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.