1-1 By: Zaffirini, et al. S.B. No. 163 1-2 (In the Senate - Filed December 30, 1996; January 14, 1997, 1-3 read first time and referred to Committee on Economic Development; 1-4 April 4, 1997, reported adversely, with favorable Committee 1-5 Substitute by the following vote: Yeas 8, Nays 0; April 4, 1997, 1-6 sent to printer.) 1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 163 By: Lucio 1-8 A BILL TO BE ENTITLED 1-9 AN ACT 1-10 relating to coverage under health benefit plans for certain 1-11 supplies and services associated with the treatment of diabetes. 1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-13 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is 1-14 amended by adding Article 21.53G to read as follows: 1-15 Art. 21.53G. COVERAGE FOR SUPPLIES AND SERVICES ASSOCIATED 1-16 WITH TREATMENT OF DIABETES 1-17 Sec. 1. DEFINITIONS. In this article: 1-18 (1) "Diabetes equipment" means: 1-19 (A) blood glucose monitors, including monitors 1-20 designed to be used by blind individuals; 1-21 (B) insulin pumps and associated appurtenances; 1-22 (C) insulin infusion devices; and 1-23 (D) podiatric appliances for the prevention of 1-24 complications associated with diabetes. 1-25 (2) "Diabetes supplies" means: 1-26 (A) test strips for blood glucose monitors; 1-27 (B) visual reading and urine test strips; 1-28 (C) lancets and lancet devices; 1-29 (D) insulin and insulin analogs; 1-30 (E) injection aids; 1-31 (F) syringes; 1-32 (G) prescriptive and nonprescriptive oral agents 1-33 for controlling blood sugar levels; and 1-34 (H) glucagon emergency kits. 1-35 (3) "Health benefit plan" means a plan described by 1-36 Section 2 of this article. 1-37 (4) "Qualified insured" means an individual eligible 1-38 for coverage under a health benefit plan who has been diagnosed 1-39 with: 1-40 (A) insulin dependent or noninsulin dependent 1-41 diabetes; 1-42 (B) elevated blood glucose levels induced by 1-43 pregnancy; or 1-44 (C) another medical condition associated with 1-45 elevated blood glucose levels. 1-46 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a 1-47 health benefit plan that: 1-48 (1) provides benefits for medical or surgical expenses 1-49 incurred as a result of a health condition, accident, or sickness, 1-50 including: 1-51 (A) an individual, group, blanket, or franchise 1-52 insurance policy or insurance agreement, a group hospital service 1-53 contract, or an individual or group evidence of coverage that is 1-54 offered by: 1-55 (i) an insurance company; 1-56 (ii) a group hospital service corporation 1-57 operating under Chapter 20 of this code; 1-58 (iii) a fraternal benefit society 1-59 operating under Chapter 10 of this code; 1-60 (iv) a stipulated premium insurance 1-61 company operating under Chapter 22 of this code; 1-62 (v) a reciprocal exchange operating under 1-63 Chapter 19 of this code; or 1-64 (vi) a health maintenance organization 2-1 operating under the Texas Health Maintenance Organization Act 2-2 (Chapter 20A, Vernon's Texas Insurance Code); or 2-3 (B) to the extent permitted by the Employee 2-4 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 2-5 seq.), a health benefit plan that is offered by a multiple employer 2-6 welfare arrangement as defined by Section 3, Employee Retirement 2-7 Income Security Act of 1974 (29 U.S.C. Section 1002); or 2-8 (2) is offered by an approved nonprofit health 2-9 corporation that is certified under Section 5.01(a), Medical 2-10 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 2-11 that holds a certificate of authority issued by the commissioner 2-12 under Article 21.52F of this code. 2-13 (b) This article does not apply to: 2-14 (1) a plan that provides coverage: 2-15 (A) only for a specified disease or other 2-16 limited benefit; 2-17 (B) only for accidental death or dismemberment; 2-18 (C) for wages or payments in lieu of wages for a 2-19 period during which an employee is absent from work because of 2-20 sickness or injury; 2-21 (D) as a supplement to liability insurance; 2-22 (E) for credit insurance; 2-23 (F) only for dental or vision care; or 2-24 (G) only for indemnity for hospital confinement; 2-25 (2) a small employer plan written under Chapter 26 of 2-26 this code; 2-27 (3) a Medicare supplemental policy as defined by 2-28 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 2-29 (4) workers' compensation insurance coverage; 2-30 (5) medical payment insurance issued as part of a 2-31 motor vehicle insurance policy; or 2-32 (6) a long-term care policy, including a nursing home 2-33 fixed indemnity policy, unless the commissioner determines that the 2-34 policy provides benefit coverage so comprehensive that the policy 2-35 is a health benefit plan as described by Subsection (a) of this 2-36 section. 2-37 Sec. 3. REQUIRED BENEFIT FOR SUPPLIES AND SERVICES 2-38 ASSOCIATED WITH TREATMENT OF DIABETES. A health benefit plan that 2-39 provides benefits for the treatment of diabetes and associated 2-40 conditions must provide coverage to each qualified insured for: 2-41 (1) diabetes equipment; 2-42 (2) diabetes supplies; and 2-43 (3) diabetes self-management training programs. 2-44 Sec. 4. DIABETES SELF-MANAGEMENT TRAINING. Diabetes 2-45 self-management training under this article must be provided by a 2-46 health care practitioner who is licensed, registered, or certified 2-47 in this state to provide appropriate health care services. 2-48 Self-management training includes: 2-49 (1) training provided to a qualified insured after the 2-50 initial diagnosis of diabetes in the care and management of that 2-51 condition, including nutritional counseling and proper use of 2-52 diabetes equipment and supplies; 2-53 (2) additional training authorized on the diagnosis of 2-54 a physician or other health care practitioner of a significant 2-55 change in the qualified insured's symptoms or condition that 2-56 requires changes in the qualified insured's self-management regime; 2-57 and 2-58 (3) periodic or episodic continuing education training 2-59 when prescribed by an appropriate health care practitioner as 2-60 warranted by the development of new techniques and treatments for 2-61 diabetes. 2-62 Sec. 5. EFFECT OF NEW TREATMENT MODALITIES. In addition to 2-63 the benefits required under Sections 3 and 4 of this article, on 2-64 the approval of the United States Food and Drug Administration of 2-65 new or improved diabetes equipment or diabetes supplies, including 2-66 improved insulin or other prescription drugs, each health benefit 2-67 plan subject to this article must include coverage of the new or 2-68 improved equipment or supplies if medically necessary and 2-69 appropriate as determined by a physician or other health care 3-1 practitioner. 3-2 Sec. 6. LIMITATION. Benefits required under this article 3-3 may be made subject to a deductible, copayment, or coinsurance 3-4 requirement. A deductible, copayment, or coinsurance required by 3-5 the health benefit plan for benefits under this article may not 3-6 exceed the deductible, copayment, or coinsurance required by the 3-7 health benefit plan for treatment of other analogous chronic 3-8 medical conditions. 3-9 Sec. 7. RULES. The commissioner shall adopt rules as 3-10 necessary for the implementation of this article. The commissioner 3-11 may consult with the commissioner of public health and other 3-12 appropriate entities in adopting rules under this section. 3-13 SECTION 2. This Act takes effect September 1, 1997, and 3-14 applies only to a health benefit plan that is delivered, issued for 3-15 delivery, or renewed on or after January 1, 1998. A health benefit 3-16 plan that is delivered, issued for delivery, or renewed before 3-17 January 1, 1998, is governed by the law as it existed immediately 3-18 before the effective date of this Act, and that law is continued in 3-19 effect for that purpose. 3-20 SECTION 3. The importance of this legislation and the 3-21 crowded condition of the calendars in both houses create an 3-22 emergency and an imperative public necessity that the 3-23 constitutional rule requiring bills to be read on three several 3-24 days in each house be suspended, and this rule is hereby suspended. 3-25 * * * * *