By: Ellis S.B. No. 1687
97S0817/1
A BILL TO BE ENTITLED
AN ACT
1-1 relating to coverage by certain health benefit plans for children
1-2 with serious emotional disturbances.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Article 3.51-14, Insurance Code, is amended to
1-5 read as follows:
1-6 Art. 3.51-14. MANDATORY PROVISION OF BENEFITS FOR CERTAIN
1-7 SERIOUS MENTAL ILLNESSES
1-8 Sec. 1. DEFINITIONS [DEFINITION]. For purposes of this
1-9 article:
1-10 (1) "Child with serious emotional disturbances" means
1-11 a person less than 18 years of age who currently or at any time
1-12 during the past year has had a diagnosable mental, behavioral, or
1-13 emotional disorder of sufficient duration to meet diagnostic
1-14 criteria specified within the Diagnostic and Statistical Manual
1-15 (DSM) III-R that resulted in functional impairment which
1-16 substantially interferes with or limits the person's role or
1-17 functioning in family, school, or community.
1-18 (2) "Health benefit plan" means a plan described by
1-19 Section 2 of this article.
1-20 (3) "Serious [, "serious] mental illness" means:
1-21 (A) the following psychiatric illnesses as
1-22 defined by the American Psychiatric Association in the Diagnostic
1-23 and Statistical Manual (DSM) III-R:
2-1 (i) [(1)] schizophrenia;
2-2 (ii) [(2)] paranoid and other psychotic
2-3 disorders;
2-4 (iii) [(3)] bipolar disorders (mixed,
2-5 manic, and depressive);
2-6 (iv) [(4)] major depressive disorders
2-7 (single episode or recurrent); and
2-8 (v) [(5)] schizo-affective disorders
2-9 (bipolar or depressive); and
2-10 (B) the mental condition of a child with serious
2-11 emotional disturbance.
2-12 Sec. 2. SCOPE OF ARTICLE [MANDATORY COVERAGE; EXEMPTION].
2-13 (a) This article applies only to a health benefit plan that
2-14 provides benefits for medical or surgical expenses incurred as a
2-15 result of a health condition, accident, or sickness, including:
2-16 (1) an individual, group, blanket, or franchise
2-17 insurance policy or insurance agreement, a group hospital service
2-18 contract, or an individual or group evidence of coverage that is
2-19 offered by:
2-20 (A) an insurance company;
2-21 (B) a group [Each insurer, nonprofit] hospital
2-22 service [plan] corporation operating under [subject to] Chapter 20
2-23 of this code;
2-24 (C) a[,] health maintenance organization
2-25 operating under [subject to] the Texas Health Maintenance
3-1 Organization Act (Chapter 20A, Vernon's Texas Insurance Code);
3-2 (D) a fraternal benefit society operating under
3-3 Chapter 10 of this code; or
3-4 (E) a stipulated premium insurance company
3-5 operating under Chapter 22 of this code; and
3-6 (2) to the extent permitted by the Employee Retirement
3-7 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
3-8 health benefit plan that is offered by:
3-9 (A) a multiple employer welfare arrangement as
3-10 defined by Section 3, Employee Retirement Income Security Act of
3-11 1974 (29 U.S.C. Section 1002); or
3-12 (B) another analogous benefit arrangement[,
3-13 employer, multiple employer, union, association, trustee, or other
3-14 self-funded or self-insured welfare or benefit plan, program, or
3-15 arrangement that issues group health insurance policies, enters
3-16 into health care service contracts or plans, or provides for group
3-17 health benefits, coverage, or services in this state for hospital,
3-18 medical, or surgical expenses incurred as a result of accident or
3-19 sickness shall offer and make available to each group policyholder,
3-20 contract holder, employer, multiple employer, union, association,
3-21 or trustee under a group policy, contract, plan, program, or
3-22 arrangement that provides hospital, surgical, and medical benefits,
3-23 coverage for services and benefits on an expense incurred, service,
3-24 or prepaid basis for expenses incurred for the necessary care,
3-25 diagnosis, and treatment of serious mental illnesses].
4-1 (b) This article [section] does not apply to coverage under:
4-2 (1) a blanket accident and health insurance policy as
4-3 that term is defined under Section 2, Article 3.51-6 of this code;
4-4 (2) a short-term travel policy;
4-5 (3) an accident-only policy;
4-6 (4) a limited or specified-disease policy; or
4-7 (5) a medicare supplement policy, as that term is
4-8 defined under Section 1(3), Article 3.74 of this code.
4-9 Sec. 3. MENTAL HEALTH [LEVEL OF] COVERAGE. A health benefit
4-10 plan must provide coverage for the medical treatment of serious
4-11 mental illness under the same terms and conditions as coverage is
4-12 provided for other illnesses. The coverage offered under this
4-13 article [for services and benefits for the condition of serious
4-14 mental illness must be at least as favorable as the coverage made
4-15 available for services and benefits provided by the insuring entity
4-16 for other major illnesses and] must include the same durational
4-17 limits, amount limits, deductibles, and coinsurance factors for
4-18 serious mental illness as for other illnesses.
4-19 SECTION 2. This Act takes effect September 1, 1997, and
4-20 applies only to a health benefit plan that is delivered, issued for
4-21 delivery, or renewed on or after January 1, 1998. A health benefit
4-22 plan that is delivered, issued for delivery, or renewed before
4-23 January 1, 1998, is governed by the law as it existed immediately
4-24 before the effective date of this Act, and that law is continued in
4-25 effect for that purpose.
5-1 SECTION 3. The importance of this legislation and the
5-2 crowded condition of the calendars in both houses create an
5-3 emergency and an imperative public necessity that the
5-4 constitutional rule requiring bills to be read on three several
5-5 days in each house be suspended, and this rule is hereby suspended.