By Nelson S.B. No. 40
75R591 PB-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to minimum coverage under certain health benefit plans for
1-3 inpatient stays and postpartum care following the birth of a child.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53D to read as follows:
1-7 Art. 21.53D. BENEFITS FOR MINIMUM INPATIENT STAY IN HEALTH
1-8 CARE FACILITY AND CERTAIN INPATIENT AND OUTPATIENT POSTPARTUM CARE
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Health benefit plan" means a plan that is offered
1-11 by an insurer that provides benefits for medical or surgical
1-12 expenses incurred as a result of a health condition, accident, or
1-13 sickness, including expenses incurred as a result of a pregnancy.
1-14 (2) "Insurer" means an insurance company, a group
1-15 hospital service corporation, or a health maintenance organization
1-16 that delivers or issues for delivery an individual, group, blanket,
1-17 or franchise insurance policy or insurance agreement, a group
1-18 hospital service contract, or an evidence of coverage.
1-19 (3) "Licensed health care provider" means a physician,
1-20 registered nurse, or other appropriately licensed health care
1-21 provider whose scope of practice includes providing postpartum
1-22 care.
1-23 (4) "Postpartum care" means health care services
2-1 provided in accordance with accepted maternal and neonatal physical
2-2 assessments. The term includes parent education, assistance and
2-3 training in breast feeding and bottle feeding, and the performance
2-4 of any necessary and appropriate clinical tests.
2-5 (5) "Treating physician" means an obstetrician,
2-6 pediatrician, or other physician who attends a woman who has given
2-7 birth or who attends the newborn child.
2-8 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
2-9 FOLLOWING BIRTH; EXCEPTION. (a) A health benefit plan that
2-10 provides maternity benefits, including benefits for childbirth,
2-11 must include coverage for:
2-12 (1) inpatient care for a mother and her newborn child
2-13 in a health care facility for a minimum of:
2-14 (A) 48 hours following a vaginal delivery
2-15 without complications; and
2-16 (B) 96 hours following a delivery by caesarean
2-17 section without complications; and
2-18 (2) if childbirth occurs at home, postpartum home
2-19 care.
2-20 (b) Notwithstanding Subsection (a) of this section, a health
2-21 benefit plan is not required to provide the minimum hours of
2-22 coverage of inpatient care required under Subsection (a) of this
2-23 section if the treating physician determines that the mother and
2-24 newborn child meet medical criteria contained in guidelines
2-25 developed by, or in cooperation with, recognized professional
2-26 organizations of physicians, including organizations such as the
3-1 American Academy of Pediatrics or the American College of
3-2 Obstetricians and Gynecologists, that establish standards for the
3-3 appropriate length of an inpatient stay based on:
3-4 (1) the antepartum, intrapartum, and postpartum course
3-5 of the mother and newborn child;
3-6 (2) the gestational stage, birth weight, and clinical
3-7 condition of the newborn child;
3-8 (3) the demonstrated ability of the mother to care for
3-9 the newborn child after discharge; and
3-10 (4) the availability of post discharge follow-up care
3-11 to evaluate the condition of the newborn child in the first 48
3-12 hours after discharge.
3-13 Sec. 3. POSTPARTUM CARE REQUIREMENTS. (a) Each health
3-14 benefit plan shall provide coverage for inpatient or outpatient
3-15 postpartum care, as applicable.
3-16 (b) Postpartum care shall be provided to the mother and
3-17 child by a licensed health care provider. Postpartum care provided
3-18 on an outpatient basis shall be provided at the election of the
3-19 mother at the mother's home, a health care provider's office, or a
3-20 health care facility.
3-21 (c) If the childbirth occurs at home, the postpartum care
3-22 must include one home visit per day within 48 hours of the delivery
3-23 by a licensed health care provider.
3-24 Sec. 4. SUPPLEMENTARY REIMBURSEMENT. If the coverage
3-25 required by this article is provided under a contract that is
3-26 subject to a capitated or per discharge rate of reimbursement, the
4-1 health plan must provide supplementary reimbursement to a licensed
4-2 health care provider who provides additional services required by
4-3 that coverage.
4-4 Sec. 5. PROHIBITIONS. A health benefit plan may not:
4-5 (1) reduce payments or other forms of reimbursement
4-6 for inpatient care below the usual and customary rate of
4-7 reimbursement for that care; or
4-8 (2) penalize a physician for recommending inpatient
4-9 care for a mother or her newborn child by:
4-10 (A) refusing to allow the physician to
4-11 participate as a provider within the health benefit plan;
4-12 (B) reducing payments made to the physician;
4-13 (C) requiring the physician to provide
4-14 additional documentation or undergo additional utilization review;
4-15 or
4-16 (D) imposing other analogous sanctions or
4-17 disincentives.
4-18 Sec. 6. NOTICE. (a) Each health benefit plan shall provide
4-19 written notice to each enrollee under the plan regarding the
4-20 coverage required by this article. The health benefit plan shall
4-21 provide the notice in accordance with rules adopted by the
4-22 commissioner.
4-23 (b) The notice required under Subsection (a) of this section
4-24 must be prominently positioned in appropriate literature or
4-25 correspondence made available or distributed by the health benefit
4-26 plan.
5-1 (c) In addition to the notice required under Subsection (a)
5-2 of this section, the insurer shall provide written notice of the
5-3 coverage to an enrollee during the course of the enrollee's
5-4 prenatal care.
5-5 Sec. 7. RULES. The commissioner shall adopt rules as
5-6 necessary to administer this article.
5-7 SECTION 2. The notice required under Section 6(a), Article
5-8 21.53D, Insurance Code, as added by this Act, must be transmitted
5-9 to each person enrolled in a health benefit plan subject to that
5-10 article not later than the earlier of:
5-11 (1) the date of the next mailing scheduled to be made
5-12 by the plan to the enrollee after January 1, 1998;
5-13 (2) the next yearly informational packet scheduled to
5-14 be sent to the enrollee after January 1, 1998; or
5-15 (3) February 1, 1998.
5-16 SECTION 3. This Act takes effect September 1, 1997, and
5-17 applies only to an insurance policy or evidence of coverage that is
5-18 delivered, issued for delivery, or renewed on or after January 1,
5-19 1998. A policy or evidence of coverage that is delivered, issued
5-20 for delivery, or renewed before January 1, 1998, is governed by the
5-21 law as it existed immediately before the effective date of this
5-22 Act, and that law is continued in effect for that purpose.
5-23 SECTION 4. The importance of this legislation and the
5-24 crowded condition of the calendars in both houses create an
5-25 emergency and an imperative public necessity that the
5-26 constitutional rule requiring bills to be read on three several
6-1 days in each house be suspended, and this rule is hereby suspended.