By: Nelson, Madla S.B. No. 585
Sibley, Moncrief
A BILL TO BE ENTITLED
AN ACT
1-1 relating to requirements for certain health insurance benefits.
1-2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-3 SECTION 1. Subsection (b), Section 3D, Article 3.51-6,
1-4 Insurance Code, is amended to read as follows:
1-5 (b) A health insurance policy that provides coverage for the
1-6 immediate family or children of a person insured under the policy
1-7 may not exclude from coverage or limit coverage to a child of the
1-8 insured solely because the child is adopted. The insurer shall
1-9 provide full coverage under the policy to the child of an insured
1-10 without limiting coverage of a preexisting condition if an
1-11 application for coverage for the child is made not later than the
1-12 31st day after the date on which the adoption is final or, for the
1-13 period during which the adoption is not final, not later than the
1-14 31st day after the date on which the insured becomes a party in a
1-15 suit in which adoption of the child by the insured is sought.
1-16 SECTION 2. Article 3.51-14, Insurance Code, is amended by
1-17 adding Section 4 to read as follows:
1-18 Sec. 4. COMPLIANCE REQUIRED. Any coverage provided under
1-19 this article to an employee welfare benefit plan as defined in
1-20 Section 3(1) of the Employee Retirement Income Security Act of 1974
1-21 (29 U.S.C. Section 1002(1)) must comply with Article 3.51-15 of
1-22 this code.
1-23 SECTION 3. Subchapter E, Chapter 3, Insurance Code, is
2-1 amended by adding Article 3.51-15 to read as follows:
2-2 Art. 3.51-15. CERTAIN INSURERS MUST MEET REQUIREMENTS FOR
2-3 PARITY
2-4 Sec. 1. PURPOSE. The purpose of this article is to
2-5 coordinate the requirements of Texas law with federal law relating
2-6 to a requirement of parity between certain mental health benefits
2-7 and medical and surgical benefits.
2-8 Sec. 2. DEFINITIONS. In this article:
2-9 (1) "Aggregate lifetime limit" means a dollar
2-10 limitation on the total amount of benefits that may be paid under
2-11 the health insurance coverage with respect to an individual or
2-12 other coverage unit.
2-13 (2) "Annual limit" means a dollar limitation on the
2-14 total amount of benefits that may be paid in a 12-month period
2-15 under the health insurance coverage with respect to an individual
2-16 or other coverage unit.
2-17 (3) "Insurer" means:
2-18 (A) an insurance company;
2-19 (B) a group hospital service corporation
2-20 operating under Chapter 20 of this code;
2-21 (C) a fraternal benefit society operating under
2-22 Chapter 10 of this code;
2-23 (D) a stipulated premium insurance company
2-24 operating under Chapter 22 of this code;
2-25 (E) a health maintenance organization operating
3-1 under the Texas Health Maintenance Organization Act (Chapter 20A,
3-2 Vernon's Texas Insurance Code); or
3-3 (F) an approved nonprofit health corporation
3-4 that is certified under Section 5.01(a), Medical Practice Act
3-5 (Article 4495b, Vernon's Texas Civil Statutes), and that holds a
3-6 certificate of authority issued by the commissioner under Article
3-7 21.52F of this code.
3-8 (4) "Medical or surgical benefits" means benefits with
3-9 respect to medical or surgical services as defined under the terms
3-10 of the coverage, but such benefits do not include mental health
3-11 benefits.
3-12 (5) "Mental health benefits" means benefits with
3-13 respect to mental health services as defined under the terms of the
3-14 coverage and includes benefits provided for mental or emotional
3-15 illnesses or disorders and serious mental illnesses as defined and
3-16 referenced in this code or in rules promulgated by the commissioner
3-17 under this code but does not include benefits with respect to
3-18 treatment of substance abuse or chemical dependency.
3-19 Sec. 3. PARITY REQUIREMENTS. (a) Any coverage for services
3-20 and benefits for the condition of mental illness or serious mental
3-21 illness provided by an insurer to an employee welfare benefit plan
3-22 as defined in Section 3(1) of the Employee Retirement Income
3-23 Security Act of 1974 (29 U.S.C. Section 1002(1)) must meet the
3-24 requirements of Subsections (b) and (c) of this section regarding
3-25 parity in annual and lifetime aggregate dollar limits between
4-1 medical and surgical benefits and mental illness benefits, unless
4-2 exempted under Section 4 of this article.
4-3 (b) In the case of coverage that provides both medical and
4-4 surgical benefits and mental health benefits:
4-5 (1) if the coverage does not include an aggregate
4-6 lifetime limit on substantially all medical and surgical benefits,
4-7 the coverage may not impose any aggregate lifetime limit on mental
4-8 health benefits; and
4-9 (2) if the coverage includes an aggregate lifetime
4-10 limit on substantially all medical and surgical benefits, in this
4-11 article referred to as the "applicable lifetime limit," the
4-12 coverage shall either:
4-13 (A) apply the applicable lifetime limit both to
4-14 the medical and surgical benefits to which it otherwise would apply
4-15 and to mental health benefits and not distinguish in the
4-16 application of such limit between medical and surgical benefits and
4-17 mental health benefits; or
4-18 (B) not include any aggregate lifetime limit on
4-19 mental health benefits that is less than the applicable lifetime
4-20 limit.
4-21 (c) In the case of coverage that is not described in
4-22 Subsection (b) of this section and that includes no or different
4-23 aggregate lifetime limits on different categories of medical and
4-24 surgical benefits, the insurer must follow rules promulgated by the
4-25 Secretary of the Treasury under the Mental Health Parity Act of
5-1 1996 (Title VII, Pub. L. No. 104-204), under which the rule in
5-2 Subsection (b)(2) of this section is applied to such coverage with
5-3 respect to mental health benefits by substituting for the
5-4 applicable lifetime limit an average aggregate lifetime limit that
5-5 is computed taking into account the weighted average of the
5-6 aggregate lifetime limits applicable to such categories.
5-7 (d) In the case of coverage that provides both medical and
5-8 surgical benefits and mental health benefits:
5-9 (1) if the coverage does not include an annual limit
5-10 on substantially all medical and surgical benefits, the coverage
5-11 may not impose any annual limit on mental health benefits; and
5-12 (2) if the coverage includes an annual limit on
5-13 substantially all medical and surgical benefits, in this article
5-14 referred to as the "applicable annual limit," the coverage shall
5-15 either:
5-16 (A) apply the applicable annual limit both to
5-17 medical and surgical benefits to which it otherwise would apply and
5-18 to mental health benefits and not distinguish in the application of
5-19 such limit between such medical and surgical benefits and mental
5-20 health benefits; or
5-21 (B) not include any annual limit on mental
5-22 health benefits that is less than the applicable annual limit.
5-23 (e) In the case of coverage that is not described in
5-24 Subsection (d) of this section and that includes no or different
5-25 annual limits on different categories of medical and surgical
6-1 benefits, the insurer must follow rules promulgated by the
6-2 Secretary of the Treasury under the Mental Health Parity Act of
6-3 1996 (Title VII, Pub. L. No. 104-204), under which the rule in
6-4 Subsection (d)(2) of this section is applied to such coverage with
6-5 respect to mental health benefits by substituting for the
6-6 applicable annual limit an average aggregate annual limit that is
6-7 computed taking into account the weighted average of the aggregate
6-8 annual limits applicable to such categories.
6-9 (f) Nothing in this section shall be construed:
6-10 (1) as requiring an insurer to provide or offer any
6-11 mental health benefits, except as otherwise specified in this code;
6-12 or
6-13 (2) in the case of coverage that provides mental
6-14 health benefits, as affecting the terms and conditions, including
6-15 cost sharing, limits on numbers of visits or days of coverage, and
6-16 requirements relating to medical necessity, relating to the amount,
6-17 duration, or scope of mental health benefits under the coverage,
6-18 except as specifically provided in this article in regard to parity
6-19 in the imposition of aggregate lifetime limits and annual limits
6-20 for mental health benefits.
6-21 Sec. 4. EXEMPTIONS. (a) This section does not apply to
6-22 coverage offered to an employee welfare benefit plan of an employer
6-23 who, with respect to a calendar year and a plan year, employed an
6-24 average of at least two but not more than 50 employees on business
6-25 days during the preceding calendar year and who employs at least
7-1 two employees on the first day of the plan year, in this article
7-2 referred to as an "exempt employer."
7-3 (b) In determining employer size for purposes of this
7-4 section:
7-5 (1) rules under Subsections (b), (c), (m), and (o),
7-6 Section 414 of the Internal Revenue Code of 1986 (26 U.S.C. Section
7-7 414) shall apply for purposes of treating persons as a single
7-8 employer;
7-9 (2) in the case of an employer which was not in
7-10 existence throughout the preceding calendar year, the determination
7-11 of whether the employer is an exempt employer shall be based on the
7-12 average number of employees that it is reasonably expected such
7-13 employer will employ on business days in the current calendar year;
7-14 and
7-15 (3) any reference in this section to an employer shall
7-16 include a reference to any predecessor of such employer.
7-17 (c) This section shall not apply with respect to insurance
7-18 coverage offered to an employee welfare benefit plan if the
7-19 application of this section to the coverage results in an increase
7-20 in the cost for the coverage of at least one percent.
7-21 Sec. 5. SEPARATE APPLICATION TO EACH OPTION OFFERED. In the
7-22 case of an employee welfare benefit plan that offers a participant
7-23 or beneficiary two or more benefit package options under the plan,
7-24 the requirements of this article shall be applied separately to
7-25 each coverage package offered by an insurer or provider with
8-1 respect to each option.
8-2 Sec. 6. RULEMAKING AUTHORITY. The commissioner may
8-3 promulgate reasonable rules to implement this article and to
8-4 coordinate or comply with minimum requirements of federal law and
8-5 regulations relating to parity of mental health benefits with any
8-6 other health and accident benefits.
8-7 SECTION 4. Subsections (E), (F), (I), and (K), Section 2,
8-8 Chapter 397, Acts of the 54th Legislature, 1955 (Article 3.70-2,
8-9 Vernon's Texas Insurance Code), are amended to read as follows:
8-10 (E) No individual policy or group policy of accident and
8-11 sickness insurance, including policies issued by companies subject
8-12 to Chapter 20, [Texas] Insurance Code, [as amended,] delivered or
8-13 issued for delivery to any person in this state which provides for
8-14 accident and sickness coverage of immediate family or children of
8-15 an enrollee, which permits the enrollment of any enrollee's
8-16 immediate family or [additional newborn] children for such
8-17 coverage, or which provides maternity benefits[,] may be issued in
8-18 this state if it contains any provisions excluding or limiting
8-19 initial coverage of a newborn infant for a period of time, or
8-20 limitations or exclusions for congenital defects of a newborn
8-21 child.
8-22 (F) A group policy of accident and sickness insurance
8-23 delivered or issued for delivery to a person in this state,
8-24 including a group policy issued by a company subject to Chapter 20,
8-25 Insurance Code, or the Texas Health Maintenance Organization Act
9-1 (Chapter 20A, Vernon's Texas Insurance Code), that provides
9-2 coverage for treatment of mental or emotional illness or disorder
9-3 for a person when confined in a hospital must also provide that
9-4 coverage, which is not less favorable, shall be applicable for
9-5 treatment under the direction and continued medical supervision of
9-6 a doctor of medicine or doctor of osteopathy in a psychiatric day
9-7 treatment facility that provides organizational structure and
9-8 individualized treatment plans separate from an in-patient program;
9-9 subject to the same durational limits, deductibles, and coinsurance
9-10 factors. Any benefits so provided shall be determined as if
9-11 necessary care and treatment in a psychiatric day treatment
9-12 facility were in-patient care and treatment in a hospital, and each
9-13 full day of treatment in a psychiatric day treatment facility shall
9-14 be considered equal to one-half of one day of treatment of mental
9-15 or emotional illness or disorder in a hospital or in-patient
9-16 program for the purpose of determining policy benefits and benefit
9-17 maximums. An insurer shall offer and the policyholder shall have
9-18 the right to reject such coverage for treatment of mental or
9-19 emotional illness or disorder when confined in a hospital or in a
9-20 psychiatric day treatment facility or may select an alternative
9-21 level of benefits thereunder if such coverage is offered by or
9-22 negotiated with such insurer, service plan corporation or health
9-23 maintenance organization, except that[; provided, however,] any
9-24 such alternative level of benefits shall provide policy benefits
9-25 and benefit maximums for treatment in psychiatric day treatment
10-1 facilities equal to at least one half of that provided for
10-2 treatment in hospital facilities, but not to exceed the usual and
10-3 customary charge of the psychiatric day treatment facility, and any
10-4 coverage provided to an employee welfare benefit plan as defined in
10-5 Section 3(1) of the Employee Retirement Income Security Act of 1974
10-6 (29 U.S.C. Section 1002(1)) must comply with Article 3.51-15,
10-7 Insurance Code. Any such policy may require that the treatment
10-8 must be provided by a day treatment facility that treats a patient
10-9 for not more than eight hours in any 24-hour period, that the
10-10 attending physician certifies that such treatment is in lieu of
10-11 hospitalization, and that the psychiatric treatment facility is
10-12 accredited by the Program for Psychiatric Facilities, or its
10-13 successor, of the Joint Commission on Accreditation of Hospitals.
10-14 For the purpose of this subsection a psychiatric day treatment
10-15 facility is a mental health facility which provides treatment for
10-16 individuals suffering from acute, mental and nervous disorders in a
10-17 structured psychiatric program utilizing individualized treatment
10-18 plans with specific attainable goals and objectives appropriate
10-19 both to the patient and the treatment modality of the program and
10-20 that is clinically supervised by a doctor of medicine who is
10-21 certified in psychiatry by the American Board of Psychiatry and
10-22 Neurology.
10-23 (I) An individual or group policy of accident and sickness
10-24 insurance that provides any emergency care benefit, including
10-25 policies issued by companies subject to Chapter 20, Insurance Code,
11-1 delivered or issued for delivery in this state must define
11-2 emergency care as follows: "Emergency care" means health care
11-3 [bona fide emergency] services provided in a hospital emergency
11-4 facility or comparable facility to evaluate and stabilize medical
11-5 conditions of a recent [after the sudden] onset and [of a medical
11-6 condition manifesting itself by acute symptoms of sufficient]
11-7 severity, including but not limited to severe pain, [such] that
11-8 would lead a prudent layperson possessing an average knowledge of
11-9 medicine and health to believe that his or her condition, sickness,
11-10 or injury is of such a nature that failure to get [the absence of]
11-11 immediate medical care [attention] could [reasonably be expected
11-12 to] result in:
11-13 (1) placing the patient's health in serious jeopardy;
11-14 (2) serious impairment to bodily functions; [or]
11-15 (3) serious dysfunction of any bodily organ or part;
11-16 (4) serious disfigurement; or
11-17 (5) in the case of a pregnant woman, serious jeopardy
11-18 to the health of the fetus.
11-19 (K) An accident and sickness insurance policy that provides
11-20 coverage for the immediate family or children of a person insured
11-21 under the policy may not exclude from coverage or limit coverage to
11-22 a child of the insured solely because the child is adopted. The
11-23 insurer shall provide full coverage under the policy to the child
11-24 without limiting coverage of a preexisting condition if an
11-25 application for the child is made not later than the 31st day after
12-1 the date on which the adoption is final or, for the period during
12-2 which the adoption is not final, not later than the 31st day after
12-3 the date on which the insured becomes a party in a suit in which
12-4 adoption of the child by the insured is sought. For the purposes
12-5 of this subsection, a child is considered to be the child of an
12-6 insured if the insured is a party in a suit in which the adoption
12-7 of the child by the insured is sought.
12-8 SECTION 5. Section 9, Texas Health Maintenance Organization
12-9 Act (Article 20A.09, Vernon's Texas Insurance Code), is amended by
12-10 adding Subsections (k), (l), and (m) to read as follows:
12-11 (k)(1) A health maintenance organization shall provide a
12-12 group continuation privilege as required by this subsection. Any
12-13 enrollee whose coverage under the group contract has been
12-14 terminated for any reason except involuntary termination for cause
12-15 and who has been continuously covered under the group contract and
12-16 under any group contract providing similar services and benefits
12-17 which it replaces for at least three consecutive months immediately
12-18 prior to termination shall be entitled to the group continuation
12-19 privilege as outlined in this subsection. Involuntary termination
12-20 for cause does not include termination for any health-related
12-21 cause. Health maintenance organization contracts subject to this
12-22 section shall provide continuation of group coverage for enrollees
12-23 subject to the following eligibility provisions:
12-24 (A) continuation of group coverage must be
12-25 requested in writing not later than the 31st day after the later
13-1 of:
13-2 (i) the date the group coverage would
13-3 otherwise terminate; or
13-4 (ii) the date the enrollee is given notice
13-5 of the right of continuation by either the employer or the group
13-6 contract holder;
13-7 (B) an enrollee electing continuation must pay
13-8 to the group contract holder or employer on a monthly basis, in
13-9 advance, the amount of contribution required by the contract holder
13-10 or employer, plus two percent of the group rate for the coverage
13-11 being continued under the group contract, on the due date of each
13-12 payment;
13-13 (C) the enrollee's written election of
13-14 continuation, together with the first contribution required to
13-15 establish contributions on a monthly basis, in advance, must be
13-16 given to the contract holder or employer not later than the 31st
13-17 day after the later of:
13-18 (i) the date the group coverage would
13-19 otherwise terminate; or
13-20 (ii) the date the enrollee is given notice
13-21 of the right of continuation by either the employer or the group
13-22 contract holder;
13-23 (D) continuation may not terminate until the
13-24 earliest of:
13-25 (i) 180 days after the date the election
14-1 is made;
14-2 (ii) the date on which failure to make
14-3 timely payments would terminate coverage;
14-4 (iii) the date on which the covered person
14-5 is covered for similar services and benefits by another hospital,
14-6 surgical, medical, or major medical expense insurance policy or
14-7 hospital or medical service subscriber contract or medical practice
14-8 or other prepayment plan or any other plan or program; or
14-9 (iv) the date on which the group coverage
14-10 terminates in its entirety; and
14-11 (E) not less than 30 days before the end of the
14-12 180-day period following the date the enrollee elects continuation
14-13 of the contract, the health maintenance organization shall notify
14-14 the enrollee that the enrollee may be eligible for coverage under
14-15 the Texas Health Insurance Risk Pool as provided under Article
14-16 3.77, Insurance Code, and shall provide the address for applying to
14-17 such pool to the enrollee.
14-18 (2) A health maintenance organization may offer to
14-19 each enrollee a conversion contract. Such conversion contract
14-20 shall be issued without evidence of insurability if a written
14-21 application and payment of the first premium are made not later
14-22 than the 31st day after the date of termination. The conversion
14-23 contract shall meet the minimum standards for services and benefits
14-24 for conversion contracts. The commissioner shall issue rules and
14-25 regulations to establish minimum standards for services and
15-1 benefits under contracts issued pursuant to this subsection.
15-2 (3) The premium for a conversion contract issued under
15-3 this Act shall be determined in accordance with the health
15-4 maintenance organization's premium rates for coverage that were
15-5 provided under the group contract or plan. The premium may be
15-6 based on the geographic location of each person to be covered and
15-7 the type of conversion contract and coverage provided. The premium
15-8 for the same coverage under a conversion contract may not exceed
15-9 200 percent of the premium determined in accordance with this
15-10 subdivision. The premium must be based on the type of conversion
15-11 contract and the coverage provided by the contract.
15-12 (l)(1) An individual health care plan provided by a health
15-13 maintenance organization must meet the requirements of this
15-14 subsection.
15-15 (2) For purposes of this subsection, an "individual
15-16 health care plan" means a health care plan:
15-17 (A) which provides health care services for
15-18 individuals and their dependents;
15-19 (B) in which an enrollee pays the premium and is
15-20 not being covered under a contract pursuant to continuation of
15-21 services and benefits provisions applicable under federal or state
15-22 law; and
15-23 (C) in which the evidence of coverage meets the
15-24 requirements of Section 2(a) of this Act.
15-25 (3) A health maintenance organization may limit its
16-1 enrollees to those who live, reside, or work within the service
16-2 area for an individual health care plan.
16-3 (4) An individual health care plan or a conversion
16-4 contract providing health care services shall be renewable with
16-5 respect to an enrollee at the option of the enrollee and may be
16-6 nonrenewed only if:
16-7 (A) premiums or contributions have not been paid
16-8 in accordance with the terms of the plan or the issuer has not
16-9 received timely premium payments;
16-10 (B) fraud or intentional misrepresentation has
16-11 occurred;
16-12 (C) the health maintenance organization is
16-13 ceasing to offer coverage in the individual market in accordance
16-14 with rules established by the commissioner;
16-15 (D) the enrollee no longer lives, resides, or
16-16 works in the area in which the health maintenance organization is
16-17 authorized to provide coverage, but only if coverage is terminated
16-18 under this paragraph uniformly without regard to any health
16-19 status-related factor of covered enrollees; or
16-20 (E) the nonrenewal is in accordance with
16-21 applicable federal law and regulations.
16-22 (5) The commissioner may adopt rules necessary to
16-23 implement this section and to meet the minimum requirements of
16-24 federal law and regulations.
16-25 (6) A health maintenance organization may impose an
17-1 affiliation period as an alternative to a preexisting condition
17-2 limitation. For the purposes of this subdivision, "affiliation
17-3 period" means a period not to exceed 60 days, or 90 days in the
17-4 case of a late enrollee, during which no premiums shall be
17-5 collected and coverage issued will not become effective. An
17-6 affiliation period shall be waived for the period an individual was
17-7 covered by qualifying previous coverage, provided that the
17-8 qualifying previous coverage was continuous to a date not more than
17-9 60 days prior to the effective date of the new coverage. An
17-10 affiliation period must be applied uniformly without regard to any
17-11 health status-related factors.
17-12 (7) A health maintenance organization may not modify
17-13 an individual health care plan with respect to an enrollee or
17-14 dependent through riders or endorsements based on health status or
17-15 claim experience or otherwise restrict or exclude coverage of
17-16 benefits for specific diseases, medical services, or conditions
17-17 otherwise covered by the health benefit plan.
17-18 (8) Denial by a health maintenance organization of an
17-19 application for coverage from an individual shall be in writing and
17-20 shall state the reason or reasons for the denial.
17-21 (9) A health maintenance organization may consider age
17-22 and gender characteristics in determining and establishing the
17-23 schedule of charges for individual coverage. The rating formulas
17-24 and methods for calculating the schedule of charges must be based
17-25 on sound actuarial principles and must produce charges that are not
18-1 excessive, inadequate, or unfairly discriminatory. Benefits must
18-2 be reasonable with respect to the rates produced by the formula or
18-3 method.
18-4 (10) The commissioner shall issue rules and
18-5 regulations to establish minimum standards for benefits and
18-6 determine the percentage increase in the premium rates charged.
18-7 (m) Articles 3.51-14 and 3.51-15, Insurance Code, and
18-8 Subsections (F) and (L), Section 2, Chapter 397, Acts of the 54th
18-9 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code),
18-10 apply to health maintenance organizations.
18-11 SECTION 6. The Texas Health Maintenance Organization Act
18-12 (Article 20A, Vernon's Texas Insurance Code), is amended by adding
18-13 Section 9A to read as follows:
18-14 Sec. 9A. REQUIRED COVERAGE FOR NEWBORNS; ADOPTED CHILDREN.
18-15 (a) Each health maintenance organization that provides coverage
18-16 for health care services for the spouse and dependent children of
18-17 an enrollee or permits the enrollment of any enrollee's immediate
18-18 family or children under a health benefit plan shall not exclude or
18-19 limit the initial coverage of a newborn child for a period of time
18-20 or exclude or limit coverage for congenital defect of a newborn
18-21 child if the child is enrolled in the health care plan not later
18-22 than the 31st day after the date of the child's birth.
18-23 (b) A health maintenance organization that provides coverage
18-24 for the immediate family or children of an enrollee or permits the
18-25 enrollment of any enrollee's immediate family or children under a
19-1 health benefit plan may not exclude from coverage in a health care
19-2 plan a child of an enrollee or limit coverage under the plan to a
19-3 child of an enrollee solely because the child is adopted. The
19-4 health maintenance organization shall provide full coverage under
19-5 the plan to the child without limiting coverage of a preexisting
19-6 condition if the child is enrolled in the plan not later than the
19-7 31st day after the date on which the adoption is final or, for the
19-8 period during which the adoption is not final, not later than the
19-9 31st day after the date on which the enrollee becomes a party in a
19-10 suit in which adoption of the child by the enrollee is sought. For
19-11 the purposes of this subsection, a child is considered to be the
19-12 child of an enrollee if the enrollee is a party in a suit in which
19-13 the adoption of the child by the enrollee is sought.
19-14 SECTION 7. Subchapter E, Chapter 21, Insurance Code, is
19-15 amended by adding Articles 21.53D and 21.53E to read as follows:
19-16 Art. 21.53D. ACCESS TO CERTAIN OBSTETRICAL OR GYNECOLOGICAL
19-17 CARE
19-18 Sec. 1. DEFINITIONS. In this article:
19-19 (1) "Enrollee" means an individual enrolled in a
19-20 health benefit plan.
19-21 (2) "Health benefit plan" means a plan described in
19-22 Section 2 of this article.
19-23 (3) "Physician" means a person licensed as a physician
19-24 by the Texas State Board of Medical Examiners.
19-25 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
20-1 health benefit plan that:
20-2 (1) provides benefits for medical or surgical expenses
20-3 incurred as a result of a health condition, accident, or sickness,
20-4 including:
20-5 (A) an individual, group, blanket, or franchise
20-6 insurance policy or insurance agreement, a group hospital service
20-7 contract, or an individual or group evidence of coverage that is
20-8 offered by:
20-9 (i) an insurance company;
20-10 (ii) a group hospital service corporation
20-11 operating under Chapter 20 of this code;
20-12 (iii) a fraternal benefit society
20-13 operating under Chapter 10 of this code;
20-14 (iv) a stipulated premium insurance
20-15 company operating under Chapter 22 of this code; or
20-16 (v) a health maintenance organization
20-17 operating under the Texas Health Maintenance Organization Act
20-18 (Chapter 20A, Vernon's Texas Insurance Code); and
20-19 (B) to the extent permitted by the Employee
20-20 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
20-21 seq.), a health benefit plan that is offered by:
20-22 (i) a multiple employer welfare
20-23 arrangement as defined by Section 3, Employee Retirement Income
20-24 Security Act of 1974 (29 U.S.C. Section 1002); or
20-25 (ii) another analogous benefit
21-1 arrangement;
21-2 (2) is offered by an approved nonprofit health
21-3 corporation that is certified under Section 5.01(a), Medical
21-4 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
21-5 that holds a certificate of authority issued by the commissioner
21-6 under Article 21.52F of this code; or
21-7 (3) is offered by any other entity not licensed under
21-8 this code or another insurance law of this state that contracts
21-9 directly for health care services on a risk-sharing basis,
21-10 including an entity that contracts for health care services on a
21-11 capitation basis.
21-12 (b) This article does not apply to:
21-13 (1) a plan that provides coverage:
21-14 (A) only for a specified disease;
21-15 (B) only for accidental death or dismemberment;
21-16 (C) for wages or payments in lieu of wages for a
21-17 period during which an employee is absent from work because of
21-18 sickness or injury; or
21-19 (D) as a supplement to liability insurance;
21-20 (2) a plan written under Chapter 26 of this code;
21-21 (3) a Medicare supplemental policy as defined by
21-22 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
21-23 (4) workers' compensation insurance coverage;
21-24 (5) medical payment insurance issued as a part of a
21-25 motor vehicle insurance policy;
22-1 (6) a long-term care policy, including a nursing home
22-2 fixed indemnity policy, unless the commissioner determines that the
22-3 policy provides benefit coverage so comprehensive that the policy
22-4 is a health benefit plan as described by Subsection (a) of this
22-5 section; or
22-6 (7) any health benefit plan that does not provide
22-7 pregnancy-related benefits.
22-8 (c) This article applies to each health benefit plan that
22-9 requires an enrollee to obtain certain specialty health care
22-10 services through a referral made by a primary care physician or
22-11 other gatekeeper.
22-12 Sec. 3. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. (a) Each
22-13 health benefit plan subject to this article shall permit a woman
22-14 who is entitled to coverage under the plan to select, in addition
22-15 to a primary care physician, an obstetrician or gynecologist to
22-16 provide health care services within the scope of the professional
22-17 specialty practice of a properly credentialed obstetrician or
22-18 gynecologist.
22-19 (b) The plan shall include in the classification of persons
22-20 authorized to provide medical services under the plan a number of
22-21 properly credentialed obstetricians and gynecologists sufficient to
22-22 ensure access to the services that fall within the scope of that
22-23 credential.
22-24 (c) This section does not affect the authority of a health
22-25 benefit plan to establish selection criteria regarding other
23-1 physicians who provide services through the plan.
23-2 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
23-3 GYNECOLOGIST. (a) In addition to other benefits authorized by the
23-4 plan, each health benefit plan shall permit a woman who designates
23-5 an obstetrician or gynecologist as provided under Section 3 of this
23-6 article direct access to the health care services of the designated
23-7 obstetrician or gynecologist without a referral by the woman's
23-8 primary care physician or prior authorization or precertification
23-9 from a health benefit plan.
23-10 (b) The access to health care services required under this
23-11 article includes, but is not limited to:
23-12 (1) one well-woman examination per year;
23-13 (2) care related to pregnancy;
23-14 (3) care for all active gynecological conditions; and
23-15 (4) diagnosis, treatment, and referral for any disease
23-16 or condition within the scope of the professional practice of a
23-17 properly credentialed obstetrician or gynecologist.
23-18 (c) A health benefit plan may not impose a copayment or
23-19 deductible for direct access to the health care services of an
23-20 obstetrician or gynecologist under this section unless such an
23-21 additional cost is imposed for access to other health care services
23-22 provided under the plan.
23-23 (d) This section does not affect the authority of a health
23-24 benefit plan to require the designated obstetrician or gynecologist
23-25 to forward information concerning the medical care of the patient
24-1 to the primary care physician; however, failure to provide such
24-2 information shall not result in any penalty, financial or
24-3 otherwise, being imposed upon the obstetrician or gynecologist or
24-4 the patient by the health benefit plan.
24-5 (e) In implementing the access required under Section 3 of
24-6 this article, a health benefit plan may limit a woman enrolled in
24-7 the plan to self-referral to one participating obstetrician and
24-8 gynecologist for both gynecological care and obstetrical care.
24-9 This subsection does not affect the right of the woman to select
24-10 the physician who provides that care.
24-11 (f) A health benefit plan shall not sanction or terminate
24-12 primary care physicians as a result of female enrollees' access to
24-13 participating obstetricians and gynecologists under this section.
24-14 Sec. 5. NOTICE. Each health benefit plan shall provide to
24-15 persons covered by the plan a timely written notice in clear and
24-16 accurate language of the direct access to health care services
24-17 required by this article.
24-18 Sec. 6. RULES. The commissioner shall adopt rules as
24-19 necessary to implement this article.
24-20 Sec. 7. ADMINISTRATIVE PENALTY. An insurance company,
24-21 health maintenance organization, or other entity that operates a
24-22 health benefit plan in violation of this article is subject to an
24-23 administrative penalty as provided by Article 1.10E of this code.
24-24 Art. 21.53E. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
24-25 CARE FACILITY
25-1 Sec. 1. DEFINITIONS. In this article:
25-2 (1) "Health benefit plan" means a plan that is offered
25-3 by any insurer that provides benefits for medical or surgical
25-4 expenses incurred as a result of a health condition, accident, or
25-5 sickness or that is offered by any insurance company, group
25-6 hospital service corporation subject to Chapter 20 of this code,
25-7 fraternal benefit society subject to Chapter 10 of this code,
25-8 stipulated premium insurance company subject to Chapter 22 of this
25-9 code, health maintenance organization subject to the Texas Health
25-10 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
25-11 Code), or multiple employer welfare arrangement subject to Article
25-12 3.95-1 of this code that delivers or issues for delivery an
25-13 individual, group, blanket, or franchise insurance policy,
25-14 certificate of insurance agreement, a group hospital service
25-15 contract, or individual evidence of coverage. The term does not
25-16 include:
25-17 (A) a plan that provides coverage:
25-18 (i) only for accidental death or
25-19 dismemberment or a specified disease;
25-20 (ii) for wages or payments in lieu of
25-21 wages for a period during which an employee is absent from work
25-22 because of sickness or injury; or
25-23 (iii) as a supplement to liability
25-24 insurance;
25-25 (B) a Medicare supplemental policy as defined by
26-1 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
26-2 (C) workers' compensation insurance coverage;
26-3 (D) medical payment insurance issued as part of
26-4 a motor vehicle insurance policy; or
26-5 (E) a long-term care policy, including a nursing
26-6 home fixed indemnity policy.
26-7 (2) "Provider" means a physician or other
26-8 appropriately licensed health care provider acting within the scope
26-9 of the physician's or other provider's license who attends an
26-10 individual who has given birth or who attends the newborn child.
26-11 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
26-12 FOLLOWING BIRTH; EXCEPTION. (a) A health benefit plan that
26-13 provides maternity benefits, including benefits for childbirth,
26-14 must:
26-15 (1) include coverage for patient care for a mother and
26-16 her newborn child in a health care facility for a minimum of:
26-17 (A) 48 hours following a vaginal delivery; and
26-18 (B) 96 hours following a delivery by caesarean
26-19 section; and
26-20 (2) provide for maternity and pediatric care in
26-21 accordance with guidelines established by the American College of
26-22 Obstetricians and Gynecologists, the American Academy of
26-23 Pediatrics, or other established medical associations.
26-24 (b) Notwithstanding Subsection (a) of this section, the
26-25 hospital length of stay shall be left to the decision of the
27-1 provider in consultation with the mother.
27-2 Sec. 3. RULES. The commissioner shall adopt rules as
27-3 necessary to administer this article.
27-4 SECTION 8. This Act takes effect July 1, 1997, and, except
27-5 as provided by Sections 9 and 10 of this Act, applies only to an
27-6 insurance policy, contract, or evidence of coverage that is issued,
27-7 delivered, or renewed on or after the effective date of this Act.
27-8 A policy, contract, or evidence of coverage that is issued,
27-9 delivered, or renewed before July 1, 1997, is governed by the law
27-10 as it existed immediately before the effective date of this Act,
27-11 and that law is continued in effect for that purpose.
27-12 SECTION 9. The requirements of Article 3.51-15, Insurance
27-13 Code, as added by Section 3 of this Act, apply to an insurance
27-14 policy or evidence of coverage that is issued, delivered, or
27-15 renewed on or after January 1, 1998.
27-16 SECTION 10. The requirements of Articles 21.53D and 21.53E,
27-17 Insurance Code, as added by Section 7 of this Act, apply to an
27-18 insurance policy or evidence of coverage that is issued, delivered,
27-19 or renewed on or after January 1, 1998.
27-20 SECTION 11. The importance of this legislation and the
27-21 crowded condition of the calendars in both houses create an
27-22 emergency and an imperative public necessity that the
27-23 constitutional rule requiring bills to be read on three several
27-24 days in each house be suspended, and this rule is hereby suspended,
27-25 and that this Act take effect and be in force according to its
28-1 terms, and it is so enacted.