By: Nelson S.B. No. 585
97S0386/3
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 such medical and surgical
4-17 benefits and 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 to evaluate and treat medical conditions of a recent
11-5 [after the sudden] onset and [of a medical condition manifesting
11-6 itself by acute symptoms of sufficient] severity, including but not
11-7 limited to severe pain, [such] that would lead a prudent layperson
11-8 possessing an average knowledge of medicine and health to believe
11-9 that his or her condition, sickness, or injury is of such a nature
11-10 that failure to get [the absence of] immediate medical care
11-11 [attention] could [reasonably be expected to] result in:
11-12 (1) placing the patient's health in serious jeopardy;
11-13 (2) serious impairment to bodily functions; [or]
11-14 (3) serious dysfunction of any bodily organ or part;
11-15 (4) serious disfigurement; or
11-16 (5) in the case of a pregnant woman, serious jeopardy
11-17 to the health of the fetus.
11-18 (K) An accident and sickness insurance policy that provides
11-19 coverage for the immediate family or children of a person insured
11-20 under the policy may not exclude from coverage or limit coverage to
11-21 a child of the insured solely because the child is adopted. The
11-22 insurer shall provide full coverage under the policy to the child
11-23 without limiting coverage of a preexisting condition if an
11-24 application for the child is made not later than the 31st day after
11-25 the date on which the adoption is final or, for the period during
12-1 which the adoption is not final, not later than the 31st day after
12-2 the date on which the insured becomes a party in a suit in which
12-3 adoption of the child by the insured is sought. For the purposes
12-4 of this subsection, a child is considered to be the child of an
12-5 insured if the insured is a party in a suit in which the adoption
12-6 of the child by the insured is sought.
12-7 SECTION 5. Section 9, Texas Health Maintenance Organization
12-8 Act (Article 20A.09, Vernon's Texas Insurance Code), is amended by
12-9 adding Subsections (k), (l), and (m) to read as follows:
12-10 (k)(1) A health maintenance organization shall provide a
12-11 group continuation privilege as required by this subsection. Any
12-12 enrollee whose coverage under the group contract has been
12-13 terminated for any reason except involuntary termination for cause
12-14 and who has been continuously covered under the group contract and
12-15 under any group contract providing similar services and benefits
12-16 which it replaces for at least three consecutive months immediately
12-17 prior to termination shall be entitled to the group continuation
12-18 privilege as outlined in this subsection. Involuntary termination
12-19 for cause does not include termination for any health-related
12-20 cause. Health maintenance organization contracts subject to this
12-21 section shall provide continuation of group coverage for enrollees
12-22 subject to the following eligibility provisions:
12-23 (A) continuation of group coverage must be
12-24 requested in writing not later than the 31st day after the later
12-25 of:
13-1 (i) the date the group coverage would
13-2 otherwise terminate; or
13-3 (ii) the date the enrollee is given notice
13-4 of the right of continuation by either the employer or the group
13-5 contract holder;
13-6 (B) an enrollee electing continuation must pay
13-7 to the group contract holder or employer on a monthly basis, in
13-8 advance, the amount of contribution required by the contract holder
13-9 or employer, plus two percent of the group rate for the coverage
13-10 being continued under the group contract, on the due date of each
13-11 payment;
13-12 (C) the enrollee's written election of
13-13 continuation, together with the first contribution required to
13-14 establish contributions on a monthly basis, in advance, must be
13-15 given to the contract holder or employer not later than the 31st
13-16 day after the later of:
13-17 (i) the date the group coverage would
13-18 otherwise terminate; or
13-19 (ii) the date the enrollee is given notice
13-20 of the right of continuation by either the employer or the group
13-21 contract holder;
13-22 (D) continuation may not terminate until the
13-23 earliest of:
13-24 (i) 180 days after the date the election
13-25 is made;
14-1 (ii) the date on which failure to make
14-2 timely payments would terminate coverage;
14-3 (iii) the date on which the covered person
14-4 is covered for similar services and benefits by another hospital,
14-5 surgical, medical, or major medical expense insurance policy or
14-6 hospital or medical service subscriber contract or medical practice
14-7 or other prepayment plan or any other plan or program; or
14-8 (iv) the date on which the group coverage
14-9 terminates in its entirety; and
14-10 (E) not less than 30 days before the end of the
14-11 180-day period following the date the enrollee elects continuation
14-12 of the contract, the health maintenance organization shall notify
14-13 the enrollee that the enrollee may be eligible for coverage under
14-14 the Texas Health Insurance Risk Pool as provided under Article
14-15 3.77, Insurance Code, and shall provide the address for applying to
14-16 such pool to the enrollee.
14-17 (2) A health maintenance organization may offer to
14-18 each enrollee a conversion contract. Such conversion contract
14-19 shall be issued without evidence of insurability if a written
14-20 application and payment of the first premium are made not later
14-21 than the 31st day after the date of termination. The conversion
14-22 contract shall meet the minimum standards for services and benefits
14-23 for conversion contracts. The commissioner shall issue rules and
14-24 regulations to establish minimum standards for services and
14-25 benefits under contracts issued pursuant to this subsection.
15-1 (3) The premium for a conversion contract issued under
15-2 this Act shall be determined in accordance with the health
15-3 maintenance organization's premium rates for coverage that were
15-4 provided under the group contract or plan. The premium may be
15-5 based on the geographic location of each person to be covered and
15-6 the type of conversion contract and coverage provided. The premium
15-7 for the same coverage under a conversion contract may not exceed
15-8 200 percent of the premium determined in accordance with this
15-9 subdivision. The premium must be based on the type of conversion
15-10 contract and the coverage provided by the contract.
15-11 (l)(1) An individual health care plan provided by a health
15-12 maintenance organization must meet the requirements of this
15-13 subsection.
15-14 (2) For purposes of this subsection, an "individual
15-15 health care plan" means a health care plan:
15-16 (A) that provides health care services for
15-17 individuals and their dependents;
15-18 (B) in which an enrollee pays the premium and is
15-19 not being covered under a contract pursuant to continuation of
15-20 services and benefits provisions applicable under federal or state
15-21 law; and
15-22 (C) in which the evidence of coverage meets the
15-23 requirements of Section 2(a) of this Act.
15-24 (3) A health maintenance organization may limit its
15-25 enrollees to those who live, reside, or work within the service
16-1 area for an individual health care plan.
16-2 (4) An individual health care plan or a conversion
16-3 contract providing health care services shall be renewable with
16-4 respect to an enrollee at the option of the enrollee and may be
16-5 nonrenewed only if:
16-6 (A) premiums or contributions have not been paid
16-7 in accordance with the terms of the plan or the issuer has not
16-8 received timely premium payments;
16-9 (B) fraud or intentional misrepresentation has
16-10 occurred;
16-11 (C) the health maintenance organization is
16-12 ceasing to offer coverage in the individual market in accordance
16-13 with rules established by the commissioner;
16-14 (D) the enrollee no longer lives, resides, or
16-15 works in the area in which the health maintenance organization is
16-16 authorized to provide coverage, but only if coverage is terminated
16-17 under this paragraph uniformly without regard to any health
16-18 status-related factor of covered enrollees; or
16-19 (E) the nonrenewal is in accordance with
16-20 applicable federal law and regulations.
16-21 (5) The commissioner may adopt rules necessary to
16-22 implement this section and to meet the minimum requirements of
16-23 federal law and regulations.
16-24 (6) A health maintenance organization may impose an
16-25 affiliation period as an alternative to a preexisting condition
17-1 limitation. For the purposes of this subdivision, "affiliation
17-2 period" means a period of time not to exceed 60 days during which
17-3 no premiums shall be collected and coverage issued will not become
17-4 effective. An affiliation period shall be waived for the period an
17-5 individual was covered by qualifying previous coverage, provided
17-6 that the qualifying previous coverage was continuous to a date not
17-7 more than 60 days prior to the effective date of the new coverage.
17-8 An affiliation period must be applied uniformly without regard to
17-9 any health status-related factors.
17-10 (7) A health maintenance organization may not modify
17-11 an individual health care plan with respect to an enrollee or
17-12 dependent through riders or endorsements based on health status or
17-13 claim experience or otherwise restrict or exclude coverage of
17-14 benefits for specific diseases, medical services, or conditions
17-15 otherwise covered by the health benefit plan.
17-16 (8) Denial by a health maintenance organization of an
17-17 application for coverage from an individual shall be in writing and
17-18 shall state the reason or reasons for the denial.
17-19 (9) A health maintenance organization may consider age
17-20 and gender characteristics in determining and establishing the
17-21 schedule of charges for individual coverage. The rating formulas
17-22 and methods for calculating the schedule of charges must be based
17-23 on sound actuarial principles and must produce charges that are not
17-24 excessive, inadequate, or unfairly discriminatory. Benefits must
17-25 be reasonable with respect to the rates produced by the formula or
18-1 method.
18-2 (10) The commissioner shall issue rules and
18-3 regulations to establish minimum standards for benefits and
18-4 determine the percentage increase in the premium rates charged.
18-5 (m) Articles 3.51-14 and 3.51-15, Insurance Code, and
18-6 Subsections (F) and (L) of Section 2, Chapter 397, Acts of the 54th
18-7 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code),
18-8 apply to health maintenance organizations.
18-9 SECTION 6. The Texas Health Maintenance Organization Act
18-10 (Article 20A, Vernon's Texas Insurance Code), is amended by adding
18-11 Section 9A to read as follows:
18-12 Sec. 9A. REQUIRED COVERAGE FOR NEWBORNS; ADOPTED CHILDREN.
18-13 (a) Each health maintenance organization that provides coverage
18-14 for health care services for the spouse and dependent children of
18-15 an enrollee or permits the enrollment of any enrollee's immediate
18-16 family or children under a health benefit plan shall not exclude or
18-17 limit the initial coverage of a newborn child for a period of time
18-18 or exclude or limit coverage for congenital defect of a newborn
18-19 child if the child is enrolled in the health care plan not later
18-20 than the 31st day after the date of the child's birth.
18-21 (b) A health maintenance organization that provides coverage
18-22 for the immediate family or children of an enrollee or permits the
18-23 enrollment of any enrollee's immediate family or children under a
18-24 health benefit plan may not exclude from coverage in a health care
18-25 plan or limit coverage under the plan to a child of an enrollee
19-1 solely because the child is adopted. The health maintenance
19-2 organization shall provide full coverage under the plan to the
19-3 child without limiting coverage of a preexisting condition if the
19-4 child is enrolled in the plan not later than the 31st day after the
19-5 date on which the adoption is final or, for the period during which
19-6 the adoption is not final, not later than the 31st day after the
19-7 date on which the enrollee becomes a party in a suit in which
19-8 adoption of the child by the enrollee is sought. For the purposes
19-9 of this subsection, a child is considered to be the child of an
19-10 enrollee if the enrollee is a party in a suit in which the adoption
19-11 of the child by the enrollee is sought.
19-12 SECTION 7. Subchapter E, Chapter 21, Insurance Code, is
19-13 amended by adding Articles 21.53D and 21.53E to read as follows:
19-14 Art. 21.53D. ACCESS TO CERTAIN OBSTETRIC OR GYNECOLOGICAL
19-15 CARE
19-16 Sec. 1. DEFINITION. In this article, "health benefit plan"
19-17 means an individual or group insurance policy, hospital service
19-18 contract, or contract issued by a health maintenance organization
19-19 that:
19-20 (1) is delivered, issued for delivery, or renewed in
19-21 this state;
19-22 (2) provides benefits for medical or surgical expenses
19-23 incurred as a result of accident, sickness, or another health
19-24 condition; and
19-25 (3) provides benefits for certain specialty health
20-1 care services only through a referral made by a primary care
20-2 physician or other gatekeeper.
20-3 Sec. 2. ACCESS TO CARE. (a) In addition to other benefits
20-4 authorized by the plan, each health benefit plan shall permit a
20-5 woman who is entitled to coverage under the plan direct access as
20-6 provided by Subsection (b) of this section to the health care
20-7 services of a participating obstetrician or gynecologist who is:
20-8 (1) authorized to provide services under the plan; and
20-9 (2) selected by the covered individual.
20-10 (b) The access to health care services required under this
20-11 section includes an annual gynecological physical examination and
20-12 additional self-referred office visits as necessary for women's
20-13 health services.
20-14 Sec. 3. RESTRICTION ON IMPOSITION OF COPAYMENT OR
20-15 DEDUCTIBLE. A health benefit plan may not impose a copayment or
20-16 deductible for direct access to the health care services of an
20-17 obstetrician or gynecologist under this article unless such an
20-18 additional cost is imposed for access to other health care services
20-19 provided under the plan.
20-20 Sec. 4. NOTICE. Each health benefit plan shall provide to
20-21 persons covered by the plan a timely written notice in clear and
20-22 accurate language of the direct access to health care services
20-23 required by this article.
20-24 Sec. 5. RULES. The commissioner shall adopt rules as
20-25 necessary to implement this article.
21-1 Sec. 6. ADMINISTRATIVE PENALTY. An insurance company,
21-2 health maintenance organization, or other entity that operates a
21-3 health benefit plan in violation of this article is subject to an
21-4 administrative penalty as provided by Article 1.10E of this code.
21-5 Art. 21.53E. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
21-6 CARE FACILITY
21-7 Sec. 1. DEFINITIONS. In this article:
21-8 (1) "Health benefit plan" means a plan that is offered
21-9 by any insurer that provides benefits for medical or surgical
21-10 expenses incurred as a result of a health condition, accident, or
21-11 sickness or that is offered by any insurance company, group
21-12 hospital service corporation subject to Chapter 20 of this code,
21-13 fraternal benefit society subject to Chapter 10 of this code,
21-14 stipulated premium insurance company subject to Chapter 22 of this
21-15 code, health maintenance organization subject to the Texas Health
21-16 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
21-17 Code), or multiple employer welfare arrangement subject to Article
21-18 3.95-1 of this code that delivers or issues for delivery an
21-19 individual, group, blanket, or franchise insurance policy,
21-20 certificate of insurance agreement, a group hospital service
21-21 contract, or individual evidence of coverage. The term does not
21-22 include:
21-23 (A) a plan that provides coverage:
21-24 (i) only for accidental death or
21-25 dismemberment or specified disease;
22-1 (ii) for wages or payments in lieu of
22-2 wages for a period during which an employee is absent from work
22-3 because of sickness or injury; or
22-4 (iii) as a supplement to liability
22-5 insurance;
22-6 (B) a medicare supplemental policy as defined by
22-7 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
22-8 (C) workers' compensation insurance coverage;
22-9 (D) medical payment insurance issued as part of
22-10 a motor vehicle insurance policy; or
22-11 (E) a long-term care policy, including a nursing
22-12 home fixed indemnity policy.
22-13 (2) "Provider" means a physician or other
22-14 appropriately licensed health care provider acting within the scope
22-15 of the physician's or other provider's license who attends an
22-16 individual who has given birth or who attends the newborn child.
22-17 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
22-18 FOLLOWING BIRTH; EXCEPTION. (a) A health benefit plan that
22-19 provides maternity benefits, including benefits for childbirth,
22-20 must:
22-21 (1) include coverage for patient care for a mother and
22-22 her newborn child in a health care facility for a minimum of:
22-23 (A) 48 hours following a vaginal delivery; and
22-24 (B) 96 hours following a delivery by caesarean
22-25 section; and
23-1 (2) provide for maternity and pediatric care in
23-2 accordance with guidelines established by the American College of
23-3 Obstetricians and Gynecologists, the American Academy of
23-4 Pediatrics, or other established medical associations.
23-5 (b) Notwithstanding Subsection (a) of this section, the
23-6 hospital length of stay shall be left to the decision of the
23-7 provider in consultation with the mother.
23-8 Sec. 3. RULES. The commissioner shall adopt rules as
23-9 necessary to administer this article.
23-10 SECTION 8. This Act takes effect July 1, 1997, and applies
23-11 only to an insurance policy, contract, or evidence of coverage that
23-12 is issued, delivered, or renewed on or after the effective date of
23-13 this Act. A policy, contract, or evidence of coverage that is
23-14 issued, delivered, or renewed before July 1, 1997, is governed by
23-15 the law as it existed immediately before the effective date of this
23-16 Act, and that law is continued in effect for that purpose.
23-17 SECTION 9. Notwithstanding Section 8 of this Act, the
23-18 requirements of Article 3.51-15, Insurance Code, as added by
23-19 Section 3 of this Act, apply to an insurance policy or evidence of
23-20 coverage that is issued, delivered, or renewed on or after
23-21 January 1, 1998. A policy or evidence of coverage that is issued,
23-22 delivered, or renewed before January 1, 1998, is governed by the
23-23 law as it existed immediately before the effective date of this
23-24 Act, and that law is continued in effect for that purpose.
23-25 SECTION 10. Notwithstanding Section 8 of this Act, the
24-1 requirements of Articles 21.53D and 21.53E, Insurance Code, as
24-2 added by Section 7 of this Act, apply to an insurance policy or
24-3 evidence of coverage that is issued, delivered, or renewed on or
24-4 after January 1, 1998. A policy, contract, or evidence of
24-5 coverage that is issued, delivered, or renewed before January 1,
24-6 1998, is governed by the law as it existed immediately before the
24-7 effective date of this Act, and that law is continued in effect for
24-8 that purpose.
24-9 SECTION 11. The importance of this legislation and the
24-10 crowded condition of the calendars in both houses create an
24-11 emergency and an imperative public necessity that the
24-12 constitutional rule requiring bills to be read on three several
24-13 days in each house be suspended, and this rule is hereby suspended,
24-14 and that this Act take effect and be in force according to its
24-15 terms, and it is so enacted.