio
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to coverage by certain health benefit plans for certain
1-11 serious mental illnesses.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Article 3.51-14, Insurance Code, is amended to
1-14 read as follows:
1-15 Art. 3.51-14. COVERAGE [MANDATORY PROVISION OF BENEFITS] FOR
1-16 CERTAIN SERIOUS MENTAL ILLNESSES
1-17 Sec. 1. DEFINITIONS [DEFINITION]. For purposes of this
1-18 article:[,]
1-19 (1) "Serious [serious] mental illness" means the
1-20 following psychiatric illnesses as defined by the American
1-21 Psychiatric Association in the Diagnostic and Statistical Manual
1-22 (DSM) [III-R]:
1-23 (A) [(1)] schizophrenia;
1-24 (B) [(2)] paranoid and other psychotic
1-25 disorders;
1-26 (C) [(3)] bipolar disorder (hypomanic [mixed],
1-27 manic, [and] depressive, and mixed);
1-28 (D) [(4)] major depressive disorders (single
1-29 episode or recurrent); [and]
1-30 (E) [(5)] schizo-affective disorders (bipolar or
1-31 depressive);
1-32 (F) pervasive developmental disorders;
1-33 (G) obsessive-compulsive disorders; and
1-34 (H) depression in childhood and adolescence.
1-35 (2) "Group health benefit plan" means a plan described
1-36 by Section 2 of this article.
1-37 (3) "Small employer" has the meaning assigned by
1-38 Article 26.02 of this code.
1-39 Sec. 2. SCOPE OF ARTICLE [MANDATORY COVERAGE; EXEMPTION].
1-40 (a) This article applies only to a group health benefit plan that
1-41 provides benefits for medical or surgical expenses incurred as a
1-42 result of a health condition, accident, or sickness, including:
1-43 (1) a group insurance policy or insurance agreement, a
1-44 group hospital service contract, or a group evidence of coverage
1-45 that is offered by:
1-46 (A) an insurance company;
1-47 (B) a group [Each insurer, nonprofit] hospital
1-48 service [plan] corporation operating under [subject to] Chapter 20
1-49 of this code;
1-50 (C) a[,] health maintenance organization
1-51 operating under [subject to] the Texas Health Maintenance
1-52 Organization Act (Chapter 20A, Vernon's Texas Insurance Code);
1-53 (D) a fraternal benefit society operating under
1-54 Chapter 10 of this code; or
1-55 (E) a stipulated premium insurance company
1-56 operating under Chapter 22 of this code; and
1-57 (2) to the extent permitted by the Employee Retirement
1-58 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
1-59 group health benefit plan that is offered under:
1-60 (A) a multiple employer welfare arrangement as
1-61 defined by Section 3, Employee Retirement Income Security Act of
1-62 1974 (29 U.S.C. Section 1002); or
1-63 (B) another analogous benefit arrangement [,
1-64 employer, multiple employer, union, association, trustee, or other
2-1 self-funded or self-insured welfare or benefit plan, program, or
2-2 arrangement that issues group health insurance policies, enters
2-3 into health care service contracts or plans, or provides for group
2-4 health benefits, coverage, or services in this state for hospital,
2-5 medical, or surgical expenses incurred as a result of accident or
2-6 sickness shall offer and make available to each group policyholder,
2-7 contract holder, employer, multiple employer, union, association,
2-8 or trustee under a group policy, contract, plan, program, or
2-9 arrangement that provides hospital, surgical, and medical benefits,
2-10 coverage for services and benefits on an expense-incurred, service,
2-11 or prepaid basis for expenses incurred for the necessary care,
2-12 diagnosis, and treatment of serious mental illnesses].
2-13 (b) This article [section] does not apply to coverage under:
2-14 (1) a blanket accident and health insurance policy as
2-15 that term is defined under Section 2, Article 3.51-6 of this code;
2-16 (2) a short-term travel policy;
2-17 (3) an accident-only policy;
2-18 (4) a limited or specified-disease policy; or
2-19 (5) a medicare supplement policy, as that term is
2-20 defined under Section 1(3), Article 3.74 of this code.
2-21 (c) Notwithstanding Section 172.014, Local Government Code,
2-22 or any other law, this article may apply to health and accident
2-23 coverage provided by a pool created under Chapter 172, Local
2-24 Government Code, if requested by an individual entity.
2-25 Sec. 3. REQUIRED [LEVEL OF] COVERAGE FOR SERIOUS MENTAL
2-26 ILLNESSES. (a) Except as provided by Section 4 of this article, a
2-27 group health benefit plan:
2-28 (1) must provide coverage for the following treatment
2-29 of serious mental illness in each calendar year:
2-30 (A) 45 days of inpatient treatment; and
2-31 (B) 60 visits for outpatient treatment,
2-32 including group and individual outpatient treatment;
2-33 (2) may not include a lifetime limit on the number of
2-34 days of inpatient treatment or the number of outpatient visits
2-35 covered under the plan; and
2-36 (3) [The coverage offered under this article for
2-37 services and benefits for the condition of serious mental illness
2-38 must be at least as favorable as the coverage made available for
2-39 services and benefits provided by the insuring entity for other
2-40 major illnesses and] must include the same [durational limits,]
2-41 amount limits, deductibles, and coinsurance factors for serious
2-42 mental illness as for physical illness.
2-43 (b) An issuer of a group health benefit plan may not count
2-44 toward the number of outpatient visits required to be covered under
2-45 Subsection (a)(1) of this section an outpatient visit for the
2-46 purpose of medication management and must cover that outpatient
2-47 visit under the same terms and conditions as it covers outpatient
2-48 visits for treatment of physical illness.
2-49 (c) An issuer of a group health benefit plan may provide or
2-50 offer coverage required under this section through a managed care
2-51 plan.
2-52 Sec. 4. SMALL EMPLOYER COVERAGE. An issuer of a group
2-53 health benefit plan to a small employer must offer the coverage
2-54 described in Section 3 of this article but is not required to
2-55 provide the coverage if the small employer rejects the coverage.
2-56 Sec. 5. CERTAIN BENEFITS PROHIBITED. (a) This article may
2-57 not be interpreted to require a group health benefit plan to
2-58 provide coverage for treatment of:
2-59 (1) addiction to a controlled substance or marihuana
2-60 that is used in violation of law; or
2-61 (2) mental illness resulting from the use of a
2-62 controlled substance or marihuana in violation of law.
2-63 (b) In this section, "controlled substance" and "marihuana"
2-64 have the meanings assigned by Section 481.002, Health and Safety
2-65 Code.
2-66 SECTION 2. This Act takes effect September 1, 1997, and
2-67 applies only to a group health benefit plan that is delivered,
2-68 issued for delivery, or renewed on or after January 1, 1998. A
2-69 group health benefit plan that is delivered, issued for delivery,
3-1 or renewed before January 1, 1998, is governed by the law as it
3-2 existed immediately before the effective date of this Act, and that
3-3 law is continued in effect for that purpose.
3-4 SECTION 3. The importance of this legislation and the
3-5 crowded condition of the calendars in both houses create an
3-6 emergency and an imperative public necessity that the
3-7 constitutional rule requiring bills to be read on three several
3-8 days in each house be suspended, and this rule is hereby suspended.
3-9 * * * * *