By Barrientos S.B. No. 153
75R3041 PB-D
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 postdelivery care following the birth of a
1-4 child.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.53D to read as follows:
1-8 Art. 21.53D. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
1-9 CARE FACILITY AND POSTDELIVERY CARE FOLLOWING BIRTH OF CHILD
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Attending physician" means an obstetrician,
1-12 pediatrician, or other physician who attends a woman who has given
1-13 birth or who attends the newborn child.
1-14 (2) "Health benefit plan" means a plan that provides
1-15 benefits for medical or surgical expenses incurred as a result of a
1-16 health condition, accident, or sickness and that is offered by any
1-17 insurance company, group hospital service corporation, fraternal
1-18 benefit society subject to Chapter 10 of this code, stipulated
1-19 premium company subject to Chapter 22 of this code, or health
1-20 maintenance organization that delivers or issues for delivery an
1-21 individual, group, blanket, or franchise insurance policy or
1-22 insurance agreement, a group hospital service contract, or a group
1-23 or individual evidence of coverage, by a multiple employer welfare
1-24 arrangement as defined by Section 3, Employee Retirement Income
2-1 Security Act of 1974 (29 U.S.C. Section 1002), or by any other
2-2 analogous benefit arrangement to the extent permitted by the
2-3 Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
2-4 1002). The term does not include:
2-5 (A) a plan that provides coverage:
2-6 (i) only for accidental death or
2-7 dismemberment;
2-8 (ii) for wages or payments in lieu of
2-9 wages for a period during which an employee is absent from work
2-10 because of sickness or injury; or
2-11 (iii) as a supplement to liability
2-12 insurance;
2-13 (B) a Medicare supplemental policy as defined by
2-14 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
2-15 (C) workers' compensation insurance coverage;
2-16 (D) medical payment insurance issued as part of
2-17 a motor vehicle insurance policy; or
2-18 (E) a long-term care policy, including a nursing
2-19 home fixed indemnity policy, unless the commissioner determines
2-20 that the policy provides benefit coverage so comprehensive that the
2-21 policy meets the definition of a health benefit plan.
2-22 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
2-23 FOLLOWING BIRTH; EXCEPTIONS. (a) A health benefit plan that
2-24 provides maternity benefits, including benefits for childbirth,
2-25 must include coverage for inpatient care for a mother and her
2-26 newborn child in a health care facility for a minimum of:
2-27 (1) 48 hours following a vaginal delivery; and
3-1 (2) 96 hours following a delivery by caesarean
3-2 section.
3-3 (b) Notwithstanding Subsection (a) of this section, a health
3-4 benefit plan that provides coverage for in-home postdelivery care
3-5 to a mother and her newborn child is not required to provide the
3-6 minimum hours of coverage of inpatient care required under
3-7 Subsection (a) of this section unless that inpatient care is
3-8 determined to be medically necessary by an attending physician or
3-9 is requested by the mother.
3-10 (c) This article does not require a mother who is eligible
3-11 for coverage under a health benefit plan to:
3-12 (1) give birth in a hospital or other health care
3-13 facility; or
3-14 (2) remain under inpatient care in a hospital or other
3-15 health care facility for any fixed term following the birth of a
3-16 child.
3-17 Sec. 3. POSTDELIVERY CARE. (a) If a decision is made to
3-18 discharge a mother and newborn child from inpatient care before the
3-19 expiration of the minimum hours of coverage of inpatient care
3-20 required under Section 2(a) of this article, the health benefit
3-21 plan shall provide coverage for timely postdelivery care. That
3-22 care may be provided to the mother and child by a physician,
3-23 registered nurse, or other appropriate licensed health care
3-24 provider and may be provided at:
3-25 (1) the mother's home, a health care provider's
3-26 office, or a health care facility; or
3-27 (2) another location determined to be appropriate
4-1 under rules adopted by the commissioner.
4-2 (b) The coverage required under Subsection (a) of this
4-3 section must allow the mother the option to have the care provided
4-4 in the mother's home.
4-5 (c) For purposes of this section, "postdelivery care" means
4-6 postpartum health care services provided in accordance with
4-7 accepted maternal and neonatal physical assessments. The term
4-8 includes parent education, assistance and training in breast
4-9 feeding and bottle feeding, and the performance of any necessary
4-10 and appropriate clinical tests. The timeliness of the care shall
4-11 be determined in accordance with recognized medical standards for
4-12 that care.
4-13 Sec. 4. PROHIBITIONS. A health benefit plan may not:
4-14 (1) modify the terms and conditions of coverage based
4-15 on the determination by a person enrolled in the health benefit
4-16 plan to request less than the minimum coverage required under
4-17 Section 2(a) of this article;
4-18 (2) offer to the mother of a newborn child financial
4-19 incentives or other compensation the receipt of which is contingent
4-20 on the waiver by the mother of the minimum hours of coverage of
4-21 inpatient care required under Section 2(a) of this article;
4-22 (3) refuse to accept a physician's recommendation for
4-23 a specified period of inpatient care made in consultation with the
4-24 mother of the newborn child if the period recommended by the
4-25 physician does not exceed the minimum periods recommended in
4-26 guidelines for perinatal care developed by the American College of
4-27 Obstetricians and Gynecologists, the American Academy of
5-1 Pediatrics, or another nationally recognized professional
5-2 association of obstetricians and gynecologists or of pediatricians;
5-3 (4) reduce payments or other forms of reimbursement
5-4 for inpatient care below the usual and customary rate of
5-5 reimbursement for that care; or
5-6 (5) penalize a physician for recommending inpatient
5-7 care for a mother or her newborn child by:
5-8 (A) refusing to allow the physician to
5-9 participate as a provider within the health benefit plan;
5-10 (B) reducing payments made to the physician;
5-11 (C) requiring the physician to provide
5-12 additional documentation or undergo additional utilization review;
5-13 or
5-14 (D) imposing other analogous sanctions or
5-15 disincentives.
5-16 Sec. 5. NOTICE. (a) Each health benefit plan shall provide
5-17 written notice to each enrollee under the plan regarding the
5-18 coverage required by this article. The health benefit plan shall
5-19 provide the notice in accordance with rules adopted by the
5-20 commissioner.
5-21 (b) The notice required under this section must be
5-22 prominently positioned in any literature or correspondence made
5-23 available or distributed by the health benefit plan.
5-24 Sec. 6. RULES. The commissioner shall adopt rules as
5-25 necessary to administer this article.
5-26 SECTION 2. This Act takes effect September 1, 1997, and
5-27 applies only to an insurance policy or evidence of coverage that is
6-1 delivered, issued for delivery, or renewed on or after January 1,
6-2 1998. A policy or evidence of coverage that is delivered, issued
6-3 for delivery, or renewed before January 1, 1998, is governed by the
6-4 law as it existed immediately before the effective date of this
6-5 Act, and that law is continued in effect for that purpose.
6-6 SECTION 3. The importance of this legislation and the
6-7 crowded condition of the calendars in both houses create an
6-8 emergency and an imperative public necessity that the
6-9 constitutional rule requiring bills to be read on three several
6-10 days in each house be suspended, and this rule is hereby suspended.