By Van de Putte H.B. No. 969
76R4483 DB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage under certain health benefit plans for
1-3 treatment of a child for craniofacial abnormalities.
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 21.53W to read as follows:
1-7 Art. 21.53W. COVERAGE FOR CRANIOFACIAL ABNORMALITIES
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Enrollee" means an individual enrolled in a
1-10 health benefit plan.
1-11 (2) "Health benefit plan" means a plan described by
1-12 Section 2(a) of this article.
1-13 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
1-14 a health benefit plan that:
1-15 (1) provides benefits for medical or surgical expenses
1-16 incurred as a result of a health condition, accident, or sickness,
1-17 including:
1-18 (A) an individual, group, blanket, or franchise
1-19 insurance policy or insurance agreement, a group hospital service
1-20 contract, or an individual or group evidence of coverage that is
1-21 offered by:
1-22 (i) an insurance company;
1-23 (ii) a group hospital service corporation
1-24 operating under Chapter 20 of this code;
2-1 (iii) a fraternal benefit society
2-2 operating under Chapter 10 of this code;
2-3 (iv) a stipulated premium insurance
2-4 company operating under Chapter 22 of this code; or
2-5 (v) a health maintenance organization
2-6 operating under the Texas Health Maintenance Organization Act
2-7 (Chapter 20A, Vernon's Texas Insurance Code); or
2-8 (B) to the extent permitted by the Employee
2-9 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-10 seq.), a health benefit plan that is offered by:
2-11 (i) a multiple employer welfare
2-12 arrangement as defined by Section 3, Employee Retirement Income
2-13 Security Act of 1974 (29 U.S.C. Section 1002);
2-14 (ii) any other entity not licensed under
2-15 this code or another insurance law of this state that contracts
2-16 directly for health care services on a risk-sharing basis,
2-17 including an entity that contracts for health care services on a
2-18 capitation basis; or
2-19 (iii) another analogous benefit
2-20 arrangement; or
2-21 (2) is offered by an approved nonprofit health
2-22 corporation that is certified under Section 5.01(a), Medical
2-23 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-24 that holds a certificate of authority issued by the commissioner
2-25 under Article 21.52F of this code.
2-26 (b) This article does not apply to:
2-27 (1) a plan that provides coverage:
3-1 (A) only for a specified disease or other
3-2 limited benefit;
3-3 (B) only for accidental death or dismemberment;
3-4 (C) for wages or payments in lieu of wages for a
3-5 period during which an employee is absent from work because of
3-6 sickness or injury;
3-7 (D) as a supplement to liability insurance;
3-8 (E) for credit insurance;
3-9 (F) only for dental or vision care; or
3-10 (G) only for indemnity for hospital confinement
3-11 or other hospital expenses;
3-12 (2) a small employer health benefit plan written under
3-13 Chapter 26 of this code;
3-14 (3) a Medicare supplemental policy as defined by
3-15 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-16 (4) workers' compensation insurance coverage;
3-17 (5) medical payment insurance issued as part of a
3-18 motor vehicle insurance policy; or
3-19 (6) a long-term care policy, including a nursing home
3-20 fixed indemnity policy, unless the commissioner determines that the
3-21 policy provides benefit coverage so comprehensive that the policy
3-22 is a health benefit plan as described by Subsection (a) of this
3-23 section.
3-24 Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan that
3-25 provides benefits for a family member of an enrollee must provide
3-26 coverage for each covered child described by Subsection (c) of this
3-27 section, from birth through the date the child is 18 years of age,
4-1 for medical procedures, including reconstructive surgery, to treat
4-2 abnormal structures of the head and neck, including craniofacial
4-3 abnormalities, caused by congenital defects, developmental
4-4 deformities, trauma, tumors, infections, or disease if the
4-5 treatment is necessary in the opinion of the treating physician to:
4-6 (1) improve the function of the structure; or
4-7 (2) provide secondary and follow-up treatment,
4-8 including additional surgery, to improve the function of the
4-9 structure or to create a more normal appearance for the structure.
4-10 (b) A child is entitled to benefits under this section if
4-11 the child, as a result of the child's relationship to the enrollee
4-12 in the health benefit plan, would be entitled to benefits under an
4-13 accident and sickness insurance policy under Subsection (K), (L),
4-14 or (M), Section 2, Chapter 397, Acts of the 54th Legislature,
4-15 Regular Session, 1955 (Article 3.70-2, Vernon's Texas Insurance
4-16 Code).
4-17 Sec. 4. PREEXISTING CONDITION RESTRICTION PROHIBITED. The
4-18 benefits required under this article may not be made subject to a
4-19 provision that denies, excludes, or limits coverage of those
4-20 benefits for a specified period after the effective date of
4-21 coverage.
4-22 Sec. 5. DEDUCTIBLE, COINSURANCE, AND COPAYMENT REQUIREMENTS.
4-23 The benefits required under this article may not be made subject to
4-24 a deductible, coinsurance, or copayment requirement that exceeds
4-25 the deductible, coinsurance, or copayment requirements applicable
4-26 to other similar benefits provided under the health benefit plan.
4-27 Sec. 6. LIMITATIONS. Except as provided by Section 3(a)(2),
5-1 a health benefit plan is not required to provide coverage under
5-2 this article for cosmetic surgery procedures performed to reshape
5-3 normal healthy structures of the body solely to improve an
5-4 enrollee's appearance or self-esteem.
5-5 Sec. 7. NOTICE. In accordance with rules adopted by the
5-6 commissioner, each health benefit plan shall provide to each
5-7 enrollee under the plan written notice regarding the coverage
5-8 required by this article.
5-9 Sec. 8. RULES. The commissioner shall adopt rules as
5-10 necessary to administer this article.
5-11 SECTION 2. This Act takes effect September 1, 1999, and
5-12 applies only to a health benefit plan that is delivered, issued for
5-13 delivery, or renewed on or after January 1, 2000. A health benefit
5-14 plan that is delivered, issued for delivery, or renewed before
5-15 January 1, 2000, is governed by the law as it existed immediately
5-16 before the effective date of this Act, and that law is continued in
5-17 effect for that purpose.
5-18 SECTION 3. The importance of this legislation and the
5-19 crowded condition of the calendars in both houses create an
5-20 emergency and an imperative public necessity that the
5-21 constitutional rule requiring bills to be read on three several
5-22 days in each house be suspended, and this rule is hereby suspended.