1-1 By: Zaffirini S.B. No. 217 1-2 (In the Senate - Filed January 16, 1997; January 21, 1997, 1-3 read first time and referred to Committee on Economic Development; 1-4 March 25, 1997, reported adversely, with favorable Committee 1-5 Substitute by the following vote: Yeas 10, Nays 0; March 25, 1997, 1-6 sent to printer.) 1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 217 By: Patterson 1-8 A BILL TO BE ENTITLED 1-9 AN ACT 1-10 relating to coverage under certain health benefit plans for 1-11 reconstructive surgery incident to a mastectomy. 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 21.53D to read as follows: 1-15 Art. 21.53D. COVERAGE FOR RECONSTRUCTIVE SURGERY AFTER 1-16 MASTECTOMY 1-17 Sec. 1. DEFINITIONS. In this article: 1-18 (1) "Health benefit plan" means a plan described by 1-19 Section 2 of this article. 1-20 (2) "Breast reconstruction" means reconstruction of a 1-21 breast incident to mastectomy to restore or achieve breast 1-22 symmetry. The term includes surgical reconstruction of a breast on 1-23 which mastectomy surgery has been performed and surgical 1-24 reconstruction of a breast on which mastectomy surgery has not been 1-25 performed. 1-26 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a 1-27 health benefit plan that: 1-28 (1) provides benefits for medical or surgical expenses 1-29 incurred as a result of a health condition, accident, or sickness, 1-30 including: 1-31 (A) an individual, group, blanket, or franchise 1-32 insurance policy or insurance agreement, a group hospital service 1-33 contract, or an individual or group evidence of coverage that is 1-34 offered by: 1-35 (i) an insurance company; 1-36 (ii) a group hospital service corporation 1-37 operating under Chapter 20 of this code; 1-38 (iii) a fraternal benefit society 1-39 operating under Chapter 10 of this code; 1-40 (iv) a stipulated premium insurance 1-41 company operating under Chapter 22 of this code; or 1-42 (v) a health maintenance organization 1-43 operating under the Texas Health Maintenance Organization Act 1-44 (Chapter 20A, Vernon's Texas Insurance Code); or 1-45 (B) to the extent permitted by the Employee 1-46 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 1-47 seq.), a health benefit plan that is offered by: 1-48 (i) a multiple employer welfare 1-49 arrangement as defined by Section 3, Employee Retirement Income 1-50 Security Act of 1974 (29 U.S.C. Section 1002); or 1-51 (ii) another analogous benefit 1-52 arrangement; or 1-53 (2) is offered by an approved nonprofit health 1-54 corporation that is certified under Section 5.01(a), Medical 1-55 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 1-56 that holds a certificate of authority issued by the commissioner 1-57 under Article 21.52F of this code. 1-58 (b) This article does not apply to: 1-59 (1) a plan that provides coverage: 1-60 (A) only for a specified disease except for 1-61 cancer; 1-62 (B) only for accidental death or dismemberment; 1-63 (C) for wages or payments in lieu of wages for a 1-64 period during which an employee is absent from work because of 2-1 sickness or injury; 2-2 (D) for specified accident, hospital indemnity, 2-3 or other limited benefits health insurance policies; 2-4 (E) for credit insurance; 2-5 (F) only for dental or vision care; 2-6 (G) for hospital confinement indemnity coverage 2-7 only; or 2-8 (H) as a supplement to liability insurance; 2-9 (2) a small employer plan written under Chapter 26 of 2-10 this code; 2-11 (3) a Medicare supplemental policy as defined by 2-12 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 2-13 (4) workers' compensation insurance coverage; 2-14 (5) medical payment insurance issued as part of a 2-15 motor vehicle insurance policy; or 2-16 (6) a long-term care policy, including a nursing home 2-17 fixed indemnity policy, unless the commissioner determines that the 2-18 policy provides benefit coverage so comprehensive that the policy 2-19 is a health benefit plan as described by Subsection (a) of this 2-20 section. 2-21 Sec. 3. COVERAGE REQUIRED. A health benefit plan that 2-22 provides coverage for mastectomy must provide coverage for breast 2-23 reconstruction. The coverage may be subject to the same deductible 2-24 or copayment applicable to mastectomy. 2-25 Sec. 4. PROHIBITION. A health benefit plan may not offer a 2-26 financial incentive for a patient to forego breast reconstruction 2-27 or to waive the coverage required by Section 3 of this article. 2-28 Sec. 5. RULES. The commissioner may adopt rules to 2-29 implement this article. 2-30 SECTION 2. This Act takes effect September 1, 1997, and 2-31 applies only to a health benefit plan that is delivered, issued for 2-32 delivery, or renewed on or after January 1, 1998. A health benefit 2-33 plan that is delivered, issued for delivery, or renewed before 2-34 January 1, 1998, is governed by the law as it existed immediately 2-35 before the effective date of this Act, and that law is continued in 2-36 effect for this purpose. 2-37 SECTION 3. The importance of this legislation and the 2-38 crowded condition of the calendars in both houses create an 2-39 emergency and an imperative public necessity that the 2-40 constitutional rule requiring bills to be read on three several 2-41 days in each house be suspended, and this rule is hereby suspended. 2-42 * * * * *