By Shapiro S.B. No. 668
75R5657 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage under certain group health benefit plans for
1-3 the diagnosis and treatment of infertility.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53I to read as follows:
1-7 Art. 21.53I. COVERAGE FOR DIAGNOSIS AND TREATMENT OF
1-8 INFERTILITY
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Enrollee" means an insured, a subscriber, an
1-11 employee, a member, or another person covered under a group health
1-12 benefit plan.
1-13 (2) "Group health benefit plan" means a group plan
1-14 described by Section 2 of this article.
1-15 (3) "Infertility" means:
1-16 (A) a disease or condition that causes the
1-17 abnormal function of the female reproductive system, resulting in
1-18 the inability to:
1-19 (i) conceive after attempts at conception
1-20 by the use of unprotected sexual intercourse have been made during
1-21 one year; or
1-22 (ii) sustain a pregnancy to a live birth;
1-23 or
1-24 (B) the presence of another demonstrated
2-1 condition recognized by a licensed physician as a cause of the
2-2 inability to conceive or sustain a pregnancy to a live birth.
2-3 (4) "Infertility services" means health care benefits
2-4 provided to an enrollee to medically treat infertility. The term
2-5 includes:
2-6 (A) drug therapy;
2-7 (B) in vitro fertilization;
2-8 (C) uterine embryo lavage;
2-9 (D) embryo transfer;
2-10 (E) artificial insemination;
2-11 (F) gamete intrafallopian tube transfer;
2-12 (G) zygote intrafallopian tube transfer; and
2-13 (H) any other medically indicated
2-14 nonexperimental service or procedure that is used to treat
2-15 infertility or induce pregnancy.
2-16 (5) "Reproductive health services" means benefits
2-17 provided under a group health benefit plan for pregnancy-related
2-18 services and services associated with the diagnosis and treatment
2-19 of infertility.
2-20 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
2-21 group health benefit plan that:
2-22 (1) provides benefits for medical or surgical expenses
2-23 incurred as a result of a health condition, accident, or sickness,
2-24 including:
2-25 (A) a group, blanket, or franchise insurance
2-26 policy or insurance agreement, a group hospital service contract,
2-27 or a group evidence of coverage that is offered by:
3-1 (i) an insurance company;
3-2 (ii) a group hospital service corporation
3-3 operating under Chapter 20 of this code;
3-4 (iii) a fraternal benefit society
3-5 operating under Chapter 10 of this code;
3-6 (iv) a stipulated premium insurance
3-7 company operating under Chapter 22 of this code; or
3-8 (v) a health maintenance organization
3-9 operating under the Texas Health Maintenance Organization Act
3-10 (Chapter 20A, Vernon's Texas Insurance Code); and
3-11 (B) to the extent permitted by the Employee
3-12 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
3-13 seq.), a health benefit plan that is offered by:
3-14 (i) a multiple employer welfare
3-15 arrangement as defined by Section 3, Employee Retirement Income
3-16 Security Act of 1974 (29 U.S.C. Section 1002); or
3-17 (ii) another analogous benefit
3-18 arrangement;
3-19 (2) is offered by an approved nonprofit health
3-20 corporation that is certified under Section 5.01(a), Medical
3-21 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-22 that holds a certificate of authority issued by the commissioner
3-23 under Article 21.52F of this code; or
3-24 (3) is offered by any other entity not licensed under
3-25 this code or another insurance law of this state that contracts
3-26 directly for health care services on a risk-sharing basis,
3-27 including an entity that contracts for health care services on a
4-1 capitation basis.
4-2 (b) This article does not apply to:
4-3 (1) a plan that provides coverage:
4-4 (A) only for a specified disease;
4-5 (B) only for accidental death or dismemberment;
4-6 (C) for wages or payments in lieu of wages for a
4-7 period during which an employee is absent from work because of
4-8 sickness or injury; or
4-9 (D) as a supplement to liability insurance;
4-10 (2) a plan written under Chapter 26 of this code;
4-11 (3) a Medicare supplemental policy as defined by
4-12 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
4-13 (4) workers' compensation insurance coverage;
4-14 (5) medical payment insurance issued as part of a
4-15 motor vehicle insurance policy; or
4-16 (6) a long-term care policy, including a nursing home
4-17 fixed indemnity policy, unless the commissioner determines that the
4-18 policy provides benefit coverage so comprehensive that the policy
4-19 is a health benefit plan as described by Subsection (a) of this
4-20 section.
4-21 Sec. 3. APPLICATION. This article does not apply to a
4-22 group health benefit plan issued to an employer who has fewer than
4-23 25 employees.
4-24 Sec. 4. COVERAGE REQUIRED. (a) Each group health benefit
4-25 plan subject to this article that otherwise provides coverage for
4-26 pregnancy-related services must provide to enrollees covered by the
4-27 plan coverage for:
5-1 (1) diagnostic testing associated with the treatment
5-2 of infertility; and
5-3 (2) infertility services.
5-4 (b) Benefits for the diagnostic testing and infertility
5-5 services must be provided to the same extent as benefits are
5-6 provided under the group health benefit plan for other
5-7 pregnancy-related services.
5-8 Sec. 5. LIMITATIONS; REQUIRED CONDITIONS. (a) Coverage for
5-9 diagnostic testing under this article is required only if the
5-10 patient for the procedure is an enrollee or is otherwise covered
5-11 under the group health benefit plan.
5-12 (b) Coverage for in vitro fertilization, gamete
5-13 intrafallopian tube transfer, or zygote intrafallopian tube
5-14 transfer is required only if:
5-15 (1) the patient for the procedure is an enrollee or is
5-16 otherwise covered under the group health benefit plan;
5-17 (2) the patient has been unable to sustain a pregnancy
5-18 to live birth through reasonable, less costly, and medically
5-19 appropriate infertility treatments for which coverage is available
5-20 under the group health benefit plan; and
5-21 (3) the procedure is performed at a medical facility
5-22 that conforms to guidelines for in vitro fertilization clinics or
5-23 programs established by:
5-24 (A) the American College of Obstetricians and
5-25 Gynecologists;
5-26 (B) the American Society of Reproductive
5-27 Medicine; or
6-1 (C) another nationally recognized organization
6-2 of obstetricians and gynecologists.
6-3 (c) In addition to the conditions imposed under Subsections
6-4 (a) and (b) of this section, an enrollee is not entitled to more
6-5 than two completed oocyte removals.
6-6 Sec. 6. REQUIRED NOTICE. (a) Each group health benefit
6-7 plan that offers reproductive health services shall provide written
6-8 notice to each enrollee in the plan of the coverage provided for
6-9 those services. The plan shall provide the notice in accordance
6-10 with rules adopted by the commissioner.
6-11 (b) The notice required under this section must be
6-12 prominently positioned in any literature or correspondence made
6-13 available or distributed by the group health benefit plan to
6-14 enrollees.
6-15 Sec. 7. EXEMPTION. An insurer that is owned by or that is
6-16 part of an entity, group, or order that is directly affiliated with
6-17 a bona fide religious denomination that includes as an integral
6-18 part of its beliefs and practices the tenet that specific
6-19 infertility services are contrary to the moral principles that the
6-20 religious denomination considers to be an essential part of its
6-21 beliefs is exempt from the requirement to offer coverage for that
6-22 particular infertility service.
6-23 SECTION 2. Section 3A, Article 3.51-6, Insurance Code, is
6-24 repealed.
6-25 SECTION 3. This Act takes effect September 1, 1997, and
6-26 applies only to an insurance policy or an evidence of coverage that
6-27 is delivered, issued for delivery, or renewed on or after January
7-1 1, 1998. A policy or evidence of coverage that is delivered,
7-2 issued for delivery, or renewed before January 1, 1998, is governed
7-3 by the law as it existed immediately before the effective date of
7-4 this Act, and that law is continued in effect for that purpose.
7-5 SECTION 4. The importance of this legislation and the
7-6 crowded condition of the calendars in both houses create an
7-7 emergency and an imperative public necessity that the
7-8 constitutional rule requiring bills to be read on three several
7-9 days in each house be suspended, and this rule is hereby suspended.