AN ACT 1-1 relating to coverage under certain health benefit plans of tests 1-2 for the detection of prostate cancer. 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 21.53F to read as follows: 1-6 Art. 21.53F. COVERAGE OF CERTAIN TESTS FOR DETECTION OF 1-7 PROSTATE CANCER 1-8 Sec. 1. DEFINITION. In this article, "health benefit plan" 1-9 means a plan described by Section 2 of this article. 1-10 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a 1-11 health benefit plan that: 1-12 (1) provides benefits for medical or surgical expenses 1-13 incurred as a result of a health condition, accident, or sickness, 1-14 including: 1-15 (A) an individual, group, blanket, or franchise 1-16 insurance policy or insurance agreement, a group hospital service 1-17 contract, or an individual or group evidence of coverage that is 1-18 offered by: 1-19 (i) an insurance company; 1-20 (ii) a group hospital service corporation 1-21 operating under Chapter 20 of this code; 1-22 (iii) a fraternal benefit society 1-23 operating under Chapter 10 of this code; 2-1 (iv) a stipulated premium insurance 2-2 company operating under Chapter 22 of this code; or 2-3 (v) a health maintenance organization 2-4 operating under the Texas Health Maintenance Organization Act 2-5 (Chapter 20A, Vernon's Texas Insurance Code); and 2-6 (B) to the extent permitted by the Employee 2-7 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et 2-8 seq.), a health benefit plan that is offered by: 2-9 (i) a multiple employer welfare 2-10 arrangement as defined by Section 3, Employee Retirement Income 2-11 Security Act of 1974 (29 U.S.C. Section 1002); or 2-12 (ii) another analogous benefit 2-13 arrangement; 2-14 (2) is offered by an approved nonprofit health 2-15 corporation that is certified under Section 5.01(a), Medical 2-16 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and 2-17 that holds a certificate of authority issued by the commissioner 2-18 under Article 21.52F of this code; 2-19 (3) is offered by any other entity not licensed under 2-20 this code or another insurance law of this state that contracts 2-21 directly for health care services on a risk-sharing basis, 2-22 including an entity that contracts for health care services on a 2-23 capitation basis; or 2-24 (4) notwithstanding Section 172.014, Local Government 2-25 Code, or any other law, provides health and accident coverage 3-1 through a risk pool created under Chapter 172, Local Government 3-2 Code. 3-3 (b) This article does not apply to: 3-4 (1) a plan that provides coverage: 3-5 (A) only for a specified disease or other 3-6 limited benefit; 3-7 (B) only for accidental death or dismemberment; 3-8 (C) for wages or payments in lieu of wages for a 3-9 period during which an employee is absent from work because of 3-10 sickness or injury; 3-11 (D) as a supplement to liability insurance; or 3-12 (E) only for indemnity for hospital confinement; 3-13 (2) a plan written under Chapter 26 of this code; 3-14 (3) a Medicare supplemental policy as defined by 3-15 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); 3-16 (4) workers' compensation insurance coverage; 3-17 (5) medical payment insurance issued as part of a 3-18 motor vehicle insurance policy; or 3-19 (6) a long-term care policy, including a nursing home 3-20 fixed indemnity policy, unless the commissioner determines that the 3-21 policy provides benefit coverage so comprehensive that the policy 3-22 is a health benefit plan as described by Subsection (a) of this 3-23 section. 3-24 Sec. 3. REQUIRED COVERAGE FOR CERTAIN TESTS FOR THE 3-25 DETECTION OF PROSTATE CANCER. (a) A health benefit plan that 4-1 provides benefits for diagnostic medical procedures must provide 4-2 coverage for each male enrolled in the plan for expenses incurred 4-3 in conducting an annual medically recognized diagnostic examination 4-4 for the detection of prostate cancer. 4-5 (b) The minimum benefits provided under Subsection (a) of 4-6 this section must include: 4-7 (1) a physical examination for the detection of 4-8 prostate cancer; and 4-9 (2) a prostate-specific antigen test used for the 4-10 detection of prostate cancer for each male enrolled in the plan who 4-11 is: 4-12 (A) at least 50 years of age and asymptomatic; 4-13 or 4-14 (B) at least 40 years of age with a family 4-15 history of prostate cancer or another prostate cancer risk factor. 4-16 Sec. 4. NOTICE. Each health benefit plan shall provide 4-17 written notice to each person enrolled in the plan regarding the 4-18 coverage required by this article. The notice must be provided in 4-19 accordance with rules adopted by the commissioner. 4-20 Sec. 5. RULES. The commissioner shall adopt rules as 4-21 necessary to administer this article. 4-22 SECTION 2. This Act takes effect September 1, 1997, and 4-23 applies only to a health benefit plan that is delivered, issued for 4-24 delivery, or renewed on or after January 1, 1998. A plan that is 4-25 delivered, issued for delivery, or renewed before January 1, 1998, 5-1 is governed by the law as it existed immediately before the 5-2 effective date of this Act, and that law is continued in effect for 5-3 that purpose. 5-4 SECTION 3. The importance of this legislation and the 5-5 crowded condition of the calendars in both houses create an 5-6 emergency and an imperative public necessity that the 5-7 constitutional rule requiring bills to be read on three several 5-8 days in each house be suspended, and this rule is hereby suspended. _______________________________ _______________________________ President of the Senate Speaker of the House I hereby certify that S.B. No. 258 passed the Senate on April 4, 1997, by a viva-voce vote; and that the Senate concurred in House amendments on May 28, 1997, by the following vote: Yeas 31, Nays 0. _______________________________ Secretary of the Senate I hereby certify that S.B. No. 258 passed the House, with amendments, on May 26, 1997, by a non-record vote. _______________________________ Chief Clerk of the House Approved: _______________________________ Date _______________________________ Governor