By Van de Putte H.B. No. 2063
75R7995 T
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to managed care coverage for certain health conditions.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-5 amended by amending Article 21.53A to read as follows:
1-6 (a) In this article, "employee benefit plan" means any plan,
1-7 fund, or program heretofore or hereafter established or maintained
1-8 by an employer or by an employee organization, or by both, to the
1-9 extent that such plan, fund, or program was established or is
1-10 maintained for the purpose of providing for its participants or
1-11 their beneficiaries, through the purchase of insurance or
1-12 otherwise, dental care, medical, or surgical benefits in the event
1-13 of accident or sickness.
1-14 (b) [(a)] In this article, "health insurance policy" means
1-15 any individual, group, blanket, or franchise insurance policy,
1-16 insurance agreement, or group hospital service contract that
1-17 provides benefits for dental care, medical, or surgical expenses
1-18 incurred as a result of an accident or sickness.
1-19 (c) [(b)] Each employee benefit plan or health insurance
1-20 policy delivered or issued for delivery in this state that provides
1-21 benefits for the [medically] necessary diagnostic and/or surgical
1-22 treatment of skeletal joints shall [must] include comparable
1-23 benefits for the [medically] necessary diagnostic and/or surgical
1-24 treatment of the temporomandibular (jaw or craniomandibular) joint.
2-1 (d) Each employee benefit plan or health insurance policy
2-2 shall provide specifically for coverage of diagnosis and treatment
2-3 which is necessary and a result of accident, trauma, congenital
2-4 defect, developmental defect or pathology, including surgical and
2-5 nonsurgical procedures for musculoskeletal disorders affecting any
2-6 bone or joint in the face, neck or head. This coverage shall be
2-7 the same as that provided for any other musculoskeletal disorder in
2-8 the body and shall be provided when prescribed or administered by a
2-9 physician or a dentist. This subsection shall not be construed to
2-10 require coverage for dental care services for the diagnosis or
2-11 treatment of disorders or dental pathology primarily affecting the
2-12 gums, teeth, or alveolar ridge.
2-13 (e) An employee benefit plan or health insurance policy may
2-14 not exclude from coverage those patients who cannot undergo dental
2-15 treatment in an office setting or under local anesthesia due to
2-16 documented physical, mental, or medical reasons as determined by
2-17 the patient's physician or the dentist providing the dental care.
2-18 (f) [(c)] All other policy provisions generally applicable
2-19 to surgical treatment may apply, including any requirements for
2-20 precertification of benefits.
2-21 (g) [(d)] This article does not require an employee benefit
2-22 plan or [a] health insurance policy to provide dental services if
2-23 dental services are not otherwise scheduled or provided as a part
2-24 of the policy benefits.
2-25 (h) [(e)] The provisions of this article shall be applicable
2-26 to a health care plan for basic health care services arranged for
2-27 or provided by a health maintenance organization pursuant to
3-1 Chapter 20A of this code.
3-2 SECTION 2. Article 20A.26, Insurance Code, is amended by
3-3 adding Subsection (k) to read as follows:
3-4 (k) Any health maintenance organization authorized under
3-5 this Act shall be subject to Article 21.53A, Chapter 21, Insurance
3-6 Code.
3-7 SECTION 3. Upon the effective date, this Act shall apply to
3-8 all employee benefit plans and health insurance policies as defined
3-9 by Article 21.53A, Insurance Code, as added and amended by this
3-10 Act, that are delivered, issued for delivery, or renewed in this
3-11 state on or after January 1, 1998. Employee benefit plans and
3-12 health insurance policies delivered, issued for delivery, or
3-13 renewed in this state before January 1, 1998, are governed by the
3-14 law that existed immediately before September 1, 1997, and that law
3-15 is continued in effect for that purpose.
3-16 SECTION 4. Upon the effective date, this Act shall apply to
3-17 all health care plans arranged for or provided by a health
3-18 maintenance organization pursuant to Chapter 20A, Insurance Code,
3-19 that are delivered, issued for delivery, or renewed in this state
3-20 on or after January 1, 1998. Such health care plans delivered,
3-21 issued for delivery, or renewed in this state before January 1,
3-22 1998, are governed by the law that existed immediately before
3-23 September 1, 1997, and that law is continued in effect for that
3-24 purpose.
3-25 SECTION 5. EFFECTIVE DATE. This Act takes effect September
3-26 1, 1997.
3-27 SECTION 6. EMERGENCY. The importance of this legislation
4-1 and the crowded condition of the calendars in both houses create an
4-2 emergency and an imperative public necessity that the
4-3 constitutional rule requiring bills to be read on three several
4-4 days in each house be suspended, and this rule is hereby suspended.