By: Zaffirini, et al. S.B. No. 217
A BILL TO BE ENTITLED
AN ACT
1-1 relating to coverage under certain health benefit plans for
1-2 reconstructive surgery incident to a mastectomy.
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 21.53D to read as follows:
1-6 Art. 21.53D. COVERAGE FOR RECONSTRUCTIVE SURGERY AFTER
1-7 MASTECTOMY
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Health benefit plan" means a plan described by
1-10 Section 2 of this article.
1-11 (2) "Breast reconstruction" means reconstruction of a
1-12 breast incident to mastectomy to restore or achieve breast
1-13 symmetry. The term includes surgical reconstruction of a breast on
1-14 which mastectomy surgery has been performed and surgical
1-15 reconstruction of a breast on which mastectomy surgery has not been
1-16 performed.
1-17 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
1-18 health benefit plan that:
1-19 (1) provides benefits for medical or surgical expenses
1-20 incurred as a result of a health condition, accident, or sickness,
1-21 including:
1-22 (A) an individual, group, blanket, or franchise
1-23 insurance policy or insurance agreement, a group hospital service
1-24 contract, or an individual or group evidence of coverage that is
2-1 offered by:
2-2 (i) an insurance company;
2-3 (ii) a group hospital service corporation
2-4 operating under Chapter 20 of this code;
2-5 (iii) a fraternal benefit society
2-6 operating under Chapter 10 of this code;
2-7 (iv) a stipulated premium insurance
2-8 company operating under Chapter 22 of this code; or
2-9 (v) a health maintenance organization
2-10 operating under the Texas Health Maintenance Organization Act
2-11 (Chapter 20A, Vernon's Texas Insurance Code); or
2-12 (B) to the extent permitted by the Employee
2-13 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-14 seq.), a health benefit plan that is offered by:
2-15 (i) a multiple employer welfare
2-16 arrangement as defined by Section 3, Employee Retirement Income
2-17 Security Act of 1974 (29 U.S.C. Section 1002); or
2-18 (ii) another analogous benefit
2-19 arrangement; or
2-20 (2) is offered by an approved nonprofit health
2-21 corporation that is certified under Section 5.01(a), Medical
2-22 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-23 that holds a certificate of authority issued by the commissioner
2-24 under Article 21.52F of this code.
2-25 (b) This article does not apply to:
2-26 (1) a plan that provides coverage:
2-27 (A) only for a specified disease except for
3-1 cancer;
3-2 (B) only for accidental death or dismemberment;
3-3 (C) for wages or payments in lieu of wages for a
3-4 period during which an employee is absent from work because of
3-5 sickness or injury;
3-6 (D) for specified accident, hospital indemnity,
3-7 or other limited benefits health insurance policies;
3-8 (E) for credit insurance;
3-9 (F) only for dental or vision care;
3-10 (G) for hospital confinement indemnity coverage
3-11 only; or
3-12 (H) as a supplement to liability insurance;
3-13 (2) a small employer plan written under Chapter 26 of
3-14 this code;
3-15 (3) a Medicare supplemental policy as defined by
3-16 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-17 (4) workers' compensation insurance coverage;
3-18 (5) medical payment insurance issued as part of a
3-19 motor vehicle insurance policy; or
3-20 (6) a long-term care policy, including a nursing home
3-21 fixed indemnity policy, unless the commissioner determines that the
3-22 policy provides benefit coverage so comprehensive that the policy
3-23 is a health benefit plan as described by Subsection (a) of this
3-24 section.
3-25 Sec. 3. COVERAGE REQUIRED. A health benefit plan that
3-26 provides coverage for mastectomy must provide coverage for breast
3-27 reconstruction. The coverage may be subject to the same deductible
4-1 or copayment applicable to mastectomy.
4-2 Sec. 4. PROHIBITION. A health benefit plan may not offer a
4-3 financial incentive for a patient to forgo breast reconstruction or
4-4 to waive the coverage required by Section 3 of this article.
4-5 Sec. 5. RULES. The commissioner may adopt rules to
4-6 implement this article.
4-7 SECTION 2. This Act takes effect September 1, 1997, and
4-8 applies only to a health benefit plan that is delivered, issued for
4-9 delivery, or renewed on or after January 1, 1998. A health benefit
4-10 plan that is delivered, issued for delivery, or renewed before
4-11 January 1, 1998, is governed by the law as it existed immediately
4-12 before the effective date of this Act, and that law is continued in
4-13 effect for this purpose.
4-14 SECTION 3. The importance of this legislation and the
4-15 crowded condition of the calendars in both houses create an
4-16 emergency and an imperative public necessity that the
4-17 constitutional rule requiring bills to be read on three several
4-18 days in each house be suspended, and this rule is hereby suspended.