By: Zaffirini, et al. S.B. No. 163 A BILL TO BE ENTITLED AN ACT 1-1 relating to coverage under health benefit plans for certain 1-2 supplies and services associated with the treatment of diabetes. 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 adding Article 21.53G to read as follows: 1-6 Art. 21.53G. COVERAGE FOR SUPPLIES AND SERVICES ASSOCIATED 1-7 WITH TREATMENT OF DIABETES 1-8 Sec. 1. DEFINITIONS. In this article: 1-9 (1) "Diabetes equipment" means: 1-10 (A) blood glucose monitors, including monitors 1-11 designed to be used by blind individuals; 1-12 (B) insulin pumps and associated appurtenances; 1-13 (C) insulin infusion devices; and 1-14 (D) podiatric appliances for the prevention of 1-15 complications associated with diabetes. 1-16 (2) "Diabetes supplies" means: 1-17 (A) test strips for blood glucose monitors; 1-18 (B) visual reading and urine test strips; 1-19 (C) lancets and lancet devices; 1-20 (D) insulin and insulin analogs; 1-21 (E) injection aids; 1-22 (F) syringes; 1-23 (G) prescriptive and nonprescriptive oral agents 2-1 for controlling blood sugar levels; and 2-2 (H) glucagon emergency kits. 2-3 (3) "Health benefit plan" means a plan described by 2-4 Section 2 of this article. 2-5 (4) "Qualified insured" means an individual eligible 2-6 for coverage under a health benefit plan who has been diagnosed 2-7 with: 2-8 (A) insulin dependent or noninsulin dependent 2-9 diabetes; 2-10 (B) elevated blood glucose levels induced by 2-11 pregnancy; or 2-12 (C) another medical condition associated with 2-13 elevated blood glucose levels. 2-14 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a 2-15 health benefit plan that: 2-16 (1) provides benefits for medical or surgical expenses 2-17 incurred as a result of a health condition, accident, or sickness, 2-18 including: 2-19 (A) an individual, group, blanket, or franchise 2-20 insurance policy or insurance agreement, a group hospital service 2-21 contract, or an individual or group evidence of coverage that is 2-22 offered by: 2-23 (i) an insurance company; 2-24 (ii) a group hospital service corporation 2-25 operating under Chapter 20 of this code; 3-1 (iii) a fraternal benefit society 3-2 operating under Chapter 10 of this code; 3-3 (iv) a stipulated premium insurance 3-4 company operating under Chapter 22 of this code; 3-5 (v) a reciprocal exchange operating under 3-6 Chapter 19 of this code; or 3-7 (vi) a health maintenance organization 3-8 operating under the Texas Health Maintenance Organization Act 3-9 (Chapter 20A, Vernon's Texas Insurance Code); or 3-10 (B) to the extent permitted by the Employee 3-11 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 3-12 seq.), a health benefit plan that is offered by a multiple employer 3-13 welfare arrangement as defined by Section 3, Employee Retirement 3-14 Income Security Act of 1974 (29 U.S.C. Section 1002); or 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. 3-20 (b) This article does not apply to: 3-21 (1) a plan that provides coverage: 3-22 (A) only for a specified disease or other 3-23 limited benefit; 3-24 (B) only for accidental death or dismemberment; 3-25 (C) for wages or payments in lieu of wages for a 4-1 period during which an employee is absent from work because of 4-2 sickness or injury; 4-3 (D) as a supplement to liability insurance; 4-4 (E) for credit insurance; 4-5 (F) only for dental or vision care; or 4-6 (G) only for indemnity for hospital confinement; 4-7 (2) a small employer plan written under Chapter 26 of 4-8 this code; 4-9 (3) a Medicare supplemental policy as defined by 4-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 4-11 (4) workers' compensation insurance coverage; 4-12 (5) medical payment insurance issued as part of a 4-13 motor vehicle insurance policy; or 4-14 (6) a long-term care policy, including a nursing home 4-15 fixed indemnity policy, unless the commissioner determines that the 4-16 policy provides benefit coverage so comprehensive that the policy 4-17 is a health benefit plan as described by Subsection (a) of this 4-18 section. 4-19 Sec. 3. REQUIRED BENEFIT FOR SUPPLIES AND SERVICES 4-20 ASSOCIATED WITH TREATMENT OF DIABETES. A health benefit plan that 4-21 provides benefits for the treatment of diabetes and associated 4-22 conditions must provide coverage to each qualified insured for: 4-23 (1) diabetes equipment; 4-24 (2) diabetes supplies; and 4-25 (3) diabetes self-management training programs. 5-1 Sec. 4. DIABETES SELF-MANAGEMENT TRAINING. Diabetes 5-2 self-management training under this article must be provided by a 5-3 health care practitioner who is licensed, registered, or certified 5-4 in this state to provide appropriate health care services. 5-5 Self-management training includes: 5-6 (1) training provided to a qualified insured after the 5-7 initial diagnosis of diabetes in the care and management of that 5-8 condition, including nutritional counseling and proper use of 5-9 diabetes equipment and supplies; 5-10 (2) additional training authorized on the diagnosis of 5-11 a physician or other health care practitioner of a significant 5-12 change in the qualified insured's symptoms or condition that 5-13 requires changes in the qualified insured's self-management regime; 5-14 and 5-15 (3) periodic or episodic continuing education training 5-16 when prescribed by an appropriate health care practitioner as 5-17 warranted by the development of new techniques and treatments for 5-18 diabetes. 5-19 Sec. 5. EFFECT OF NEW TREATMENT MODALITIES. In addition to 5-20 the benefits required under Sections 3 and 4 of this article, on 5-21 the approval of the United States Food and Drug Administration of 5-22 new or improved diabetes equipment or diabetes supplies, including 5-23 improved insulin or other prescription drugs, each health benefit 5-24 plan subject to this article must include coverage of the new or 5-25 improved equipment or supplies if medically necessary and 6-1 appropriate as determined by a physician or other health care 6-2 practitioner. 6-3 Sec. 6. LIMITATION. Benefits required under this article 6-4 may be made subject to a deductible, copayment, or coinsurance 6-5 requirement. A deductible, copayment, or coinsurance required by 6-6 the health benefit plan for benefits under this article may not 6-7 exceed the deductible, copayment, or coinsurance required by the 6-8 health benefit plan for treatment of other analogous chronic 6-9 medical conditions. 6-10 Sec. 7. RULES. The commissioner shall adopt rules as 6-11 necessary for the implementation of this article. The commissioner 6-12 may consult with the commissioner of public health and other 6-13 appropriate entities in adopting rules under this section. 6-14 SECTION 2. This Act takes effect September 1, 1997, and 6-15 applies only to a health benefit plan that is delivered, issued for 6-16 delivery, or renewed on or after January 1, 1998. A health benefit 6-17 plan that is delivered, issued for delivery, or renewed before 6-18 January 1, 1998, is governed by the law as it existed immediately 6-19 before the effective date of this Act, and that law is continued in 6-20 effect for that purpose. 6-21 SECTION 3. The importance of this legislation and the 6-22 crowded condition of the calendars in both houses create an 6-23 emergency and an imperative public necessity that the 6-24 constitutional rule requiring bills to be read on three several 6-25 days in each house be suspended, and this rule is hereby suspended.