By Dukes H.B. No. 859
76R3980 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to certain health benefit plan coverages involving women's
1-3 health issues.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 21.53C, Insurance Code, is amended to
1-6 read as follows:
1-7 Art. 21.53C. BENEFITS FOR DETECTION AND PREVENTION OF
1-8 OSTEOPOROSIS
1-9 Sec. 1. DEFINITION. In this article, "qualified [UNDER
1-10 GROUP POLICIES. (a) In this article, "group health insurance
1-11 policy" means a group insurance policy, group hospital service
1-12 contract, or group contract issued by a health maintenance
1-13 organization that is delivered, issued for delivery, or renewed in
1-14 this state and that provides benefits for medical or surgical
1-15 expenses incurred as a result of accident or sickness.]
1-16 [(b) "Qualified] individual" means:
1-17 (1) a postmenopausal woman who is not receiving
1-18 estrogen replacement therapy or an individual who is estrogen
1-19 deficient and at clinical risk for osteoporosis;
1-20 (2) an individual with:
1-21 (A) vertebral abnormalities;
1-22 (B) primary hyperparathyroidism; [or]
1-23 (C) a history of bone fractures; or
1-24 (D) a specific sign suggestive of spinal
2-1 osteoporosis; or
2-2 (3) an individual who is:
2-3 (A) receiving long-term glucocorticoid therapy;
2-4 or
2-5 (B) being monitored to assess the response to or
2-6 efficacy of an approved osteoporosis drug therapy.
2-7 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
2-8 a health benefit plan that:
2-9 (1) provides benefits for medical or surgical expenses
2-10 incurred as a result of a health condition, accident, or sickness,
2-11 including:
2-12 (A) an individual, group, blanket, or franchise
2-13 insurance policy or insurance agreement, a group hospital service
2-14 contract, or an individual or group evidence of coverage that is
2-15 offered by:
2-16 (i) an insurance company;
2-17 (ii) a group hospital service corporation
2-18 operating under Chapter 20 of this code;
2-19 (iii) a fraternal benefit society
2-20 operating under Chapter 10 of this code;
2-21 (iv) a stipulated premium insurance
2-22 company operating under Chapter 22 of this code; or
2-23 (v) a health maintenance organization
2-24 operating under the Texas Health Maintenance Organization Act
2-25 (Chapter 20A, Vernon's Texas Insurance Code); or
2-26 (B) to the extent permitted by the Employee
2-27 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
3-1 seq.), a health benefit plan that is offered by a multiple employer
3-2 welfare arrangement as defined by Section 3, Employee Retirement
3-3 Income Security Act of 1974 (29 U.S.C. Section 1002), or another
3-4 analogous benefit arrangement; or
3-5 (2) is offered by an approved nonprofit health
3-6 corporation that is certified under Section 5.01(a), Medical
3-7 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-8 that holds a certificate of authority issued by the commissioner
3-9 under Article 21.52F of this code.
3-10 (b) This article does not apply to:
3-11 (1) a plan that provides coverage:
3-12 (A) only for a specified disease or other
3-13 limited benefit;
3-14 (B) only for accidental death or dismemberment;
3-15 (C) for wages or payments in lieu of wages for a
3-16 period during which an employee is absent from work because of
3-17 sickness or injury;
3-18 (D) as a supplement to liability insurance; or
3-19 (E) only for indemnity for hospital confinement
3-20 or other hospital expenses;
3-21 (2) a small employer health benefit plan written under
3-22 Chapter 26 of this code;
3-23 (3) a Medicare supplemental policy as defined by
3-24 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-25 (4) workers' compensation insurance coverage;
3-26 (5) medical payment insurance issued as part of a
3-27 motor vehicle insurance policy; or
4-1 (6) a long-term care policy, including a nursing home
4-2 fixed indemnity policy, unless the commissioner determines that the
4-3 policy provides benefit coverage so comprehensive that the policy
4-4 is a health benefit plan as described by Subsection (a) of this
4-5 section.
4-6 Sec. 3. COVERAGE REQUIRED. [(c)] A group health insurance
4-7 policy must, on the prescription of a health care provider,
4-8 provide coverage for a qualified individual covered by the policy
4-9 for:
4-10 (1) medically accepted bone mass measurement for the
4-11 detection of low bone mass and to determine the person's risk of
4-12 osteoporosis and fractures associated with osteoporosis; and
4-13 (2) hormone replacement or other drug therapies.
4-14 SECTION 2. Section 2(b), Article 21.53D, Insurance Code, as
4-15 added by Chapter 84, Acts of the 75th Legislature, Regular Session,
4-16 1997, is amended to read as follows:
4-17 (b) This article does not apply to:
4-18 (1) a plan that provides coverage:
4-19 (A) only for a specified disease except for
4-20 cancer;
4-21 (B) only for accidental death or dismemberment;
4-22 (C) for wages or payments in lieu of wages for a
4-23 period during which an employee is absent from work because of
4-24 sickness or injury;
4-25 (D) for specified accident, hospital indemnity,
4-26 or other limited benefits health insurance policies;
4-27 (E) for credit insurance;
5-1 (F) only for dental or vision care;
5-2 (G) for hospital confinement indemnity coverage
5-3 only; [or]
5-4 (H) as a supplement to liability insurance; or
5-5 (I) for one type of cancer only, as identified
5-6 by department rule, except for a plan covering breast cancer only;
5-7 (2) a small employer plan written under Chapter 26 of
5-8 this code;
5-9 (3) a Medicare supplemental policy as defined by
5-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
5-11 (4) workers' compensation insurance coverage;
5-12 (5) medical payment insurance issued as part of a
5-13 motor vehicle insurance policy; or
5-14 (6) a long-term care policy, including a nursing home
5-15 fixed indemnity policy, unless the commissioner determines that the
5-16 policy provides benefit coverage so comprehensive that the policy
5-17 is a health benefit plan as described by Subsection (a) of this
5-18 section.
5-19 SECTION 3. Section 3, Article 21.53D, Insurance Code, as
5-20 added by Chapter 84, Acts of the 75th Legislature, Regular Session,
5-21 1997, is amended to read as follows:
5-22 Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan that
5-23 provides coverage for any of the group of related diseases commonly
5-24 known as cancer must provide coverage for treatment for breast
5-25 cancer, including coverage for mastectomy and breast
5-26 reconstruction.
5-27 (b) A health benefit plan that provides coverage for
6-1 mastectomy must provide coverage for breast reconstruction.
6-2 (c) The coverage required under Subsection (a) of this
6-3 section may be subject to the same deductible or copayment
6-4 applicable to coverage for any other type of cancer treatment
6-5 [mastectomy].
6-6 SECTION 4. Article 21.53D, Insurance Code, as added by
6-7 Chapter 912, Acts of the 75th Legislature, Regular Session, 1997,
6-8 is redesignated as Article 21.53H and amended to read as follows:
6-9 Art. 21.53H [21.53D]. CARE INVOLVING CERTAIN WOMEN'S HEALTH
6-10 ISSUES [ACCESS TO CERTAIN OBSTETRICAL OR GYNECOLOGICAL CARE]
6-11 Sec. 1. DEFINITIONS. In this article:
6-12 (1) "Enrollee" means an individual enrolled in a
6-13 health benefit plan.
6-14 (2) "Health benefit plan" means a plan described in
6-15 Section 2 of this article.
6-16 (3) "Physician" means a person licensed as a physician
6-17 by the Texas State Board of Medical Examiners.
6-18 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
6-19 health benefit plan that:
6-20 (1) provides benefits for medical or surgical expenses
6-21 incurred as a result of a health condition, accident, or sickness,
6-22 including:
6-23 (A) an individual, group, blanket, or franchise
6-24 insurance policy or insurance agreement, a group hospital service
6-25 contract, or an individual or group evidence of coverage that is
6-26 offered by:
6-27 (i) an insurance company;
7-1 (ii) a group hospital service corporation
7-2 operating under Chapter 20 of this code;
7-3 (iii) a fraternal benefit society
7-4 operating under Chapter 10 of this code;
7-5 (iv) a stipulated premium insurance
7-6 company operating under Chapter 22 of this code; or
7-7 (v) a health maintenance organization
7-8 operating under the Texas Health Maintenance Organization Act
7-9 (Chapter 20A, Vernon's Texas Insurance Code); and
7-10 (B) to the extent permitted by the Employee
7-11 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
7-12 seq.), a health benefit plan that is offered by:
7-13 (i) a multiple employer welfare
7-14 arrangement as defined by Section 3, Employee Retirement Income
7-15 Security Act of 1974 (29 U.S.C. Section 1002); or
7-16 (ii) another analogous benefit
7-17 arrangement;
7-18 (2) is offered by an approved nonprofit health
7-19 corporation that is certified under Section 5.01(a), Medical
7-20 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
7-21 that holds a certificate of authority issued by the commissioner
7-22 under Article 21.52F of this code; or
7-23 (3) is offered by any other entity not licensed under
7-24 this code or another insurance law of this state that contracts
7-25 directly for health care services on a risk-sharing basis,
7-26 including an entity that contracts for health care services on a
7-27 capitation basis.
8-1 (b) Notwithstanding Section 172.014, Local Government Code,
8-2 or any other law, this article applies to health and accident
8-3 coverage provided by a risk pool created under Chapter 172, Local
8-4 Government Code.
8-5 (c) This article does not apply to:
8-6 (1) a plan that provides coverage:
8-7 (A) only for a specified disease;
8-8 (B) only for accidental death or dismemberment;
8-9 (C) for wages or payments in lieu of wages for a
8-10 period during which an employee is absent from work because of
8-11 sickness or injury; or
8-12 (D) as a supplement to liability insurance;
8-13 (2) a plan written under Chapter 26 of this code;
8-14 (3) a Medicare supplemental policy as defined by
8-15 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
8-16 (4) workers' compensation insurance coverage;
8-17 (5) medical payment insurance issued as a part of a
8-18 motor vehicle insurance policy; or
8-19 (6) a long-term care policy, including a nursing home
8-20 fixed indemnity policy, unless the commissioner determines that the
8-21 policy provides benefit coverage so comprehensive that the policy
8-22 is a health benefit plan as described by Subsection (a) of this
8-23 section. [;]
8-24 (d) Sections 3 and 4 of this article do not apply to:
8-25 (1) [(7)] any health benefit plan that does not
8-26 provide pregnancy-related benefits; or
8-27 (2) [(8)] any health benefit plan that does not
9-1 provide well-woman care benefits.
9-2 (e) [(d)] This article applies to each health benefit plan
9-3 that requires an enrollee to obtain certain specialty health care
9-4 services through a referral made by a primary care physician or
9-5 other gatekeeper.
9-6 Sec. 3. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. (a) Each
9-7 health benefit plan subject to this article shall permit a woman
9-8 who is entitled to coverage under the plan to select, in addition
9-9 to a primary care physician, an obstetrician or gynecologist to
9-10 provide health care services within the scope of the professional
9-11 specialty practice of a properly credentialed obstetrician or
9-12 gynecologist. This section does not preclude a woman from
9-13 selecting a family physician, internal medicine physician, or other
9-14 qualified physician to provide that care.
9-15 (b) The plan shall include in the classification of persons
9-16 authorized to provide medical services under the plan a number of
9-17 properly credentialed obstetricians and gynecologists sufficient to
9-18 ensure access to the services that fall within the scope of that
9-19 credential.
9-20 (c) This section does not affect the authority of a health
9-21 benefit plan to establish selection criteria regarding other
9-22 physicians who provide services through the plan.
9-23 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
9-24 GYNECOLOGIST. (a) In addition to other benefits authorized by the
9-25 plan, each health benefit plan shall permit a woman who designates
9-26 an obstetrician or gynecologist as provided under Section 3 of this
9-27 article direct access to the health care services of the designated
10-1 obstetrician or gynecologist without a referral by the woman's
10-2 primary care physician or prior authorization or precertification
10-3 from a health benefit plan.
10-4 (b) The access to health care services required under this
10-5 article includes, but is not limited to:
10-6 (1) one well-woman examination per year;
10-7 (2) care related to pregnancy;
10-8 (3) care for all active gynecological conditions; and
10-9 (4) diagnosis, treatment, and referral for any disease
10-10 or condition within the scope of the professional practice of a
10-11 properly credentialed obstetrician or gynecologist.
10-12 (c) A health benefit plan may not impose a copayment or
10-13 deductible for direct access to the health care services of an
10-14 obstetrician or gynecologist under this section unless such an
10-15 additional cost is imposed for access to other health care services
10-16 provided under the plan.
10-17 (d) This section does not affect the authority of a health
10-18 benefit plan to require the designated obstetrician or gynecologist
10-19 to forward information concerning the medical care of the patient
10-20 to the primary care physician. Failure to provide this information
10-21 may not result in any penalty, financial or otherwise, being
10-22 imposed upon the obstetrician or gynecologist or the patient by the
10-23 health benefit plan if the obstetrician or gynecologist has made a
10-24 reasonable and good-faith effort to provide the information to the
10-25 primary care physician.
10-26 (e) In implementing the access required under Section 3 of
10-27 this article, a health benefit plan may limit a woman enrolled in
11-1 the plan to self-referral to one participating obstetrician and
11-2 gynecologist for both gynecological care and obstetrical care.
11-3 This subsection does not affect the right of the woman to select
11-4 the physician who provides that care.
11-5 (f) A health benefit plan shall not sanction or terminate
11-6 primary care physicians as a result of female enrollees' access to
11-7 participating obstetricians and gynecologists under this section.
11-8 Sec. 5. TREATMENT OF HORMONE DEFICIENCY. A health benefit
11-9 plan shall, on the prescription of a health care provider, provide
11-10 to a woman who is entitled to coverage under the plan coverage for
11-11 hormone replacement therapy for the treatment of menopausal
11-12 symptoms other than osteoporosis.
11-13 Sec. 6. CERVICAL CYTOLOGY. A health benefit plan may not
11-14 impose a deductible, coinsurance, or a copayment specifically for a
11-15 cervical cytology procedure.
11-16 Sec. 7. ANNUAL MAMMOGRAPHY FOR CERTAIN ENROLLEES. (a) A
11-17 health benefit plan shall provide coverage for an annual mammogram
11-18 for a woman who is entitled to coverage under the plan and who is
11-19 at least 40 years of age.
11-20 (b) A health benefit plan may not impose a deductible,
11-21 coinsurance, or a copayment for services under this section.
11-22 Sec. 8 [5]. NOTICE. Each health benefit plan shall provide
11-23 to persons covered by the plan a timely written notice in clear and
11-24 accurate language of the choices of types of physician providers
11-25 for the direct access to health care services required by Sections
11-26 3 and 4 of this article.
11-27 Sec. 9 [6]. RULES. The commissioner shall adopt rules as
12-1 necessary to implement this article.
12-2 Sec. 10 [7]. ADMINISTRATIVE PENALTY. An insurance company,
12-3 health maintenance organization, or other entity that operates a
12-4 health benefit plan in violation of this article is subject to an
12-5 administrative penalty as provided by Article 1.10E of this code.
12-6 SECTION 5. This Act takes effect September 1, 1999, and
12-7 applies only to an insurance policy, evidence of coverage,
12-8 contract, or other document establishing coverage under a health
12-9 benefit plan that is delivered, issued for delivery, or renewed on
12-10 or after the effective date of this Act. An insurance policy,
12-11 evidence of coverage, contract, or other document establishing
12-12 coverage under a health benefit plan that is delivered, issued for
12-13 delivery, or renewed before the effective date of this Act is
12-14 governed by the law as it existed immediately before that date, and
12-15 that law is continued in effect for that purpose.
12-16 SECTION 6. The importance of this legislation and the
12-17 crowded condition of the calendars in both houses create an
12-18 emergency and an imperative public necessity that the
12-19 constitutional rule requiring bills to be read on three several
12-20 days in each house be suspended, and this rule is hereby suspended.