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
1-24 for controlling blood sugar levels; and
2-1 (H) glucagon emergency kits.
2-2 (3) "Health benefit plan" means a plan described by
2-3 Section 2 of this article.
2-4 (4) "Qualified insured" means an individual eligible
2-5 for coverage under a health benefit plan who has been diagnosed
2-6 with:
2-7 (A) insulin dependent or noninsulin dependent
2-8 diabetes;
2-9 (B) elevated blood glucose levels induced by
2-10 pregnancy; or
2-11 (C) another medical condition associated with
2-12 elevated blood glucose levels.
2-13 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
2-14 health benefit plan that:
2-15 (1) provides benefits for medical or surgical expenses
2-16 incurred as a result of a health condition, accident, or sickness,
2-17 including:
2-18 (A) an individual, group, blanket, or franchise
2-19 insurance policy or insurance agreement, a group hospital service
2-20 contract, or an individual or group evidence of coverage that is
2-21 offered by:
2-22 (i) an insurance company;
2-23 (ii) a group hospital service corporation
2-24 operating under Chapter 20 of this code;
2-25 (iii) a fraternal benefit society
2-26 operating under Chapter 10 of this code;
2-27 (iv) a stipulated premium insurance
3-1 company operating under Chapter 22 of this code;
3-2 (v) a reciprocal exchange operating under
3-3 Chapter 19 of this code; or
3-4 (vi) 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 a multiple employer
3-10 welfare arrangement as defined by Section 3, Employee Retirement
3-11 Income Security Act of 1974 (29 U.S.C. Section 1002); or
3-12 (2) is offered by an approved nonprofit health
3-13 corporation that is certified under Section 5.01(a), Medical
3-14 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-15 that holds a certificate of authority issued by the commissioner
3-16 under Article 21.52F of this code.
3-17 (b) This article does not apply to:
3-18 (1) a plan that provides coverage:
3-19 (A) only for a specified disease or other
3-20 limited benefit;
3-21 (B) only for accidental death or dismemberment;
3-22 (C) for wages or payments in lieu of wages for a
3-23 period during which an employee is absent from work because of
3-24 sickness or injury;
3-25 (D) as a supplement to liability insurance;
3-26 (E) for credit insurance;
3-27 (F) only for dental or vision care; or
4-1 (G) only for indemnity for hospital confinement;
4-2 (2) a small employer plan written under Chapter 26 of
4-3 this code;
4-4 (3) a Medicare supplemental policy as defined by
4-5 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
4-6 (4) workers' compensation insurance coverage;
4-7 (5) medical payment insurance issued as part of a
4-8 motor vehicle insurance policy; or
4-9 (6) a long-term care policy, including a nursing home
4-10 fixed indemnity policy, unless the commissioner determines that the
4-11 policy provides benefit coverage so comprehensive that the policy
4-12 is a health benefit plan as described by Subsection (a) of this
4-13 section.
4-14 Sec. 3. REQUIRED BENEFIT FOR SUPPLIES AND SERVICES
4-15 ASSOCIATED WITH TREATMENT OF DIABETES. A health benefit plan that
4-16 provides benefits for the treatment of diabetes and associated
4-17 conditions must provide coverage to each qualified insured for:
4-18 (1) diabetes equipment;
4-19 (2) diabetes supplies; and
4-20 (3) diabetes self-management training programs.
4-21 Sec. 4. DIABETES SELF-MANAGEMENT TRAINING. Diabetes
4-22 self-management training under this article must be provided by a
4-23 health care practitioner who is licensed, registered, or certified
4-24 in this state to provide appropriate health care services.
4-25 Self-management training includes:
4-26 (1) training provided to a qualified insured after the
4-27 initial diagnosis of diabetes in the care and management of that
5-1 condition, including nutritional counseling and proper use of
5-2 diabetes equipment and supplies;
5-3 (2) additional training authorized on the diagnosis of
5-4 a physician or other health care practitioner of a significant
5-5 change in the qualified insured's symptoms or condition that
5-6 requires changes in the qualified insured's self-management regime;
5-7 and
5-8 (3) periodic or episodic continuing education training
5-9 when prescribed by an appropriate health care practitioner as
5-10 warranted by the development of new techniques and treatments for
5-11 diabetes.
5-12 Sec. 5. EFFECT OF NEW TREATMENT MODALITIES. In addition to
5-13 the benefits required under Sections 3 and 4 of this article, on
5-14 the approval of the United States Food and Drug Administration of
5-15 new or improved diabetes equipment or diabetes supplies, including
5-16 improved insulin or other prescription drugs, each health benefit
5-17 plan subject to this article must include coverage of the new or
5-18 improved equipment or supplies if medically necessary and
5-19 appropriate as determined by a physician or other health care
5-20 practitioner.
5-21 Sec. 6. LIMITATION. Benefits required under this article
5-22 may be made subject to a deductible, copayment, or coinsurance
5-23 requirement. A deductible, copayment, or coinsurance required by
5-24 the health benefit plan for benefits under this article may not
5-25 exceed the deductible, copayment, or coinsurance required by the
5-26 health benefit plan for treatment of other analogous chronic
5-27 medical conditions.
6-1 Sec. 7. RULES. The commissioner shall adopt rules as
6-2 necessary for the implementation of this article. The commissioner
6-3 may consult with the commissioner of public health and other
6-4 appropriate entities in adopting rules under this section.
6-5 SECTION 2. This Act takes effect September 1, 1997, and
6-6 applies only to a health benefit plan that is delivered, issued for
6-7 delivery, or renewed on or after January 1, 1998. A health benefit
6-8 plan that is delivered, issued for delivery, or renewed before
6-9 January 1, 1998, is governed by the law as it existed immediately
6-10 before the effective date of this Act, and that law is continued in
6-11 effect for that purpose.
6-12 SECTION 3. The importance of this legislation and the
6-13 crowded condition of the calendars in both houses create an
6-14 emergency and an imperative public necessity that the
6-15 constitutional rule requiring bills to be read on three several
6-16 days in each house be suspended, and this rule is hereby suspended.