Bill not drafted by TLC or Senate E&E.
Line and page numbers may not match official copy.
By Van de Putte H.B. No. 1679
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to requirements for certain health insurance benefits.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subsection (b), Section 3D, Article 3.51-6,
1-5 Insurance Code, is amended to read as follows:
1-6 (b) A health insurance policy that provides coverage for the
1-7 immediate family or children of a person insured under the policy
1-8 may not exclude from coverage or limit coverage to a child of the
1-9 insured solely because the child is adopted. The insurer shall
1-10 provide full coverage under the policy to the child of an insured
1-11 without limiting coverage of a preexisting condition if an
1-12 application for coverage for the child is made not later than the
1-13 31st day after the date on which the adoption is final or, for the
1-14 period during which the adoption is not final, not later than the
1-15 31st day after the date on which the insured becomes a party in a
1-16 suit in which adoption of the child by the insured is sought.
1-17 SECTION 2. Article 3.51-14, Insurance Code, is amended by
1-18 adding Section 4 to read as follows:
1-19 Sec. 4. COMPLIANCE REQUIRED. Any coverage provided under
1-20 this article to an employee welfare benefit plan as defined in
1-21 Section 3(1) of the Employee Retirement Income Security Act of 1974
1-22 (29 U.S.C. Section 1002(1)) must comply with Article 3.51-15 of
1-23 this code.
1-24 SECTION 3. Subchapter E, Chapter 3, Insurance Code, is
2-1 amended by adding Article 3.51-15 to read as follows:
2-2 Art. 3.51-15. CERTAIN INSURERS MUST MEET REQUIREMENTS FOR
2-3 PARITY
2-4 Sec. 1. PURPOSE. The purpose of this article is to
2-5 coordinate the requirements of Texas law with federal law relating
2-6 to a requirement of parity between certain mental health benefits
2-7 and medical and surgical benefits.
2-8 Sec. 2. DEFINITIONS. In this article:
2-9 (1) "Aggregate lifetime limit" means a dollar
2-10 limitation on the total amount of benefits that may be paid under
2-11 the health insurance coverage with respect to an individual or
2-12 other coverage unit.
2-13 (2) "Annual limit" means a dollar limitation on the
2-14 total amount of benefits that may be paid in a 12-month period
2-15 under the health insurance coverage with respect to an individual
2-16 or other coverage unit.
2-17 (3) "Insurer" means:
2-18 (A) an insurance company;
2-19 (B) a group hospital service corporation
2-20 operating under Chapter 20 of this code;
2-21 (C) a fraternal benefit society operating under
2-22 Chapter 10 of this code;
2-23 (D) a stipulated premium insurance company
2-24 operating under Chapter 22 of this code;
2-25 (E) a health maintenance organization operating
2-26 under the Texas Health Maintenance Organization Act (Chapter 20A,
2-27 Vernon's Texas Insurance Code); or
2-28 (F) an approved nonprofit health corporation
2-29 that is certified under Section 5.01(a), Medical Practice Act
2-30 (Article 4495b, Vernon's Texas Civil Statutes), and that holds a
3-1 certificate of authority issued by the commissioner under Article
3-2 21.52F of this code.
3-3 (4) "Medical or surgical benefits" means benefits with
3-4 respect to medical or surgical services as defined under the terms
3-5 of the coverage, but such benefits do not include mental health
3-6 benefits.
3-7 (5) "Mental health benefits" means benefits with
3-8 respect to mental health services as defined under the terms of the
3-9 coverage and includes benefits provided for mental or emotional
3-10 illnesses or disorders and serious mental illnesses as defined and
3-11 referenced in this code or in rules promulgated by the commissioner
3-12 under this code but does not include benefits with respect to
3-13 treatment of substance abuse or chemical dependency.
3-14 Sec. 3. PARITY REQUIREMENTS. (a) Any coverage for services
3-15 and benefits for the condition of mental illness or serious mental
3-16 illness provided by an insurer to an employee welfare benefit plan
3-17 as defined in Section 3(1) of the Employee Retirement Income
3-18 Security Act of 1974 (29 U.S.C. Section 1002(1)) must meet the
3-19 requirements of Subsections (b) and (c) of this section regarding
3-20 parity in annual and lifetime aggregate dollar limits between
3-21 medical and surgical benefits and mental illness benefits, unless
3-22 exempted under Section 4 of this article.
3-23 (b) In the case of coverage that provides both medical and
3-24 surgical benefits and mental health benefits:
3-25 (1) if the coverage does not include an aggregate
3-26 lifetime limit on substantially all medical and surgical benefits,
3-27 the coverage may not impose any aggregate lifetime limit on mental
3-28 health benefits; and
3-29 (2) if the coverage includes an aggregate lifetime
3-30 limit on substantially all medical and surgical benefits, in this
4-1 article referred to as the "applicable lifetime limit," the
4-2 coverage shall either:
4-3 (A) apply the applicable lifetime limit both to
4-4 the medical and surgical benefits to which it otherwise would apply
4-5 and to mental health benefits and not distinguish in the
4-6 application of such limit between medical and surgical benefits and
4-7 mental health benefits; or
4-8 (B) not include any aggregate lifetime limit on
4-9 mental health benefits that is less than the applicable lifetime
4-10 limit.
4-11 (c) In the case of coverage that is not described in
4-12 Subsection (b) of this section and that includes no or different
4-13 aggregate lifetime limits on different categories of medical and
4-14 surgical benefits, the insurer must follow rules promulgated by the
4-15 Secretary of the Treasury under the Mental Health Parity Act of
4-16 1996 (Title VII, Pub. L. No. 104-204), under which the rule in
4-17 Subsection (b)(2) of this section is applied to such coverage with
4-18 respect to mental health benefits by substituting for the
4-19 applicable lifetime limit an average aggregate lifetime limit that
4-20 is computed taking into account the weighted average of the
4-21 aggregate lifetime limits applicable to such categories.
4-22 (d) In the case of coverage that provides both medical and
4-23 surgical benefits and mental health benefits:
4-24 (1) if the coverage does not include an annual limit
4-25 on substantially all medical and surgical benefits, the coverage
4-26 may not impose any annual limit on mental health benefits; and
4-27 (2) if the coverage includes an annual limit on
4-28 substantially all medical and surgical benefits, in this article
4-29 referred to as the "applicable annual limit," the coverage shall
4-30 either:
5-1 (A) apply the applicable annual limit both to
5-2 medical and surgical benefits to which it otherwise would apply and
5-3 to mental health benefits and not distinguish in the application of
5-4 such limit between such medical and surgical benefits and mental
5-5 health benefits; or
5-6 (B) not include any annual limit on mental
5-7 health benefits that is less than the applicable annual limit.
5-8 (e) In the case of coverage that is not described in
5-9 Subsection (d) of this section and that includes no or different
5-10 annual limits on different categories of medical and surgical
5-11 benefits, the insurer must follow rules promulgated by the
5-12 Secretary of the Treasury under the Mental Health Parity Act of
5-13 1996 (Title VII, Pub. L. No. 104-204), under which the rule in
5-14 Subsection (d)(2) of this section is applied to such coverage with
5-15 respect to mental health benefits by substituting for the
5-16 applicable annual limit an average aggregate annual limit that is
5-17 computed taking into account the weighted average of the aggregate
5-18 annual limits applicable to such categories.
5-19 (f) Nothing in this section shall be construed:
5-20 (1) as requiring an insurer to provide or offer any
5-21 mental health benefits, except as otherwise specified in this code;
5-22 or
5-23 (2) in the case of coverage that provides mental
5-24 health benefits, as affecting the terms and conditions, including
5-25 cost sharing, limits on numbers of visits or days of coverage, and
5-26 requirements relating to medical necessity, relating to the amount,
5-27 duration, or scope of mental health benefits under the coverage,
5-28 except as specifically provided in this article in regard to parity
5-29 in the imposition of aggregate lifetime limits and annual limits
5-30 for mental health benefits.
6-1 Sec. 4. EXEMPTIONS. (a) This section does not apply to
6-2 coverage offered to an employee welfare benefit plan of an employer
6-3 who, with respect to a calendar year and a plan year, employed an
6-4 average of at least two but not more than 50 employees on business
6-5 days during the preceding calendar year and who employs at least
6-6 two employees on the first day of the plan year, in this article
6-7 referred to as an "exempt employer."
6-8 (b) In determining employer size for purposes of this
6-9 section:
6-10 (1) rules under Subsections (b), (c), (m), and (o),
6-11 Section 414 of the Internal Revenue Code of 1986 (26 U.S.C. Section
6-12 414) shall apply for purposes of treating persons as a single
6-13 employer;
6-14 (2) in the case of an employer which was not in
6-15 existence throughout the preceding calendar year, the determination
6-16 of whether the employer is an exempt employer shall be based on the
6-17 average number of employees that it is reasonably expected such
6-18 employer will employ on business days in the current calendar year;
6-19 and
6-20 (3) any reference in this section to an employer shall
6-21 include a reference to any predecessor of such employer.
6-22 (c) This section shall not apply with respect to insurance
6-23 coverage offered to an employee welfare benefit plan if the
6-24 application of this section to the coverage results in an increase
6-25 in the cost for the coverage of at least one percent.
6-26 Sec. 5. SEPARATE APPLICATION TO EACH OPTION OFFERED. In the
6-27 case of an employee welfare benefit plan that offers a participant
6-28 or beneficiary two or more benefit package options under the plan,
6-29 the requirements of this article shall be applied separately to
6-30 each coverage package offered by an insurer or provider with
7-1 respect to each option.
7-2 Sec. 6. RULEMAKING AUTHORITY. The commissioner may
7-3 promulgate reasonable rules to implement this article and to
7-4 coordinate or comply with minimum requirements of federal law and
7-5 regulations relating to parity of mental health benefits with any
7-6 other health and accident benefits.
7-7 SECTION 4. Subsections (E), (F), (I), and (K), Section 2,
7-8 Chapter 397, Acts of the 54th Legislature, 1955 (Article 3.70-2,
7-9 Vernon's Texas Insurance Code), are amended to read as follows:
7-10 (E) No individual policy or group policy of
7-11 accident and sickness insurance, including policies issued by
7-12 companies subject to Chapter 20, [Texas] Insurance Code, [as
7-13 amended,] delivered or issued for delivery to any person in this
7-14 state which provides for accident and sickness coverage of
7-15 immediate family or children of an enrollee, which permits the
7-16 enrollment of any enrollee's immediate family or [additional
7-17 newborn] children for such coverage, or which provides maternity
7-18 benefits[,] may be issued in this state if it contains any
7-19 provisions excluding or limiting initial coverage of a newborn
7-20 infant for a period of time, or limitations or exclusions for
7-21 congenital defects of a newborn child.
7-22 (F) A group policy of accident and sickness
7-23 insurance delivered or issued for delivery to a person in this
7-24 state, including a group policy issued by a company subject to
7-25 Chapter 20, Insurance Code, or the Texas Health Maintenance
7-26 Organization Act (Chapter 20A, Vernon's Texas Insurance Code), that
7-27 provides coverage for treatment of mental or emotional illness or
7-28 disorder for a person when confined in a hospital must also provide
7-29 that coverage, which is not less favorable, shall be applicable for
7-30 treatment under the direction and continued medical supervision of
8-1 a doctor of medicine or doctor of osteopathy in a psychiatric day
8-2 treatment facility that provides organizational structure and
8-3 individualized treatment plans separate from an in-patient program;
8-4 subject to the same durational limits, deductibles, and coinsurance
8-5 factors. Any benefits so provided shall be determined as if
8-6 necessary care and treatment in a psychiatric day treatment
8-7 facility were in-patient care and treatment in a hospital, and each
8-8 full day of treatment in a psychiatric day treatment facility shall
8-9 be considered equal to one-half of one day of treatment of mental
8-10 or emotional illness or disorder in a hospital or in-patient
8-11 program for the purpose of determining policy benefits and benefit
8-12 maximums. An insurer shall offer and the policyholder shall have
8-13 the right to reject such coverage for treatment of mental or
8-14 emotional illness or disorder when confined in a hospital or in a
8-15 psychiatric day treatment facility or may select an alternative
8-16 level of benefits thereunder if such coverage is offered by or
8-17 negotiated with such insurer, service plan corporation or health
8-18 maintenance organization, except that[; provided, however,] any
8-19 such alternative level of benefits shall provide policy benefits
8-20 and benefit maximums for treatment in psychiatric day treatment
8-21 facilities equal to at least one half of that provided for
8-22 treatment in hospital facilities, but not to exceed the usual and
8-23 customary charge of the psychiatric day treatment facility, and any
8-24 coverage provided to an employee welfare benefit plan as defined in
8-25 Section 3(1) of the Employee Retirement Income Security Act of 1974
8-26 (29 U.S.C. Section 1002(1)) must comply with Article 3.51-15,
8-27 Insurance Code. Any such policy may require that the treatment
8-28 must be provided by a day treatment facility that treats a patient
8-29 for not more than eight hours in any 24-hour period, that the
8-30 attending physician certifies that such treatment is in lieu of
9-1 hospitalization, and that the psychiatric treatment facility is
9-2 accredited by the Program for Psychiatric Facilities, or its
9-3 successor, of the Joint Commission on Accreditation of Hospitals.
9-4 For the purpose of this subsection a psychiatric day treatment
9-5 facility is a mental health facility which provides treatment for
9-6 individuals suffering from acute, mental and nervous disorders in a
9-7 structured psychiatric program utilizing individualized treatment
9-8 plans with specific attainable goals and objectives appropriate
9-9 both to the patient and the treatment modality of the program and
9-10 that is clinically supervised by a doctor of medicine who is
9-11 certified in psychiatry by the American Board of Psychiatry and
9-12 Neurology.
9-13 (I) An individual or group policy of accident
9-14 and sickness insurance that provides any emergency care benefit,
9-15 including policies issued by companies subject to Chapter 20,
9-16 Insurance Code, delivered or issued for delivery in this state must
9-17 define emergency care as follows: "Emergency care" means health
9-18 care [bona fide emergency] services provided in a hospital
9-19 emergency facility to evaluate and treat medical conditions of a
9-20 recent [after the sudden] onset and [of a medical condition
9-21 manifesting itself by acute symptoms of sufficient] severity,
9-22 including but not limited to severe pain, [such] that would lead a
9-23 prudent layperson possessing an average knowledge of medicine and
9-24 health to believe that his or her condition, sickness, or injury is
9-25 of such a nature that failure to get [the absence of] immediate
9-26 medical care [attention] could [reasonably be expected to] result
9-27 in:
9-28 (1) placing the patient's health in serious jeopardy;
9-29 (2) serious impairment to bodily functions; [or]
9-30 (3) serious dysfunction of any bodily organ or part;
10-1 (4) serious disfigurement; or
10-2 (5) in the case of a pregnant woman, serious jeopardy
10-3 to the health of the fetus.
10-4 (K) An accident and sickness insurance policy
10-5 that provides coverage for the immediate family or children of a
10-6 person insured under the policy may not exclude from coverage or
10-7 limit coverage to a child of the insured solely because the child
10-8 is adopted. The insurer shall provide full coverage under the
10-9 policy to the child without limiting coverage of a preexisting
10-10 condition if an application for the child is made not later than
10-11 the 31st day after the date on which the adoption is final or, for
10-12 the period during which the adoption is not final, not later than
10-13 the 31st day after the date on which the insured becomes a party in
10-14 a suit in which adoption of the child by the insured is sought.
10-15 For the purposes of this subsection, a child is considered to be
10-16 the child of an insured if the insured is a party in a suit in
10-17 which the adoption of the child by the insured is sought.
10-18 SECTION 5. Section 9, Texas Health Maintenance Organization
10-19 Act (Article 20A.09, Vernon's Texas Insurance Code), is amended by
10-20 adding Subsections (k), (l), and (m) to read as follows:
10-21 (k)(1) A health maintenance organization shall provide a
10-22 group continuation privilege as required by this subsection. Any
10-23 enrollee whose coverage under the group contract has been
10-24 terminated for any reason except involuntary termination for cause
10-25 and who has been continuously covered under the group contract and
10-26 under any group contract providing similar services and benefits
10-27 which it replaces for at least three consecutive months immediately
10-28 prior to termination shall be entitled to the group continuation
10-29 privilege as outlined in this subsection. Involuntary termination
10-30 for cause does not include termination for any health-related
11-1 cause. Health maintenance organization contracts subject to this
11-2 section shall provide continuation of group coverage for enrollees
11-3 subject to the following eligibility provisions:
11-4 (A) continuation of group coverage must be
11-5 requested in writing not later than the 31st day after the later
11-6 of:
11-7 (i) the date the group coverage would
11-8 otherwise terminate; or
11-9 (ii) the date the enrollee is given notice
11-10 of the right of continuation by either the employer or the group
11-11 contract holder;
11-12 (B) an enrollee electing continuation must pay
11-13 to the group contract holder or employer on a monthly basis, in
11-14 advance, the amount of contribution required by the contract holder
11-15 or employer, plus two percent of the group rate for the coverage
11-16 being continued under the group contract, on the due date of each
11-17 payment;
11-18 (C) the enrollee's written election of
11-19 continuation, together with the first contribution required to
11-20 establish contributions on a monthly basis, in advance, must be
11-21 given to the contract holder or employer not later than the 31st
11-22 day after the later of:
11-23 (i) the date the group coverage would
11-24 otherwise terminate; or
11-25 (ii) the date the enrollee is given notice
11-26 of the right of continuation by either the employer or the group
11-27 contract holder;
11-28 (D) continuation may not terminate until the
11-29 earliest of:
11-30 (i) 180 days after the date the election
12-1 is made;
12-2 (ii) the date on which failure to make
12-3 timely payments would terminate coverage;
12-4 (iii) the date on which the covered person
12-5 is covered for similar services and benefits by another hospital,
12-6 surgical, medical, or major medical expense insurance policy or
12-7 hospital or medical service subscriber contract or medical practice
12-8 or other prepayment plan or any other plan or program; or
12-9 (iv) the date on which the group coverage
12-10 terminates in its entirety; and
12-11 (E) not less than 30 days before the end of the
12-12 180-day period following the date the enrollee elects continuation
12-13 of the contract, the health maintenance organization shall notify
12-14 the enrollee that the enrollee may be eligible for coverage under
12-15 the Texas Health Insurance Risk Pool as provided under Article
12-16 3.77, Insurance Code, and shall provide the address for applying to
12-17 such pool to the enrollee.
12-18 (2) A health maintenance organization may offer to
12-19 each enrollee a conversion contract. Such conversion contract
12-20 shall be issued without evidence of insurability if a written
12-21 application and payment of the first premium are made not later
12-22 than the 31st day after the date of termination. The conversion
12-23 contract shall meet the minimum standards for services and benefits
12-24 for conversion contracts. The commissioner shall issue rules and
12-25 regulations to establish minimum standards for services and
12-26 benefits under contracts issued pursuant to this subsection.
12-27 (3) The premium for a conversion contract issued under
12-28 this Act shall be determined in accordance with the health
12-29 maintenance organization's premium rates for coverage that were
12-30 provided under the group contract or plan. The premium may be
13-1 based on the geographic location of each person to be covered and
13-2 the type of conversion contract and coverage provided. The premium
13-3 for the same coverage under a conversion contract may not exceed
13-4 200 percent of the premium determined in accordance with this
13-5 subdivision. The premium must be based on the type of conversion
13-6 contract and the coverage provided by the contract.
13-7 (l)(1) An individual health care plan provided by a health
13-8 maintenance organization must meet the requirements of this
13-9 subsection.
13-10 (2) For purposes of this subsection, an "individual
13-11 health care plan" means a health care plan:
13-12 (A) which provides health care services for
13-13 individuals and their dependents;
13-14 (B) in which an enrollee pays the premium and is
13-15 not being covered under a contract pursuant to continuation of
13-16 services and benefits provisions applicable under federal or state
13-17 law; and
13-18 (C) in which the evidence of coverage meets the
13-19 requirements of Section 2(a) of this Act.
13-20 (3) A health maintenance organization may limit its
13-21 enrollees to those who live, reside, or work within the service
13-22 area for an individual health care plan.
13-23 (4) An individual health care plan or a conversion
13-24 contract providing health care services shall be renewable with
13-25 respect to an enrollee at the option of the enrollee and may be
13-26 nonrenewed only if:
13-27 (A) premiums or contributions have not been paid
13-28 in accordance with the terms of the plan or the issuer has not
13-29 received timely premium payments;
13-30 (B) fraud or intentional misrepresentation has
14-1 occurred;
14-2 (C) the health maintenance organization is
14-3 ceasing to offer coverage in the individual market in accordance
14-4 with rules established by the commissioner;
14-5 (D) the enrollee no longer lives, resides, or
14-6 works in the area in which the health maintenance organization is
14-7 authorized to provide coverage, but only if coverage is terminated
14-8 under this paragraph uniformly without regard to any health
14-9 status-related factor of covered enrollees; or
14-10 (E) the nonrenewal is in accordance with
14-11 applicable federal law and regulations.
14-12 (5) The commissioner may adopt rules necessary to
14-13 implement this section and to meet the minimum requirements of
14-14 federal law and regulations.
14-15 (6) A health maintenance organization may impose an
14-16 affiliation period as an alternative to a preexisting condition
14-17 limitation. For the purposes of this subdivision, "affiliation
14-18 period" means a period not to exceed 60 days during which no
14-19 premiums shall be collected and coverage issued will not become
14-20 effective. An affiliation period shall be waived for the period an
14-21 individual was covered by qualifying previous coverage, provided
14-22 that the qualifying previous coverage was continuous to a date not
14-23 more than 60 days prior to the effective date of the new coverage.
14-24 An affiliation period must be applied uniformly without regard to
14-25 any health status-related factors.
14-26 (7) A health maintenance organization may not modify
14-27 an individual health care plan with respect to an enrollee or
14-28 dependent through riders or endorsements based on health status or
14-29 claim experience or otherwise restrict or exclude coverage of
14-30 benefits for specific diseases, medical services, or conditions
15-1 otherwise covered by the health benefit plan.
15-2 (8) Denial by a health maintenance organization of an
15-3 application for coverage from an individual shall be in writing and
15-4 shall state the reason or reasons for the denial.
15-5 (9) A health maintenance organization may consider age
15-6 and gender characteristics in determining and establishing the
15-7 schedule of charges for individual coverage. The rating formulas
15-8 and methods for calculating the schedule of charges must be based
15-9 on sound actuarial principles and must produce charges that are not
15-10 excessive, inadequate, or unfairly discriminatory. Benefits must
15-11 be reasonable with respect to the rates produced by the formula or
15-12 method.
15-13 (10) The commissioner shall issue rules and
15-14 regulations to establish minimum standards for benefits and
15-15 determine the percentage increase in the premium rates charged.
15-16 (m) Articles 3.51-14 and 3.51-15, Insurance Code, and
15-17 Subsections (F) and (L), Section 2, Chapter 397, Acts of the 54th
15-18 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code),
15-19 apply to health maintenance organizations.
15-20 SECTION 6. The Texas Health Maintenance Organization Act
15-21 (Article 20A, Vernon's Texas Insurance Code), is amended by adding
15-22 Section 9A to read as follows:
15-23 Sec. 9A. REQUIRED COVERAGE FOR NEWBORNS; ADOPTED CHILDREN.
15-24 (a) Each health maintenance organization that provides coverage
15-25 for health care services for the spouse and dependent children of
15-26 an enrollee or permits the enrollment of any enrollee's immediate
15-27 family or children under a health benefit plan shall not exclude or
15-28 limit the initial coverage of a newborn child for a period of time
15-29 or exclude or limit coverage for congenital defect of a newborn
15-30 child if the child is enrolled in the health care plan not later
16-1 than the 31st day after the date of the child's birth.
16-2 (b) A health maintenance organization that provides coverage
16-3 for the immediate family or children of an enrollee or permits the
16-4 enrollment of any enrollee's immediate family or children under a
16-5 health benefit plan may not exclude from coverage in a health care
16-6 plan a child of an enrollee or limit coverage under the plan to a
16-7 child of an enrollee solely because the child is adopted. The
16-8 health maintenance organization shall provide full coverage under
16-9 the plan to the child without limiting coverage of a preexisting
16-10 condition if the child is enrolled in the plan not later than the
16-11 31st day after the date on which the adoption is final or, for the
16-12 period during which the adoption is not final, not later than the
16-13 31st day after the date on which the enrollee becomes a party in a
16-14 suit in which adoption of the child by the enrollee is sought. For
16-15 the purposes of this subsection, a child is considered to be the
16-16 child of an enrollee if the enrollee is a party in a suit in which
16-17 the adoption of the child by the enrollee is sought.
16-18 SECTION 7. Subchapter E, Chapter 21, Insurance Code, is
16-19 amended by adding Articles 21.53D and 21.53E to read as follows:
16-20 Art. 21.53D. ACCESS TO CERTAIN OBSTETRIC OR GYNECOLOGICAL
16-21 CARE
16-22 Sec. 1. DEFINITION. In this article, "health benefit plan"
16-23 means a plan described by Section 2 of this article.
16-24 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
16-25 health benefit plan that provides benefits for medical or surgical
16-26 expenses incurred as a result of a health condition, accident, or
16-27 sickness, including:
16-28 (1) an individual, group, blanket, or franchise
16-29 insurance policy or insurance agreement, a group hospital service
16-30 contract, or an individual or group evidence of coverage that is
17-1 offered by:
17-2 (A) an insurance company;
17-3 (B) a group hospital service corporation
17-4 operating under Chapter 20 of this code;
17-5 (C) a fraternal benefit society operating under
17-6 Chapter 10 of this code;
17-7 (D) a stipulated premium insurance company
17-8 operating under Chapter 22 of this code; or
17-9 (E) a health maintenance organization operating
17-10 under the Texas Health Maintenance Organization Act (Chapter 20A,
17-11 Vernon's Texas Insurance Code); and
17-12 (2) to the extent permitted by the Employee Retirement
17-13 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
17-14 health benefit plan that is offered by:
17-15 (A) a multiple employer welfare arrangement as
17-16 defined by Section 3, Employee Retirement Income Security Act of
17-17 1974 (29 U.S.C. Section 1002); or
17-18 (B) another analogous benefit arrangement.
17-19 (b) This article does not apply to:
17-20 (1) a plan that provides coverage:
17-21 (A) only for a specified disease;
17-22 (B) only for accidental death or dismemberment;
17-23 (C) for wages or payments in lieu of wages for a
17-24 period during which an employee is absent from work because of
17-25 sickness or injury; or
17-26 (D) as a supplement to liability insurance;
17-27 (2) a plan written under Chapter 26 of this code;
17-28 (3) a Medicare supplemental policy as defined by
17-29 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
17-30 (4) workers' compensation insurance coverage;
18-1 (5) medical payment insurance issued as part of a
18-2 motor vehicle insurance policy; or
18-3 (6) a long-term care policy, including a nursing home
18-4 fixed indemnity policy, unless the commissioner determines that the
18-5 policy provides benefit coverage so comprehensive that the policy
18-6 is a health benefit plan as described by Subsection (a) of this
18-7 section.
18-8 Sec. 3. ACCESS TO CARE. (a) In addition to other benefits
18-9 as authorized by the plan, each health benefit plan shall permit a
18-10 woman who is entitled to coverage under the plan direct access as
18-11 provided by Subsection (b) of this section to primary and
18-12 preventative obstetric and gynecological health care services from
18-13 a qualified provider of those services who is:
18-14 (1) authorized to provide services under the plan; and
18-15 (2) selected by the covered individual.
18-16 (b) The access to health care services required under this
18-17 section includes:
18-18 (1) physical examinations for those obstetric and
18-19 gynecological health care services;
18-20 (2) any care related to pregnancy; and
18-21 (3) any additional services determined to be necessary
18-22 based on a physical examination provided under Subdivision (1) of
18-23 this subsection or as a result of an active gynecological
18-24 condition.
18-25 Sec. 4. LIMITATION; CONSULTATION. (a) A health benefit
18-26 plan may limit the physical examinations provided under Section
18-27 3(b)(1) of this article to two physical examinations per year.
18-28 (b) If a health care provider who provides services to a
18-29 woman under Section 3 of this article is not the woman's primary
18-30 care practitioner and the health benefit plan provides benefits for
19-1 certain specialty health care services only through a referral made
19-2 by a primary care practitioner, the provider shall, in accordance
19-3 with any requirements adopted by that health benefit plan, discuss
19-4 with the woman's primary care practitioner the gynecological health
19-5 care services to be provided and the treatment plan proposed by
19-6 that provider. This subsection does not require that health care
19-7 provider to obtain a referral from the woman's primary care
19-8 practitioner in order to be authorized to provide any additional
19-9 services determined to be necessary under Section 3(b)(3) of this
19-10 article.
19-11 Sec. 5. RESTRICTION ON IMPOSITION OF COPAYMENT OR
19-12 DEDUCTIBLE. A health benefit plan may not impose a copayment or
19-13 deductible for direct access to the health care services of an
19-14 obstetrician or gynecologist under this article unless such an
19-15 additional cost is imposed for access to other health care services
19-16 provided under the plan.
19-17 Sec. 6. NOTICE. Each health benefit plan shall provide to
19-18 persons covered by the plan a timely written notice in clear and
19-19 accurate language of the direct access to health care services
19-20 required by this article.
19-21 Sec. 7. RULES. The commissioner shall adopt rules as
19-22 necessary to implement this article.
19-23 Sec. 8. ADMINISTRATIVE PENALTY. An insurance company,
19-24 health maintenance organization, or other entity that operates a
19-25 health benefit plan in violation of this article is subject to an
19-26 administrative penalty as provided by Article 1.10E of this code.
19-27 Art. 21.53E. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
19-28 CARE FACILITY
19-29 Sec. 1. DEFINITIONS. In this article:
19-30 (1) "Health benefit plan" means a plan that is offered
20-1 by any insurer that provides benefits for medical or surgical
20-2 expenses incurred as a result of a health condition, accident, or
20-3 sickness or that is offered by any insurance company, group
20-4 hospital service corporation subject to Chapter 20 of this code,
20-5 fraternal benefit society subject to Chapter 10 of this code,
20-6 stipulated premium insurance company subject to Chapter 22 of this
20-7 code, health maintenance organization subject to the Texas Health
20-8 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
20-9 Code), or multiple employer welfare arrangement subject to Article
20-10 3.95-1 of this code that delivers or issues for delivery an
20-11 individual, group, blanket, or franchise insurance policy,
20-12 certificate of insurance agreement, a group hospital service
20-13 contract, or individual evidence of coverage. The term does not
20-14 include:
20-15 (A) a plan that provides coverage:
20-16 (i) only for accidental death or
20-17 dismemberment or a specified disease;
20-18 (ii) for wages or payments in lieu of
20-19 wages for a period during which an employee is absent from work
20-20 because of sickness or injury; or
20-21 (iii) as a supplement to liability
20-22 insurance;
20-23 (B) a Medicare supplemental policy as defined by
20-24 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
20-25 (C) workers' compensation insurance coverage;
20-26 (D) medical payment insurance issued as part of
20-27 a motor vehicle insurance policy; or
20-28 (E) a long-term care policy, including a nursing
20-29 home fixed indemnity policy.
20-30 (2) "Provider" means a physician or other
21-1 appropriately licensed health care provider acting within the scope
21-2 of the physician's or other provider's license who attends an
21-3 individual who has given birth or who attends the newborn child.
21-4 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
21-5 FOLLOWING BIRTH; EXCEPTION. (a) A health benefit plan that
21-6 provides maternity benefits, including benefits for childbirth,
21-7 must:
21-8 (1) include coverage for patient care for a mother and
21-9 her newborn child in a health care facility for a minimum of:
21-10 (A) 48 hours following a vaginal delivery; and
21-11 (B) 96 hours following a delivery by caesarean
21-12 section; and
21-13 (2) provide for maternity and pediatric care in
21-14 accordance with guidelines established by the American College of
21-15 Obstetricians and Gynecologists, the American Academy of
21-16 Pediatrics, or other established medical associations.
21-17 (b) Notwithstanding Subsection (a) of this section, the
21-18 hospital length of stay shall be left to the decision of the
21-19 provider in consultation with the mother.
21-20 Sec. 3. RULES. The commissioner shall adopt rules as
21-21 necessary to administer this article.
21-22 SECTION 8. This Act takes effect July 1, 1997, and, except
21-23 as provided by Sections 9 and 10 of this Act, applies only to an
21-24 insurance policy, contract, or evidence of coverage that is issued,
21-25 delivered, or renewed on or after the effective date of this Act.
21-26 A policy, contract, or evidence of coverage that is issued,
21-27 delivered, or renewed before July 1, 1997, is governed by the law
21-28 as it existed immediately before the effective date of this Act,
21-29 and that law is continued in effect for that purpose.
21-30 SECTION 9. The requirements of Article 3.51-15, Insurance
22-1 Code, as added by Section 3 of this Act, apply to an insurance
22-2 policy or evidence of coverage that is issued, delivered, or
22-3 renewed on or after January 1, 1998.
22-4 SECTION 10. The requirements of Articles 21.53D and 21.53E,
22-5 Insurance Code, as added by Section 7 of this Act, apply to an
22-6 insurance policy or evidence of coverage that is issued, delivered,
22-7 or renewed on or after January 1, 1998.
22-8 SECTION 11. The importance of this legislation and the
22-9 crowded condition of the calendars in both houses create an
22-10 emergency and an imperative public necessity that the
22-11 constitutional rule requiring bills to be read on three several
22-12 days in each house be suspended, and this rule is hereby suspended,
22-13 and that this Act take effect and be in force according to its
22-14 terms, and it is so enacted.