1-1 By: Van de Putte (Senate Sponsor - Cain) H.B. No. 2063
1-2 (In the Senate - Received from the House May 12, 1997;
1-3 May 13, 1997, read first time and referred to Committee on Economic
1-4 Development; May 17, 1997, reported favorably by the following
1-5 vote: Yeas 7, Nays 0; May 17, 1997, sent to printer.)
1-6 A BILL TO BE ENTITLED
1-7 AN ACT
1-8 relating to coverage under a group health benefit plan for
1-9 diagnosis and treatment of certain conditions affecting the
1-10 temporomandibular joint.
1-11 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-12 SECTION 1. Article 21.53A, Insurance Code, is amended to
1-13 read as follows:
1-14 Art. 21.53A. BENEFITS FOR CERTAIN BONE AND JOINT PROCEDURES
1-15 Sec. 1. DEFINITION. [(a)] In this article, "health
1-16 benefit plan" means a plan described by Section 2 of this article.
1-17 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
1-18 group health benefit plan that:
1-19 (1) provides benefits for dental, medical, or surgical
1-20 expenses incurred as a result of a health condition, accident, or
1-21 sickness, including:
1-22 (A) a group, blanket, or franchise insurance
1-23 policy or insurance agreement, a group hospital service contract,
1-24 or a group evidence of coverage that is offered by:
1-25 (i) an insurance company;
1-26 (ii) a group hospital service corporation
1-27 operating under Chapter 20 of this code;
1-28 (iii) a fraternal benefit society
1-29 operating under Chapter 10 of this code;
1-30 (iv) a stipulated premium insurance
1-31 company operating under Chapter 22 of this code;
1-32 (v) a small employer plan written under
1-33 Chapter 26 of this code; or
1-34 (vi) a health maintenance organization
1-35 operating under the Texas Health Maintenance Organization Act
1-36 (Chapter 20A, Vernon's Texas Insurance Code); or
1-37 (B) to the extent permitted by the Employee
1-38 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
1-39 seq.), a health benefit plan that is offered by:
1-40 (i) a multiple employer welfare
1-41 arrangement as defined by Section 3, Employee Retirement Income
1-42 Security Act of 1974 (29 U.S.C. Section 1002);
1-43 (ii) any other entity not licensed under
1-44 this code or another insurance law of this state that contracts
1-45 directly for health care services on a risk-sharing basis,
1-46 including an entity that contracts for health care services on a
1-47 capitation basis; or
1-48 (iii) another analogous benefit
1-49 arrangement; or
1-50 (2) is offered by an approved nonprofit health
1-51 corporation that is certified under Section 5.01(a), Medical
1-52 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
1-53 that holds a certificate of authority issued by the commissioner
1-54 under Article 21.52F of this code.
1-55 (b) This article does not apply to:
1-56 (1) a plan that provides coverage:
1-57 (A) only for a specified disease or other
1-58 limited benefit;
1-59 (B) only for accidental death or dismemberment;
1-60 (C) for wages or payments in lieu of wages for a
1-61 period during which an employee is absent from work because of
1-62 sickness or injury;
1-63 (D) as a supplement to liability insurance;
1-64 (E) for credit insurance;
2-1 (F) only for vision care; or
2-2 (G) only for indemnity for hospital confinement;
2-3 (2) a Medicare supplemental policy as defined by
2-4 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
2-5 (3) workers' compensation insurance coverage;
2-6 (4) medical payment insurance issued as part of a
2-7 motor vehicle insurance policy; or
2-8 (5) a long-term care policy, including a nursing home
2-9 fixed indemnity policy, unless the commissioner determines that the
2-10 policy provides benefit coverage so comprehensive that the policy
2-11 is a health benefit plan as described by Subsection (a) of this
2-12 section [insurance policy" means any individual, group, blanket, or
2-13 franchise insurance policy, insurance agreement, or group hospital
2-14 service contract that provides benefits for medical or surgical
2-15 expenses incurred as a result of accident or sickness].
2-16 Sec. 3. REQUIRED BENEFIT FOR DIAGNOSIS AND TREATMENT
2-17 AFFECTING TEMPOROMANDIBULAR JOINT. (a) [(b)] Each health benefit
2-18 plan [insurance policy] delivered or issued for delivery in this
2-19 state that provides benefits for the medically necessary diagnostic
2-20 or [and/or] surgical treatment of skeletal joints must provide
2-21 [include] comparable coverage as provided by this article
2-22 [benefits] for the medically necessary diagnostic or [and/or]
2-23 surgical treatment of conditions affecting the temporomandibular
2-24 [(jaw or craniomandibular)] joint. For purposes of this section,
2-25 the temporomandibular joint includes the jaw and the
2-26 craniomandibular joint.
2-27 (b) Each health benefit plan shall provide coverage under
2-28 this article for diagnosis or surgical treatment medically
2-29 necessary as a result of:
2-30 (1) an accident;
2-31 (2) a trauma;
2-32 (3) a congenital defect;
2-33 (4) a developmental defect; or
2-34 (5) a pathology.
2-35 (c) All other [policy] provisions generally applicable to
2-36 surgical treatment under the health benefit plan may be applied to
2-37 the benefits required under this article [apply], including any
2-38 requirements for precertification of benefits.
2-39 Sec. 4. DENTAL SERVICES. (a) [(d)] This article does not
2-40 require a health benefit plan [insurance policy] to provide dental
2-41 services if dental services are not otherwise scheduled or provided
2-42 as a part of the [policy] benefits covered under the health benefit
2-43 plan.
2-44 (b) A health benefit plan may not exclude from coverage
2-45 under the plan an individual who is unable to undergo dental
2-46 treatment in an office setting or under local anesthesia due to a
2-47 documented physical, mental, or medical reason as determined by the
2-48 individual's physician or the dentist providing the dental care.
2-49 [(e) The provisions of this article shall be applicable to a
2-50 health care plan for basic health care services arranged for or
2-51 provided by a health maintenance organization pursuant to Chapter
2-52 20A of this code.]
2-53 SECTION 2. This Act takes effect September 1, 1997, and
2-54 applies only to a group health benefit plan that is delivered,
2-55 issued for delivery, or renewed on or after January 1, 1998. A
2-56 group health benefit plan that is delivered, issued for delivery,
2-57 or renewed before January 1, 1998, is governed by the law as it
2-58 existed immediately before the effective date of this Act, and that
2-59 law is continued in effect for that purpose.
2-60 SECTION 3. The importance of this legislation and the
2-61 crowded condition of the calendars in both houses create an
2-62 emergency and an imperative public necessity that the
2-63 constitutional rule requiring bills to be read on three several
2-64 days in each house be suspended, and this rule is hereby suspended.
2-65 * * * * *