By Greenberg H.B. No. 1804
75R5500 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage under certain group health benefit plans for
1-3 infertility.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53I to read as follows:
1-7 Art. 21.53I. COVERAGE FOR INFERTILITY
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Enrollee" means an insured, a subscriber, an
1-10 employee, a member, or another person covered under a group health
1-11 benefit plan.
1-12 (2) "Group health benefit plan" means a group plan
1-13 described by Section 2 of this article.
1-14 (3) "Infertility" means:
1-15 (A) a disease or condition that causes the
1-16 abnormal function of the female reproductive system, resulting in
1-17 the inability to:
1-18 (i) conceive after attempts at conception
1-19 by the use of unprotected sexual intercourse have been made during
1-20 one year; or
1-21 (ii) sustain a pregnancy to a live birth;
1-22 or
1-23 (B) the presence of another demonstrated
1-24 condition recognized by a licensed physician as a cause of the
2-1 inability to conceive or sustain a pregnancy to a live birth.
2-2 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
2-3 group health benefit plan that:
2-4 (1) provides benefits for medical or surgical expenses
2-5 incurred as a result of a health condition, accident, or sickness,
2-6 including:
2-7 (A) a group, blanket, or franchise insurance
2-8 policy or insurance agreement, a group hospital service contract,
2-9 or a group evidence of coverage that is offered by:
2-10 (i) an insurance company;
2-11 (ii) a group hospital service corporation
2-12 operating under Chapter 20 of this code;
2-13 (iii) a fraternal benefit society
2-14 operating under Chapter 10 of this code;
2-15 (iv) a stipulated premium insurance
2-16 company operating under Chapter 22 of this code; or
2-17 (v) a health maintenance organization
2-18 operating under the Texas Health Maintenance Organization Act
2-19 (Chapter 20A, Vernon's Texas Insurance Code); and
2-20 (B) to the extent permitted by the Employee
2-21 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-22 seq.), a health benefit plan that is offered by:
2-23 (i) a multiple employer welfare
2-24 arrangement as defined by Section 3, Employee Retirement Income
2-25 Security Act of 1974 (29 U.S.C. Section 1002); or
2-26 (ii) another analogous benefit
2-27 arrangement;
3-1 (2) is offered by an approved nonprofit health
3-2 corporation that is certified under Section 5.01(a), Medical
3-3 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-4 that holds a certificate of authority issued by the commissioner
3-5 under Article 21.52F of this code; or
3-6 (3) is offered by any other entity not licensed under
3-7 this code or another insurance law of this state that contracts
3-8 directly for health care services on a risk-sharing basis,
3-9 including an entity that contracts for health care services on a
3-10 capitation basis.
3-11 (b) This article does not apply to:
3-12 (1) a plan that provides coverage:
3-13 (A) only for a specified disease;
3-14 (B) only for accidental death or dismemberment;
3-15 (C) for wages or payments in lieu of wages for a
3-16 period during which an employee is absent from work because of
3-17 sickness or injury; or
3-18 (D) as a supplement to liability insurance;
3-19 (2) a plan written under Chapter 26 of this code;
3-20 (3) a Medicare supplemental policy as defined by
3-21 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-22 (4) workers' compensation insurance coverage;
3-23 (5) medical payment insurance issued as part of a
3-24 motor vehicle insurance policy; or
3-25 (6) a long-term care policy, including a nursing home
3-26 fixed indemnity policy, unless the commissioner determines that the
3-27 policy provides benefit coverage so comprehensive that the policy
4-1 is a health benefit plan as described by Subsection (a) of this
4-2 section.
4-3 Sec. 3. COVERAGE REQUIRED. (a) Each group health benefit
4-4 plan subject to this article that otherwise provides coverage for
4-5 pregnancy-related services must provide to enrollees covered by the
4-6 plan coverage for drug therapy for infertility and in vitro
4-7 fertilization.
4-8 (b) Benefits for drug therapy for infertility and in vitro
4-9 fertilization must be provided to the same extent as benefits are
4-10 provided under the group health benefit plan for other
4-11 pregnancy-related services.
4-12 Sec. 4. IN VITRO FERTILIZATION: REQUIRED CONDITIONS.
4-13 Coverage for in vitro fertilization is required only if:
4-14 (1) the patient for the procedure is an enrollee or is
4-15 otherwise covered under the group health benefit plan;
4-16 (2) the patient has been unable to sustain a pregnancy
4-17 to live birth through less costly applicable infertility treatments
4-18 for which coverage is available under the group health benefit
4-19 plan; and
4-20 (3) the procedure is performed at a medical facility
4-21 that conforms to guidelines for in vitro fertilization clinics or
4-22 programs established by:
4-23 (A) the American College of Obstetricians and
4-24 Gynecologists;
4-25 (B) the American Society of Reproductive
4-26 Medicine; or
4-27 (C) another nationally recognized organization
5-1 of obstetricians and gynecologists.
5-2 Sec. 5. EXEMPTION. An issuer of a health benefit plan that
5-3 is owned by or that is part of an entity, group, or order that is
5-4 directly affiliated with a bona fide religious denomination that
5-5 includes as an integral part of its beliefs and practices the tenet
5-6 that drug therapy for infertility or in vitro fertilization
5-7 services are contrary to the moral principles that the religious
5-8 denomination considers to be an essential part of its beliefs is
5-9 exempt from the requirement to offer coverage for that particular
5-10 infertility service.
5-11 SECTION 2. Section 3A, Article 3.51-6, Insurance Code, is
5-12 repealed.
5-13 SECTION 3. This Act takes effect September 1, 1997, and
5-14 applies only to a health benefit plan that is delivered, issued for
5-15 delivery, or renewed on or after January 1, 1998. A health benefit
5-16 plan that is delivered, issued for delivery, or renewed before
5-17 January 1, 1998, is governed by the law as it existed immediately
5-18 before the effective date of this Act, and that law is continued in
5-19 effect for that purpose.
5-20 SECTION 4. 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.