By Davila H.B. No. 3187
75R7567 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to benefits for the detection and prevention of
1-3 osteoporosis under health benefit plans.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 21.53C, Insurance Code, is amended to
1-6 read as follows:
1-7 Art. 21.53C. BENEFITS FOR DETECTION AND PREVENTION OF
1-8 OSTEOPOROSIS UNDER HEALTH BENEFIT PLANS [GROUP POLICIES]
1-9 Sec. 1. DEFINITIONS. [(a)] In this article:
1-10 (1) "Bone mass measurement" means a radiologic or
1-11 radioisotopic procedure or other scientifically proven technology
1-12 that is performed on an individual to:
1-13 (A) identify bone mass or bone quality; or
1-14 (B) detect bone loss.
1-15 (2) "Enrollee" means an individual enrolled in a
1-16 health benefit plan.
1-17 (3) "Health benefit plan" means a plan described by
1-18 Section 2 of this article.
1-19 (4) [, "group health insurance policy" means a group
1-20 insurance policy, group hospital service contract, or group
1-21 contract issued by a health maintenance organization that is
1-22 delivered, issued for delivery, or renewed in this state and that
1-23 provides benefits for medical or surgical expenses incurred as a
1-24 result of accident or sickness.]
2-1 [(b)] "Qualified individual" means:
2-2 (A) an estrogen-deficient [(1) a postmenopausal]
2-3 woman at clinical risk of osteoporosis [who is not receiving
2-4 estrogen replacement therapy];
2-5 (B) [(2)] an individual with:
2-6 (i) [(A)] vertebral abnormalities; or
2-7 (ii) [(B)] primary hyperparathyroidism[;
2-8 or]
2-9 [(C) a history of bone fractures]; or
2-10 (C) [(3)] an individual who is:
2-11 (i) [(A)] receiving long-term
2-12 glucocorticoid therapy; or
2-13 (ii) [(B)] being monitored to assess the
2-14 response to or efficacy of an approved osteoporosis drug therapy.
2-15 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
2-16 health benefit plan that:
2-17 (1) provides benefits for medical or surgical expenses
2-18 incurred as a result of a health condition, accident, or sickness,
2-19 including:
2-20 (A) an individual, group, blanket, or franchise
2-21 insurance policy or insurance agreement, a group hospital service
2-22 contract, or an individual or group evidence of coverage that is
2-23 offered by:
2-24 (i) an insurance company;
2-25 (ii) a group hospital service corporation
2-26 operating under Chapter 20 of this code;
2-27 (iii) a fraternal benefit society
3-1 operating under Chapter 10 of this code;
3-2 (iv) a stipulated premium insurance
3-3 company operating under Chapter 22 of this code; or
3-4 (v) a health maintenance organization
3-5 operating under the Texas Health Maintenance Organization Act
3-6 (Chapter 20A, Vernon's Texas Insurance Code); or
3-7 (B) to the extent permitted by the Employee
3-8 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
3-9 seq.), a health benefit plan that is offered by:
3-10 (i) a multiple employer welfare
3-11 arrangement as defined by Section 3, Employee Retirement Income
3-12 Security Act of 1974 (29 U.S.C. Section 1002); or
3-13 (ii) another analogous benefit
3-14 arrangement;
3-15 (2) is offered by an approved nonprofit health
3-16 corporation that is certified under Section 5.01(a), Medical
3-17 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-18 that holds a certificate of authority issued by the commissioner
3-19 under Article 21.52F of this code; or
3-20 (3) is offered by any other entity not licensed under
3-21 this code or another insurance law of this state that contracts
3-22 directly for health care services on a risk-sharing basis,
3-23 including an entity that contracts for health care services on a
3-24 capitation basis, to the extent permitted by the Employee
3-25 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
3-26 seq.).
3-27 (b) This article does not apply to:
4-1 (1) a plan that provides coverage:
4-2 (A) only for a specified disease;
4-3 (B) only for accidental death or dismemberment;
4-4 (C) for wages or payments in lieu of wages for a
4-5 period during which an employee is absent from work because of
4-6 sickness or injury; or
4-7 (D) as a supplement to liability insurance;
4-8 (2) a small employer health benefit plan written under
4-9 Chapter 26 of this code;
4-10 (3) a Medicare supplemental policy as defined by
4-11 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
4-12 (4) workers' compensation insurance coverage;
4-13 (5) medical payment insurance issued as part of a
4-14 motor vehicle insurance policy; or
4-15 (6) a long-term care policy, including a nursing home
4-16 fixed indemnity policy, unless the commissioner determines that the
4-17 policy provides benefit coverage so comprehensive that the policy
4-18 is a health benefit plan as described by Subsection (a) of this
4-19 section.
4-20 Sec. 3. OSTEOPOROSIS BENEFITS. (a) In addition to other
4-21 benefits provided under the plan, each health benefit plan shall
4-22 provide to an enrollee who is [(c) A group health insurance policy
4-23 must provide coverage for] a qualified individual coverage under
4-24 the plan [covered by the policy] for [medically accepted] bone mass
4-25 measurement for the prevention, diagnosis, and treatment [detection
4-26 of low bone mass and to determine the person's risk] of
4-27 osteoporosis [and fractures associated with osteoporosis].
5-1 (b) Each health benefit plan shall identify and use
5-2 up-to-date, scientifically accurate educational materials to
5-3 increase patient awareness and knowledge and encourage the
5-4 prevention and treatment of osteoporosis. The plan shall make
5-5 those materials accessible to each enrollee who is treated for
5-6 osteoporosis and to other enrollees who are qualified individuals.
5-7 Sec. 4. RULES. The commissioner shall adopt rules as
5-8 necessary to implement and enforce this article.
5-9 SECTION 2. Article 21.53C, Insurance Code, as amended by
5-10 this Act, applies only to a health benefit plan delivered, issued
5-11 for delivery, or renewed on or after January 1, 1998. A health
5-12 benefit plan delivered, issued for delivery, or renewed before
5-13 January 1, 1998, is governed by the law as it existed immediately
5-14 before the effective date of this Act, and that law is continued in
5-15 effect for that purpose.
5-16 SECTION 3. This Act takes effect September 1, 1997.
5-17 SECTION 4. The importance of this legislation and the
5-18 crowded condition of the calendars in both houses create an
5-19 emergency and an imperative public necessity that the
5-20 constitutional rule requiring bills to be read on three several
5-21 days in each house be suspended, and this rule is hereby suspended.