1-1 By: Nelson, Madla S.B. No. 585
1-2 (In the Senate - Filed February 12, 1997; February 13, 1997,
1-3 read first time and referred to Committee on Economic Development;
1-4 March 3, 1997, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 8, Nays 0; March 3, 1997,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 585 By: Haywood
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to requirements for certain health insurance benefits.
1-11 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-12 SECTION 1. Subsection (b), Section 3D, Article 3.51-6,
1-13 Insurance Code, is amended to read as follows:
1-14 (b) A health insurance policy that provides coverage for the
1-15 immediate family or children of a person insured under the policy
1-16 may not exclude from coverage or limit coverage to a child of the
1-17 insured solely because the child is adopted. The insurer shall
1-18 provide full coverage under the policy to the child of an insured
1-19 without limiting coverage of a preexisting condition if an
1-20 application for coverage for the child is made not later than the
1-21 31st day after the date on which the adoption is final or, for the
1-22 period during which the adoption is not final, not later than the
1-23 31st day after the date on which the insured becomes a party in a
1-24 suit in which adoption of the child by the insured is sought.
1-25 SECTION 2. Article 3.51-14, Insurance Code, is amended by
1-26 adding Section 4 to read as follows:
1-27 Sec. 4. COMPLIANCE REQUIRED. Any coverage provided under
1-28 this article to an employee welfare benefit plan as defined in
1-29 Section 3(1) of the Employee Retirement Income Security Act of 1974
1-30 (29 U.S.C. Section 1002(1)) must comply with Article 3.51-15 of
1-31 this code.
1-32 SECTION 3. Subchapter E, Chapter 3, Insurance Code, is
1-33 amended by adding Article 3.51-15 to read as follows:
1-34 Art. 3.51-15. CERTAIN INSURERS MUST MEET REQUIREMENTS FOR
1-35 PARITY
1-36 Sec. 1. PURPOSE. The purpose of this article is to
1-37 coordinate the requirements of Texas law with federal law relating
1-38 to a requirement of parity between certain mental health benefits
1-39 and medical and surgical benefits.
1-40 Sec. 2. DEFINITIONS. In this article:
1-41 (1) "Aggregate lifetime limit" means a dollar
1-42 limitation on the total amount of benefits that may be paid under
1-43 the health insurance coverage with respect to an individual or
1-44 other coverage unit.
1-45 (2) "Annual limit" means a dollar limitation on the
1-46 total amount of benefits that may be paid in a 12-month period
1-47 under the health insurance coverage with respect to an individual
1-48 or other coverage unit.
1-49 (3) "Insurer" means:
1-50 (A) an insurance company;
1-51 (B) a group hospital service corporation
1-52 operating under Chapter 20 of this code;
1-53 (C) a fraternal benefit society operating under
1-54 Chapter 10 of this code;
1-55 (D) a stipulated premium insurance company
1-56 operating under Chapter 22 of this code;
1-57 (E) a health maintenance organization operating
1-58 under the Texas Health Maintenance Organization Act (Chapter 20A,
1-59 Vernon's Texas Insurance Code); or
1-60 (F) an approved nonprofit health corporation
1-61 that is certified under Section 5.01(a), Medical Practice Act
1-62 (Article 4495b, Vernon's Texas Civil Statutes), and that holds a
1-63 certificate of authority issued by the commissioner under Article
1-64 21.52F of this code.
2-1 (4) "Medical or surgical benefits" means benefits with
2-2 respect to medical or surgical services as defined under the terms
2-3 of the coverage, but such benefits do not include mental health
2-4 benefits.
2-5 (5) "Mental health benefits" means benefits with
2-6 respect to mental health services as defined under the terms of the
2-7 coverage and includes benefits provided for mental or emotional
2-8 illnesses or disorders and serious mental illnesses as defined and
2-9 referenced in this code or in rules promulgated by the commissioner
2-10 under this code but does not include benefits with respect to
2-11 treatment of substance abuse or chemical dependency.
2-12 Sec. 3. PARITY REQUIREMENTS. (a) Any coverage for services
2-13 and benefits for the condition of mental illness or serious mental
2-14 illness provided by an insurer to an employee welfare benefit plan
2-15 as defined in Section 3(1) of the Employee Retirement Income
2-16 Security Act of 1974 (29 U.S.C. Section 1002(1)) must meet the
2-17 requirements of Subsections (b) and (c) of this section regarding
2-18 parity in annual and lifetime aggregate dollar limits between
2-19 medical and surgical benefits and mental illness benefits, unless
2-20 exempted under Section 4 of this article.
2-21 (b) In the case of coverage that provides both medical and
2-22 surgical benefits and mental health benefits:
2-23 (1) if the coverage does not include an aggregate
2-24 lifetime limit on substantially all medical and surgical benefits,
2-25 the coverage may not impose any aggregate lifetime limit on mental
2-26 health benefits; and
2-27 (2) if the coverage includes an aggregate lifetime
2-28 limit on substantially all medical and surgical benefits, in this
2-29 article referred to as the "applicable lifetime limit," the
2-30 coverage shall either:
2-31 (A) apply the applicable lifetime limit both to
2-32 the medical and surgical benefits to which it otherwise would apply
2-33 and to mental health benefits and not distinguish in the
2-34 application of such limit between medical and surgical benefits and
2-35 mental health benefits; or
2-36 (B) not include any aggregate lifetime limit on
2-37 mental health benefits that is less than the applicable lifetime
2-38 limit.
2-39 (c) In the case of coverage that is not described in
2-40 Subsection (b) of this section and that includes no or different
2-41 aggregate lifetime limits on different categories of medical and
2-42 surgical benefits, the insurer must follow rules promulgated by the
2-43 Secretary of the Treasury under the Mental Health Parity Act of
2-44 1996 (Title VII, Pub. L. No. 104-204), under which the rule in
2-45 Subsection (b)(2) of this section is applied to such coverage with
2-46 respect to mental health benefits by substituting for the
2-47 applicable lifetime limit an average aggregate lifetime limit that
2-48 is computed taking into account the weighted average of the
2-49 aggregate lifetime limits applicable to such categories.
2-50 (d) In the case of coverage that provides both medical and
2-51 surgical benefits and mental health benefits:
2-52 (1) if the coverage does not include an annual limit
2-53 on substantially all medical and surgical benefits, the coverage
2-54 may not impose any annual limit on mental health benefits; and
2-55 (2) if the coverage includes an annual limit on
2-56 substantially all medical and surgical benefits, in this article
2-57 referred to as the "applicable annual limit," the coverage shall
2-58 either:
2-59 (A) apply the applicable annual limit both to
2-60 medical and surgical benefits to which it otherwise would apply and
2-61 to mental health benefits and not distinguish in the application of
2-62 such limit between such medical and surgical benefits and mental
2-63 health benefits; or
2-64 (B) not include any annual limit on mental
2-65 health benefits that is less than the applicable annual limit.
2-66 (e) In the case of coverage that is not described in
2-67 Subsection (d) of this section and that includes no or different
2-68 annual limits on different categories of medical and surgical
2-69 benefits, the insurer must follow rules promulgated by the
3-1 Secretary of the Treasury under the Mental Health Parity Act of
3-2 1996 (Title VII, Pub. L. No. 104-204), under which the rule in
3-3 Subsection (d)(2) of this section is applied to such coverage with
3-4 respect to mental health benefits by substituting for the
3-5 applicable annual limit an average aggregate annual limit that is
3-6 computed taking into account the weighted average of the aggregate
3-7 annual limits applicable to such categories.
3-8 (f) Nothing in this section shall be construed:
3-9 (1) as requiring an insurer to provide or offer any
3-10 mental health benefits, except as otherwise specified in this code;
3-11 or
3-12 (2) in the case of coverage that provides mental
3-13 health benefits, as affecting the terms and conditions, including
3-14 cost sharing, limits on numbers of visits or days of coverage, and
3-15 requirements relating to medical necessity, relating to the amount,
3-16 duration, or scope of mental health benefits under the coverage,
3-17 except as specifically provided in this article in regard to parity
3-18 in the imposition of aggregate lifetime limits and annual limits
3-19 for mental health benefits.
3-20 Sec. 4. EXEMPTIONS. (a) This section does not apply to
3-21 coverage offered to an employee welfare benefit plan of an employer
3-22 who, with respect to a calendar year and a plan year, employed an
3-23 average of at least two but not more than 50 employees on business
3-24 days during the preceding calendar year and who employs at least
3-25 two employees on the first day of the plan year, in this article
3-26 referred to as an "exempt employer."
3-27 (b) In determining employer size for purposes of this
3-28 section:
3-29 (1) rules under Subsections (b), (c), (m), and (o),
3-30 Section 414 of the Internal Revenue Code of 1986 (26 U.S.C. Section
3-31 414) shall apply for purposes of treating persons as a single
3-32 employer;
3-33 (2) in the case of an employer which was not in
3-34 existence throughout the preceding calendar year, the determination
3-35 of whether the employer is an exempt employer shall be based on the
3-36 average number of employees that it is reasonably expected such
3-37 employer will employ on business days in the current calendar year;
3-38 and
3-39 (3) any reference in this section to an employer shall
3-40 include a reference to any predecessor of such employer.
3-41 (c) This section shall not apply with respect to insurance
3-42 coverage offered to an employee welfare benefit plan if the
3-43 application of this section to the coverage results in an increase
3-44 in the cost for the coverage of at least one percent.
3-45 Sec. 5. SEPARATE APPLICATION TO EACH OPTION OFFERED. In the
3-46 case of an employee welfare benefit plan that offers a participant
3-47 or beneficiary two or more benefit package options under the plan,
3-48 the requirements of this article shall be applied separately to
3-49 each coverage package offered by an insurer or provider with
3-50 respect to each option.
3-51 Sec. 6. RULEMAKING AUTHORITY. The commissioner may
3-52 promulgate reasonable rules to implement this article and to
3-53 coordinate or comply with minimum requirements of federal law and
3-54 regulations relating to parity of mental health benefits with any
3-55 other health and accident benefits.
3-56 SECTION 4. Subsections (E), (F), (I), and (K), Section 2,
3-57 Chapter 397, Acts of the 54th Legislature, 1955 (Article 3.70-2,
3-58 Vernon's Texas Insurance Code), are amended to read as follows:
3-59 (E) No individual policy or group policy of accident and
3-60 sickness insurance, including policies issued by companies subject
3-61 to Chapter 20, [Texas] Insurance Code, [as amended,] delivered or
3-62 issued for delivery to any person in this state which provides for
3-63 accident and sickness coverage of immediate family or children of
3-64 an enrollee, which permits the enrollment of any enrollee's
3-65 immediate family or [additional newborn] children for such
3-66 coverage, or which provides maternity benefits[,] may be issued in
3-67 this state if it contains any provisions excluding or limiting
3-68 initial coverage of a newborn infant for a period of time, or
3-69 limitations or exclusions for congenital defects of a newborn
4-1 child.
4-2 (F) A group policy of accident and sickness insurance
4-3 delivered or issued for delivery to a person in this state,
4-4 including a group policy issued by a company subject to Chapter 20,
4-5 Insurance Code, or the Texas Health Maintenance Organization Act
4-6 (Chapter 20A, Vernon's Texas Insurance Code), that provides
4-7 coverage for treatment of mental or emotional illness or disorder
4-8 for a person when confined in a hospital must also provide that
4-9 coverage, which is not less favorable, shall be applicable for
4-10 treatment under the direction and continued medical supervision of
4-11 a doctor of medicine or doctor of osteopathy in a psychiatric day
4-12 treatment facility that provides organizational structure and
4-13 individualized treatment plans separate from an in-patient program;
4-14 subject to the same durational limits, deductibles, and coinsurance
4-15 factors. Any benefits so provided shall be determined as if
4-16 necessary care and treatment in a psychiatric day treatment
4-17 facility were in-patient care and treatment in a hospital, and each
4-18 full day of treatment in a psychiatric day treatment facility shall
4-19 be considered equal to one-half of one day of treatment of mental
4-20 or emotional illness or disorder in a hospital or in-patient
4-21 program for the purpose of determining policy benefits and benefit
4-22 maximums. An insurer shall offer and the policyholder shall have
4-23 the right to reject such coverage for treatment of mental or
4-24 emotional illness or disorder when confined in a hospital or in a
4-25 psychiatric day treatment facility or may select an alternative
4-26 level of benefits thereunder if such coverage is offered by or
4-27 negotiated with such insurer, service plan corporation or health
4-28 maintenance organization, except that[; provided, however,] any
4-29 such alternative level of benefits shall provide policy benefits
4-30 and benefit maximums for treatment in psychiatric day treatment
4-31 facilities equal to at least one half of that provided for
4-32 treatment in hospital facilities, but not to exceed the usual and
4-33 customary charge of the psychiatric day treatment facility, and any
4-34 coverage provided to an employee welfare benefit plan as defined in
4-35 Section 3(1) of the Employee Retirement Income Security Act of 1974
4-36 (29 U.S.C. Section 1002(1)) must comply with Article 3.51-15,
4-37 Insurance Code. Any such policy may require that the treatment
4-38 must be provided by a day treatment facility that treats a patient
4-39 for not more than eight hours in any 24-hour period, that the
4-40 attending physician certifies that such treatment is in lieu of
4-41 hospitalization, and that the psychiatric treatment facility is
4-42 accredited by the Program for Psychiatric Facilities, or its
4-43 successor, of the Joint Commission on Accreditation of Hospitals.
4-44 For the purpose of this subsection a psychiatric day treatment
4-45 facility is a mental health facility which provides treatment for
4-46 individuals suffering from acute, mental and nervous disorders in a
4-47 structured psychiatric program utilizing individualized treatment
4-48 plans with specific attainable goals and objectives appropriate
4-49 both to the patient and the treatment modality of the program and
4-50 that is clinically supervised by a doctor of medicine who is
4-51 certified in psychiatry by the American Board of Psychiatry and
4-52 Neurology.
4-53 (I) An individual or group policy of accident and sickness
4-54 insurance that provides any emergency care benefit, including
4-55 policies issued by companies subject to Chapter 20, Insurance Code,
4-56 delivered or issued for delivery in this state must define
4-57 emergency care as follows: "Emergency care" means health care
4-58 [bona fide emergency] services provided in a hospital emergency
4-59 facility or comparable facility to evaluate and stabilize medical
4-60 conditions of a recent [after the sudden] onset and [of a medical
4-61 condition manifesting itself by acute symptoms of sufficient]
4-62 severity, including but not limited to severe pain, [such] that
4-63 would lead a prudent layperson possessing an average knowledge of
4-64 medicine and health to believe that his or her condition, sickness,
4-65 or injury is of such a nature that failure to get [the absence of]
4-66 immediate medical care [attention] could [reasonably be expected
4-67 to] result in:
4-68 (1) placing the patient's health in serious jeopardy;
4-69 (2) serious impairment to bodily functions; [or]
5-1 (3) serious dysfunction of any bodily organ or part;
5-2 (4) serious disfigurement; or
5-3 (5) in the case of a pregnant woman, serious jeopardy
5-4 to the health of the fetus.
5-5 (K) An accident and sickness insurance policy that provides
5-6 coverage for the immediate family or children of a person insured
5-7 under the policy may not exclude from coverage or limit coverage to
5-8 a child of the insured solely because the child is adopted. The
5-9 insurer shall provide full coverage under the policy to the child
5-10 without limiting coverage of a preexisting condition if an
5-11 application for the child is made not later than the 31st day after
5-12 the date on which the adoption is final or, for the period during
5-13 which the adoption is not final, not later than the 31st day after
5-14 the date on which the insured becomes a party in a suit in which
5-15 adoption of the child by the insured is sought. For the purposes
5-16 of this subsection, a child is considered to be the child of an
5-17 insured if the insured is a party in a suit in which the adoption
5-18 of the child by the insured is sought.
5-19 SECTION 5. Section 9, Texas Health Maintenance Organization
5-20 Act (Article 20A.09, Vernon's Texas Insurance Code), is amended by
5-21 adding Subsections (k), (l), and (m) to read as follows:
5-22 (k)(1) A health maintenance organization shall provide a
5-23 group continuation privilege as required by this subsection. Any
5-24 enrollee whose coverage under the group contract has been
5-25 terminated for any reason except involuntary termination for cause
5-26 and who has been continuously covered under the group contract and
5-27 under any group contract providing similar services and benefits
5-28 which it replaces for at least three consecutive months immediately
5-29 prior to termination shall be entitled to the group continuation
5-30 privilege as outlined in this subsection. Involuntary termination
5-31 for cause does not include termination for any health-related
5-32 cause. Health maintenance organization contracts subject to this
5-33 section shall provide continuation of group coverage for enrollees
5-34 subject to the following eligibility provisions:
5-35 (A) continuation of group coverage must be
5-36 requested in writing not later than the 31st day after the later
5-37 of:
5-38 (i) the date the group coverage would
5-39 otherwise terminate; or
5-40 (ii) the date the enrollee is given notice
5-41 of the right of continuation by either the employer or the group
5-42 contract holder;
5-43 (B) an enrollee electing continuation must pay
5-44 to the group contract holder or employer on a monthly basis, in
5-45 advance, the amount of contribution required by the contract holder
5-46 or employer, plus two percent of the group rate for the coverage
5-47 being continued under the group contract, on the due date of each
5-48 payment;
5-49 (C) the enrollee's written election of
5-50 continuation, together with the first contribution required to
5-51 establish contributions on a monthly basis, in advance, must be
5-52 given to the contract holder or employer not later than the 31st
5-53 day after the later of:
5-54 (i) the date the group coverage would
5-55 otherwise terminate; or
5-56 (ii) the date the enrollee is given notice
5-57 of the right of continuation by either the employer or the group
5-58 contract holder;
5-59 (D) continuation may not terminate until the
5-60 earliest of:
5-61 (i) 180 days after the date the election
5-62 is made;
5-63 (ii) the date on which failure to make
5-64 timely payments would terminate coverage;
5-65 (iii) the date on which the covered person
5-66 is covered for similar services and benefits by another hospital,
5-67 surgical, medical, or major medical expense insurance policy or
5-68 hospital or medical service subscriber contract or medical practice
5-69 or other prepayment plan or any other plan or program; or
6-1 (iv) the date on which the group coverage
6-2 terminates in its entirety; and
6-3 (E) not less than 30 days before the end of the
6-4 180-day period following the date the enrollee elects continuation
6-5 of the contract, the health maintenance organization shall notify
6-6 the enrollee that the enrollee may be eligible for coverage under
6-7 the Texas Health Insurance Risk Pool as provided under Article
6-8 3.77, Insurance Code, and shall provide the address for applying to
6-9 such pool to the enrollee.
6-10 (2) A health maintenance organization may offer to
6-11 each enrollee a conversion contract. Such conversion contract
6-12 shall be issued without evidence of insurability if a written
6-13 application and payment of the first premium are made not later
6-14 than the 31st day after the date of termination. The conversion
6-15 contract shall meet the minimum standards for services and benefits
6-16 for conversion contracts. The commissioner shall issue rules and
6-17 regulations to establish minimum standards for services and
6-18 benefits under contracts issued pursuant to this subsection.
6-19 (3) The premium for a conversion contract issued under
6-20 this Act shall be determined in accordance with the health
6-21 maintenance organization's premium rates for coverage that were
6-22 provided under the group contract or plan. The premium may be
6-23 based on the geographic location of each person to be covered and
6-24 the type of conversion contract and coverage provided. The premium
6-25 for the same coverage under a conversion contract may not exceed
6-26 200 percent of the premium determined in accordance with this
6-27 subdivision. The premium must be based on the type of conversion
6-28 contract and the coverage provided by the contract.
6-29 (l)(1) An individual health care plan provided by a health
6-30 maintenance organization must meet the requirements of this
6-31 subsection.
6-32 (2) For purposes of this subsection, an "individual
6-33 health care plan" means a health care plan:
6-34 (A) which provides health care services for
6-35 individuals and their dependents;
6-36 (B) in which an enrollee pays the premium and is
6-37 not being covered under a contract pursuant to continuation of
6-38 services and benefits provisions applicable under federal or state
6-39 law; and
6-40 (C) in which the evidence of coverage meets the
6-41 requirements of Section 2(a) of this Act.
6-42 (3) A health maintenance organization may limit its
6-43 enrollees to those who live, reside, or work within the service
6-44 area for an individual health care plan.
6-45 (4) An individual health care plan or a conversion
6-46 contract providing health care services shall be renewable with
6-47 respect to an enrollee at the option of the enrollee and may be
6-48 nonrenewed only if:
6-49 (A) premiums or contributions have not been paid
6-50 in accordance with the terms of the plan or the issuer has not
6-51 received timely premium payments;
6-52 (B) fraud or intentional misrepresentation has
6-53 occurred;
6-54 (C) the health maintenance organization is
6-55 ceasing to offer coverage in the individual market in accordance
6-56 with rules established by the commissioner;
6-57 (D) the enrollee no longer lives, resides, or
6-58 works in the area in which the health maintenance organization is
6-59 authorized to provide coverage, but only if coverage is terminated
6-60 under this paragraph uniformly without regard to any health
6-61 status-related factor of covered enrollees; or
6-62 (E) the nonrenewal is in accordance with
6-63 applicable federal law and regulations.
6-64 (5) The commissioner may adopt rules necessary to
6-65 implement this section and to meet the minimum requirements of
6-66 federal law and regulations.
6-67 (6) A health maintenance organization may impose an
6-68 affiliation period as an alternative to a preexisting condition
6-69 limitation. For the purposes of this subdivision, "affiliation
7-1 period" means a period not to exceed 60 days, or 90 days in the
7-2 case of a late enrollee, during which no premiums shall be
7-3 collected and coverage issued will not become effective. An
7-4 affiliation period shall be waived for the period an individual was
7-5 covered by qualifying previous coverage, provided that the
7-6 qualifying previous coverage was continuous to a date not more than
7-7 60 days prior to the effective date of the new coverage. An
7-8 affiliation period must be applied uniformly without regard to any
7-9 health status-related factors.
7-10 (7) A health maintenance organization may not modify
7-11 an individual health care plan with respect to an enrollee or
7-12 dependent through riders or endorsements based on health status or
7-13 claim experience or otherwise restrict or exclude coverage of
7-14 benefits for specific diseases, medical services, or conditions
7-15 otherwise covered by the health benefit plan.
7-16 (8) Denial by a health maintenance organization of an
7-17 application for coverage from an individual shall be in writing and
7-18 shall state the reason or reasons for the denial.
7-19 (9) A health maintenance organization may consider age
7-20 and gender characteristics in determining and establishing the
7-21 schedule of charges for individual coverage. The rating formulas
7-22 and methods for calculating the schedule of charges must be based
7-23 on sound actuarial principles and must produce charges that are not
7-24 excessive, inadequate, or unfairly discriminatory. Benefits must
7-25 be reasonable with respect to the rates produced by the formula or
7-26 method.
7-27 (10) The commissioner shall issue rules and
7-28 regulations to establish minimum standards for benefits and
7-29 determine the percentage increase in the premium rates charged.
7-30 (m) Articles 3.51-14 and 3.51-15, Insurance Code, and
7-31 Subsections (F) and (L), Section 2, Chapter 397, Acts of the 54th
7-32 Legislature, 1955 (Article 3.70-2, Vernon's Texas Insurance Code),
7-33 apply to health maintenance organizations.
7-34 SECTION 6. The Texas Health Maintenance Organization Act
7-35 (Article 20A, Vernon's Texas Insurance Code), is amended by adding
7-36 Section 9A to read as follows:
7-37 Sec. 9A. REQUIRED COVERAGE FOR NEWBORNS; ADOPTED CHILDREN.
7-38 (a) Each health maintenance organization that provides coverage
7-39 for health care services for the spouse and dependent children of
7-40 an enrollee or permits the enrollment of any enrollee's immediate
7-41 family or children under a health benefit plan shall not exclude or
7-42 limit the initial coverage of a newborn child for a period of time
7-43 or exclude or limit coverage for congenital defect of a newborn
7-44 child if the child is enrolled in the health care plan not later
7-45 than the 31st day after the date of the child's birth.
7-46 (b) A health maintenance organization that provides coverage
7-47 for the immediate family or children of an enrollee or permits the
7-48 enrollment of any enrollee's immediate family or children under a
7-49 health benefit plan may not exclude from coverage in a health care
7-50 plan a child of an enrollee or limit coverage under the plan to a
7-51 child of an enrollee solely because the child is adopted. The
7-52 health maintenance organization shall provide full coverage under
7-53 the plan to the child without limiting coverage of a preexisting
7-54 condition if the child is enrolled in the plan not later than the
7-55 31st day after the date on which the adoption is final or, for the
7-56 period during which the adoption is not final, not later than the
7-57 31st day after the date on which the enrollee becomes a party in a
7-58 suit in which adoption of the child by the enrollee is sought. For
7-59 the purposes of this subsection, a child is considered to be the
7-60 child of an enrollee if the enrollee is a party in a suit in which
7-61 the adoption of the child by the enrollee is sought.
7-62 SECTION 7. Subchapter E, Chapter 21, Insurance Code, is
7-63 amended by adding Articles 21.53D and 21.53E to read as follows:
7-64 Art. 21.53D. ACCESS TO CERTAIN OBSTETRICAL OR GYNECOLOGICAL
7-65 CARE
7-66 Sec. 1. DEFINITIONS. In this article:
7-67 (1) "Enrollee" means an individual enrolled in a
7-68 health benefit plan.
7-69 (2) "Health benefit plan" means a plan described in
8-1 Section 2 of this article.
8-2 (3) "Physician" means a person licensed as a physician
8-3 by the Texas State Board of Medical Examiners.
8-4 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
8-5 health benefit plan that:
8-6 (1) provides benefits for medical or surgical expenses
8-7 incurred as a result of a health condition, accident, or sickness,
8-8 including:
8-9 (A) an individual, group, blanket, or franchise
8-10 insurance policy or insurance agreement, a group hospital service
8-11 contract, or an individual or group evidence of coverage that is
8-12 offered by:
8-13 (i) an insurance company;
8-14 (ii) a group hospital service corporation
8-15 operating under Chapter 20 of this code;
8-16 (iii) a fraternal benefit society
8-17 operating under Chapter 10 of this code;
8-18 (iv) a stipulated premium insurance
8-19 company operating under Chapter 22 of this code; or
8-20 (v) a health maintenance organization
8-21 operating under the Texas Health Maintenance Organization Act
8-22 (Chapter 20A, Vernon's Texas Insurance Code); and
8-23 (B) to the extent permitted by the Employee
8-24 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
8-25 seq.), a health benefit plan that is offered by:
8-26 (i) a multiple employer welfare
8-27 arrangement as defined by Section 3, Employee Retirement Income
8-28 Security Act of 1974 (29 U.S.C. Section 1002); or
8-29 (ii) another analogous benefit
8-30 arrangement;
8-31 (2) is offered by an approved nonprofit health
8-32 corporation that is certified under Section 5.01(a), Medical
8-33 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
8-34 that holds a certificate of authority issued by the commissioner
8-35 under Article 21.52F of this code; or
8-36 (3) is offered by any other entity not licensed under
8-37 this code or another insurance law of this state that contracts
8-38 directly for health care services on a risk-sharing basis,
8-39 including an entity that contracts for health care services on a
8-40 capitation basis.
8-41 (b) This article does not apply to:
8-42 (1) a plan that provides coverage:
8-43 (A) only for a specified disease;
8-44 (B) only for accidental death or dismemberment;
8-45 (C) for wages or payments in lieu of wages for a
8-46 period during which an employee is absent from work because of
8-47 sickness or injury; or
8-48 (D) as a supplement to liability insurance;
8-49 (2) a plan written under Chapter 26 of this code;
8-50 (3) a Medicare supplemental policy as defined by
8-51 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
8-52 (4) workers' compensation insurance coverage;
8-53 (5) medical payment insurance issued as a part of a
8-54 motor vehicle insurance policy;
8-55 (6) a long-term care policy, including a nursing home
8-56 fixed indemnity policy, unless the commissioner determines that the
8-57 policy provides benefit coverage so comprehensive that the policy
8-58 is a health benefit plan as described by Subsection (a) of this
8-59 section; or
8-60 (7) any health benefit plan that does not provide
8-61 pregnancy-related benefits.
8-62 (c) This article applies to each health benefit plan that
8-63 requires an enrollee to obtain certain specialty health care
8-64 services through a referral made by a primary care physician or
8-65 other gatekeeper.
8-66 Sec. 3. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. (a) Each
8-67 health benefit plan subject to this article shall permit a woman
8-68 who is entitled to coverage under the plan to select, in addition
8-69 to a primary care physician, an obstetrician or gynecologist to
9-1 provide health care services within the scope of the professional
9-2 specialty practice of a properly credentialed obstetrician or
9-3 gynecologist.
9-4 (b) The plan shall include in the classification of persons
9-5 authorized to provide medical services under the plan a number of
9-6 properly credentialed obstetricians and gynecologists sufficient to
9-7 ensure access to the services that fall within the scope of that
9-8 credential.
9-9 (c) This section does not affect the authority of a health
9-10 benefit plan to establish selection criteria regarding other
9-11 physicians who provide services through the plan.
9-12 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
9-13 GYNECOLOGIST. (a) In addition to other benefits authorized by the
9-14 plan, each health benefit plan shall permit a woman who designates
9-15 an obstetrician or gynecologist as provided under Section 3 of this
9-16 article direct access to the health care services of the designated
9-17 obstetrician or gynecologist without a referral by the woman's
9-18 primary care physician or prior authorization or precertification
9-19 from a health benefit plan.
9-20 (b) The access to health care services required under this
9-21 article includes, but is not limited to:
9-22 (1) one well-woman examination per year;
9-23 (2) care related to pregnancy;
9-24 (3) care for all active gynecological conditions; and
9-25 (4) diagnosis, treatment, and referral for any disease
9-26 or condition within the scope of the professional practice of a
9-27 properly credentialed obstetrician or gynecologist.
9-28 (c) A health benefit plan may not impose a copayment or
9-29 deductible for direct access to the health care services of an
9-30 obstetrician or gynecologist under this section unless such an
9-31 additional cost is imposed for access to other health care services
9-32 provided under the plan.
9-33 (d) This section does not affect the authority of a health
9-34 benefit plan to require the designated obstetrician or gynecologist
9-35 to forward information concerning the medical care of the patient
9-36 to the primary care physician; however, failure to provide such
9-37 information shall not result in any penalty, financial or
9-38 otherwise, being imposed upon the obstetrician or gynecologist or
9-39 the patient by the health benefit plan.
9-40 (e) In implementing the access required under Section 3 of
9-41 this article, a health benefit plan may limit a woman enrolled in
9-42 the plan to self-referral to one participating obstetrician and
9-43 gynecologist for both gynecological care and obstetrical care.
9-44 This subsection does not affect the right of the woman to select
9-45 the physician who provides that care.
9-46 (f) A health benefit plan shall not sanction or terminate
9-47 primary care physicians as a result of female enrollees' access to
9-48 participating obstetricians and gynecologists under this section.
9-49 Sec. 5. NOTICE. Each health benefit plan shall provide to
9-50 persons covered by the plan a timely written notice in clear and
9-51 accurate language of the direct access to health care services
9-52 required by this article.
9-53 Sec. 6. RULES. The commissioner shall adopt rules as
9-54 necessary to implement this article.
9-55 Sec. 7. ADMINISTRATIVE PENALTY. An insurance company,
9-56 health maintenance organization, or other entity that operates a
9-57 health benefit plan in violation of this article is subject to an
9-58 administrative penalty as provided by Article 1.10E of this code.
9-59 Art. 21.53E. COVERAGE FOR MINIMUM INPATIENT STAY IN HEALTH
9-60 CARE FACILITY
9-61 Sec. 1. DEFINITIONS. In this article:
9-62 (1) "Health benefit plan" means a plan that is offered
9-63 by any insurer that provides benefits for medical or surgical
9-64 expenses incurred as a result of a health condition, accident, or
9-65 sickness or that is offered by any insurance company, group
9-66 hospital service corporation subject to Chapter 20 of this code,
9-67 fraternal benefit society subject to Chapter 10 of this code,
9-68 stipulated premium insurance company subject to Chapter 22 of this
9-69 code, health maintenance organization subject to the Texas Health
10-1 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
10-2 Code), or multiple employer welfare arrangement subject to Article
10-3 3.95-1 of this code that delivers or issues for delivery an
10-4 individual, group, blanket, or franchise insurance policy,
10-5 certificate of insurance agreement, a group hospital service
10-6 contract, or individual evidence of coverage. The term does not
10-7 include:
10-8 (A) a plan that provides coverage:
10-9 (i) only for accidental death or
10-10 dismemberment or a specified disease;
10-11 (ii) for wages or payments in lieu of
10-12 wages for a period during which an employee is absent from work
10-13 because of sickness or injury; or
10-14 (iii) as a supplement to liability
10-15 insurance;
10-16 (B) a Medicare supplemental policy as defined by
10-17 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
10-18 (C) workers' compensation insurance coverage;
10-19 (D) medical payment insurance issued as part of
10-20 a motor vehicle insurance policy; or
10-21 (E) a long-term care policy, including a nursing
10-22 home fixed indemnity policy.
10-23 (2) "Provider" means a physician or other
10-24 appropriately licensed health care provider acting within the scope
10-25 of the physician's or other provider's license who attends an
10-26 individual who has given birth or who attends the newborn child.
10-27 Sec. 2. REQUIRED COVERAGE FOR MINIMUM INPATIENT STAY
10-28 FOLLOWING BIRTH; EXCEPTION. (a) A health benefit plan that
10-29 provides maternity benefits, including benefits for childbirth,
10-30 must:
10-31 (1) include coverage for patient care for a mother and
10-32 her newborn child in a health care facility for a minimum of:
10-33 (A) 48 hours following a vaginal delivery; and
10-34 (B) 96 hours following a delivery by caesarean
10-35 section; and
10-36 (2) provide for maternity and pediatric care in
10-37 accordance with guidelines established by the American College of
10-38 Obstetricians and Gynecologists, the American Academy of
10-39 Pediatrics, or other established medical associations.
10-40 (b) Notwithstanding Subsection (a) of this section, the
10-41 hospital length of stay shall be left to the decision of the
10-42 provider in consultation with the mother.
10-43 Sec. 3. RULES. The commissioner shall adopt rules as
10-44 necessary to administer this article.
10-45 SECTION 8. This Act takes effect July 1, 1997, and, except
10-46 as provided by Sections 9 and 10 of this Act, applies only to an
10-47 insurance policy, contract, or evidence of coverage that is issued,
10-48 delivered, or renewed on or after the effective date of this Act.
10-49 A policy, contract, or evidence of coverage that is issued,
10-50 delivered, or renewed before July 1, 1997, is governed by the law
10-51 as it existed immediately before the effective date of this Act,
10-52 and that law is continued in effect for that purpose.
10-53 SECTION 9. The requirements of Article 3.51-15, Insurance
10-54 Code, as added by Section 3 of this Act, apply to an insurance
10-55 policy or evidence of coverage that is issued, delivered, or
10-56 renewed on or after January 1, 1998.
10-57 SECTION 10. The requirements of Articles 21.53D and 21.53E,
10-58 Insurance Code, as added by Section 7 of this Act, apply to an
10-59 insurance policy or evidence of coverage that is issued, delivered,
10-60 or renewed on or after January 1, 1998.
10-61 SECTION 11. The importance of this legislation and the
10-62 crowded condition of the calendars in both houses create an
10-63 emergency and an imperative public necessity that the
10-64 constitutional rule requiring bills to be read on three several
10-65 days in each house be suspended, and this rule is hereby suspended,
10-66 and that this Act take effect and be in force according to its
10-67 terms, and it is so enacted.
10-68 * * * * *