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.

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