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.