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.