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.