By Van de Putte H.B. No. 2063
75R10583 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage under a group health benefit plan for
1-3 diagnosis and treatment of certain conditions affecting the
1-4 temporomandibular joint.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Article 21.53A, Insurance Code, is amended to
1-7 read as follows:
1-8 Art. 21.53A. BENEFITS FOR CERTAIN BONE AND JOINT PROCEDURES
1-9 Sec. 1. DEFINITION. [(a)] In this article, "health
1-10 benefit plan" means a plan described by Section 2 of this article.
1-11 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
1-12 group health benefit plan that:
1-13 (1) provides benefits for dental, medical, or surgical
1-14 expenses incurred as a result of a health condition, accident, or
1-15 sickness, including:
1-16 (A) a group, blanket, or franchise insurance
1-17 policy or insurance agreement, a group hospital service contract,
1-18 or a group evidence of coverage that is offered by:
1-19 (i) an insurance company;
1-20 (ii) a group hospital service corporation
1-21 operating under Chapter 20 of this code;
1-22 (iii) a fraternal benefit society
1-23 operating under Chapter 10 of this code;
1-24 (iv) a stipulated premium insurance
2-1 company operating under Chapter 22 of this code;
2-2 (v) a small employer plan written under
2-3 Chapter 26 of this code; or
2-4 (vi) a health maintenance organization
2-5 operating under the Texas Health Maintenance Organization Act
2-6 (Chapter 20A, Vernon's Texas Insurance Code); or
2-7 (B) to the extent permitted by the Employee
2-8 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-9 seq.), a health benefit plan that is offered by:
2-10 (i) a multiple employer welfare
2-11 arrangement as defined by Section 3, Employee Retirement Income
2-12 Security Act of 1974 (29 U.S.C. Section 1002);
2-13 (ii) any other entity not licensed under
2-14 this code or another insurance law of this state that contracts
2-15 directly for health care services on a risk-sharing basis,
2-16 including an entity that contracts for health care services on a
2-17 capitation basis; or
2-18 (iii) another analogous benefit
2-19 arrangement; or
2-20 (2) is offered by an approved nonprofit health
2-21 corporation that is certified under Section 5.01(a), Medical
2-22 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-23 that holds a certificate of authority issued by the commissioner
2-24 under Article 21.52F of this code.
2-25 (b) This article does not apply to:
2-26 (1) a plan that provides coverage:
2-27 (A) only for a specified disease or other
3-1 limited benefit;
3-2 (B) only for accidental death or dismemberment;
3-3 (C) for wages or payments in lieu of wages for a
3-4 period during which an employee is absent from work because of
3-5 sickness or injury;
3-6 (D) as a supplement to liability insurance;
3-7 (E) for credit insurance;
3-8 (F) only for vision care; or
3-9 (G) only for indemnity for hospital confinement;
3-10 (2) a Medicare supplemental policy as defined by
3-11 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-12 (3) workers' compensation insurance coverage;
3-13 (4) medical payment insurance issued as part of a
3-14 motor vehicle insurance policy; or
3-15 (5) a long-term care policy, including a nursing home
3-16 fixed indemnity policy, unless the commissioner determines that the
3-17 policy provides benefit coverage so comprehensive that the policy
3-18 is a health benefit plan as described by Subsection (a) of this
3-19 section [insurance policy" means any individual, group, blanket, or
3-20 franchise insurance policy, insurance agreement, or group hospital
3-21 service contract that provides benefits for medical or surgical
3-22 expenses incurred as a result of accident or sickness].
3-23 Sec. 3. REQUIRED BENEFIT FOR DIAGNOSIS AND TREATMENT
3-24 AFFECTING TEMPOROMANDIBULAR JOINT. (a) [(b)] Each health benefit
3-25 plan [insurance policy] delivered or issued for delivery in this
3-26 state that provides benefits for the medically necessary diagnostic
3-27 or [and/or] surgical treatment of skeletal joints must provide
4-1 [include] comparable coverage as provided by this article
4-2 [benefits] for the medically necessary diagnostic or [and/or]
4-3 surgical treatment of conditions affecting the temporomandibular
4-4 [(jaw or craniomandibular)] joint. For purposes of this section,
4-5 the temporomandibular joint includes the jaw and the
4-6 craniomandibular joint.
4-7 (b) Each health benefit plan shall provide coverage under
4-8 this article for diagnosis or surgical treatment medically
4-9 necessary as a result of:
4-10 (1) an accident;
4-11 (2) a trauma;
4-12 (3) a congenital defect;
4-13 (4) a developmental defect; or
4-14 (5) a pathology.
4-15 (c) All other [policy] provisions generally applicable to
4-16 surgical treatment under the health benefit plan may be applied to
4-17 the benefits required under this article [apply], including any
4-18 requirements for precertification of benefits.
4-19 Sec. 4. DENTAL SERVICES. (a) [(d)] This article does not
4-20 require a health benefit plan [insurance policy] to provide dental
4-21 services if dental services are not otherwise scheduled or provided
4-22 as a part of the [policy] benefits covered under the health benefit
4-23 plan.
4-24 (b) A health benefit plan may not exclude from coverage
4-25 under the plan an individual who is unable to undergo dental
4-26 treatment in an office setting or under local anesthesia due to a
4-27 documented physical, mental, or medical reason as determined by the
5-1 individual's physician or the dentist providing the dental care.
5-2 [(e) The provisions of this article shall be applicable to a
5-3 health care plan for basic health care services arranged for or
5-4 provided by a health maintenance organization pursuant to Chapter
5-5 20A of this code.]
5-6 SECTION 2. This Act takes effect September 1, 1997, and
5-7 applies only to a group health benefit plan that is delivered,
5-8 issued for delivery, or renewed on or after January 1, 1998. A
5-9 group health benefit plan that is delivered, issued for delivery,
5-10 or renewed before January 1, 1998, is governed by the law as it
5-11 existed immediately before the effective date of this Act, and that
5-12 law is continued in effect for that purpose.
5-13 SECTION 3. The importance of this legislation and the
5-14 crowded condition of the calendars in both houses create an
5-15 emergency and an imperative public necessity that the
5-16 constitutional rule requiring bills to be read on three several
5-17 days in each house be suspended, and this rule is hereby suspended.