By Coleman H.B. No. 1406
76R4851 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health benefit plan coverage for certain serious mental
1-3 illnesses in children.
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 21.53R to read as follows:
1-7 Art. 21.53R. COVERAGE FOR CERTAIN SERIOUS MENTAL ILLNESSES
1-8 IN CHILDREN
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Child" means a person younger than 19 years of
1-11 age.
1-12 (2) "Health benefit plan" means a health benefit plan
1-13 described by Section 2 of this article.
1-14 (3) "Serious mental illness" means:
1-15 (A) the following psychiatric illnesses as
1-16 defined by the American Psychiatric Association's Diagnostic and
1-17 Statistical Manual designated DSM-IV-R:
1-18 (i) schizophrenia;
1-19 (ii) paranoid and other psychotic
1-20 disorders;
1-21 (iii) bipolar disorders (hypomanic, manic,
1-22 depressive, and mixed);
1-23 (iv) major depressive disorders (single
1-24 episode or recurrent);
2-1 (v) schizo-affective disorders (bipolar or
2-2 depressive);
2-3 (vi) pervasive developmental disorders;
2-4 (vii) obsessive-compulsive disorders; and
2-5 (viii) depression; or
2-6 (B) a diagnosable behavioral or emotional
2-7 disorder or a neuropsychiatric condition:
2-8 (i) that results in a serious disability
2-9 requiring sustained treatment interventions;
2-10 (ii) that is of sufficient duration to
2-11 meet diagnostic criteria specified in the American Psychiatric
2-12 Association's Diagnostic and Statistical Manual designated
2-13 DSM-IV-R; and
2-14 (iii) with respect to which the person
2-15 exhibits impairment in thought, perception, affect, or behavior
2-16 that substantially interferes with or limits the person's role or
2-17 functioning in the person's community, school, family, or peer
2-18 group.
2-19 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
2-20 a health benefit plan that provides benefits for medical or
2-21 surgical expenses incurred as a result of a health condition,
2-22 accident, or sickness, including an individual, group, blanket, or
2-23 franchise insurance policy or insurance agreement, a group hospital
2-24 service contract, or an individual or group evidence of coverage or
2-25 similar coverage document that is offered by:
2-26 (1) an insurance company;
2-27 (2) a group hospital service corporation operating
3-1 under Chapter 20 of this code;
3-2 (3) a fraternal benefit society operating under
3-3 Chapter 10 of this code;
3-4 (4) a stipulated premium insurance company operating
3-5 under Chapter 22 of this code;
3-6 (5) a reciprocal exchange operating under Chapter 19
3-7 of this code;
3-8 (6) a health maintenance organization operating under
3-9 the Texas Health Maintenance Organization Act (Chapter 20A,
3-10 Vernon's Texas Insurance Code);
3-11 (7) a small employer carrier under Chapter 26 of this
3-12 code;
3-13 (8) a multiple employer welfare arrangement that holds
3-14 a certificate of authority under Article 3.95-2 of this code; or
3-15 (9) an approved nonprofit health corporation that
3-16 holds a certificate of authority issued by the commissioner under
3-17 Article 21.52F of this code.
3-18 (b) This article does not apply to:
3-19 (1) a plan that provides coverage:
3-20 (A) only for a specified disease or other
3-21 limited benefit;
3-22 (B) only for accidental death or dismemberment;
3-23 (C) for wages or payments in lieu of wages for a
3-24 period during which an employee is absent from work because of
3-25 sickness or injury;
3-26 (D) as a supplement to liability insurance;
3-27 (E) for credit insurance;
4-1 (F) only for dental or vision care;
4-2 (G) only for hospital expenses; or
4-3 (H) only for indemnity for hospital confinement;
4-4 (2) a Medicare supplemental policy as defined by
4-5 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
4-6 (3) workers' compensation insurance coverage;
4-7 (4) medical payment insurance coverage issued as part
4-8 of a motor vehicle insurance policy; or
4-9 (5) a long-term care policy, including a nursing home
4-10 fixed indemnity policy, unless the commissioner determines that the
4-11 policy provides benefit coverage so comprehensive that the policy
4-12 is a health benefit plan as described by Subsection (a) of this
4-13 section.
4-14 Sec. 3. REQUIRED COVERAGE FOR SERIOUS MENTAL ILLNESSES IN
4-15 CHILDREN. (a) A health benefit plan:
4-16 (1) must provide coverage for an enrollee who is a
4-17 child for the following treatment of serious mental illness in each
4-18 calendar year:
4-19 (A) 45 days of inpatient treatment; and
4-20 (B) 60 visits for outpatient treatment,
4-21 including group and individual outpatient treatment;
4-22 (2) may not include a lifetime limit on the number of
4-23 days of inpatient treatment or the number of outpatient visits
4-24 covered under the plan; and
4-25 (3) must include the same amount limits, deductibles,
4-26 and coinsurance factors for serious mental illness as for physical
4-27 illness.
5-1 (b) An issuer of a health benefit plan may not count toward
5-2 the number of outpatient visits required to be covered under
5-3 Subsection (a)(1) of this section an outpatient visit for the
5-4 purpose of medication management and must cover that outpatient
5-5 visit under the same terms and conditions as it covers outpatient
5-6 visits for treatment of physical illness.
5-7 (c) An issuer of a health benefit plan may provide or offer
5-8 coverage required under this section through another health benefit
5-9 plan that is a managed care plan.
5-10 Sec. 4. CERTAIN CONDITIONS EXCLUDED. For purposes of this
5-11 article, a child does not suffer from a serious mental illness
5-12 solely because the child:
5-13 (1) has mental retardation;
5-14 (2) has epilepsy;
5-15 (3) commits alcohol or substance abuse or experiences
5-16 a brief period of intoxication; or
5-17 (4) commits criminal or delinquent acts.
5-18 SECTION 2. Section 1(1), Article 3.51-14, Insurance Code, is
5-19 amended to read as follows:
5-20 (1) "Serious mental illness" means the following
5-21 psychiatric illnesses as defined by the American Psychiatric
5-22 Association in the Diagnostic and Statistical Manual (DSM):
5-23 (A) schizophrenia;
5-24 (B) paranoid and other psychotic disorders;
5-25 (C) bipolar disorders (hypomanic, manic,
5-26 depressive, and mixed);
5-27 (D) major depressive disorders (single episode
6-1 or recurrent);
6-2 (E) schizo-affective disorders (bipolar or
6-3 depressive);
6-4 (F) pervasive developmental disorders; and
6-5 (G) obsessive-compulsive disorders[; and]
6-6 [(H) depression in childhood and adolescence].
6-7 SECTION 3. Article 3.51-14, Insurance Code, is amended by
6-8 adding Section 6 to read as follows:
6-9 Sec. 6. COVERAGE FOR CHILDREN EXCLUDED. This article does
6-10 not apply to coverage for an enrollee younger than 19 years of age.
6-11 SECTION 4. This Act takes effect September 1, 1999.
6-12 SECTION 5. This Act applies only to a health benefit plan
6-13 that is delivered, issued for delivery, or renewed on or after
6-14 January 1, 2000. A health benefit plan that is delivered, issued
6-15 for delivery, or renewed before January 1, 2000, is governed by the
6-16 law as it existed immediately before the effective date of this
6-17 Act, and that law is continued in effect for that purpose.
6-18 SECTION 6. The importance of this legislation and the
6-19 crowded condition of the calendars in both houses create an
6-20 emergency and an imperative public necessity that the
6-21 constitutional rule requiring bills to be read on three several
6-22 days in each house be suspended, and this rule is hereby suspended.