1-1                                   AN ACT
 1-2     relating to coverage by a health benefit plan of reconstructive
 1-3     breast surgery  after mastectomy.
 1-4           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
 1-5           SECTION 1.  Article 21.53D, Insurance Code, as added by
 1-6     Chapter 84, Acts of the 75th Legislature, Regular Session, 1997, is
 1-7     redesignated as Article 21.53I and amended to read as follows:
 1-8           Art. 21.53I [21.53D].  COVERAGE FOR RECONSTRUCTIVE SURGERY
 1-9     AFTER MASTECTOMY
1-10           Sec. 1.  DEFINITIONS.  In this article:
1-11                 (1)  "Health benefit plan" means a plan described by
1-12     Section 2 of this article.
1-13                 (2)  "Breast reconstruction" means reconstruction of a
1-14     breast incident to mastectomy to restore or achieve breast
1-15     symmetry.  The term includes surgical reconstruction of a breast on
1-16     which mastectomy surgery has been performed and surgical
1-17     reconstruction of a breast on which mastectomy surgery has not been
1-18     performed.
1-19                 (3)  "Enrollee" means a person entitled to coverage
1-20     under a health benefit plan.
1-21           Sec. 2.  SCOPE OF ARTICLE.  (a)  This article applies only to
1-22     a health benefit plan that[:]
1-23                 [(1)]  provides benefits for medical or surgical
1-24     expenses incurred as a result of a health condition, accident, or
 2-1     sickness, including[:]
 2-2                       [(A)]  an individual, group, blanket, or
 2-3     franchise insurance policy or insurance agreement, a group hospital
 2-4     service contract, or an individual or group evidence of coverage or
 2-5     similar coverage document that is offered by:
 2-6                 (1) [(i)]  an insurance company;
 2-7                 (2) [(ii)]  a group hospital service corporation
 2-8     operating under Chapter 20 of this code;
 2-9                 (3) [(iii)]  a fraternal benefit society operating
2-10     under Chapter 10 of this code;
2-11                 (4) [(iv)]  a stipulated premium insurance company
2-12     operating under Chapter 22 of this code;
2-13                 (5)  a reciprocal exchange operating under Chapter 19
2-14     of this code;
2-15                 (6)  [or (v)]  a health maintenance organization
2-16     operating under the Texas Health Maintenance Organization Act
2-17     (Chapter 20A, Vernon's Texas Insurance Code);
2-18                 (7)  a multiple employer welfare arrangement that holds
2-19     a certificate of authority under Article 3.95-2 of this code; or
2-20                 (8)  an approved nonprofit health corporation that
2-21     holds a certificate of authority issued by the commissioner under
2-22     Article 21.52F of this code
2-23                       [(B)  to the extent permitted by the Employee
2-24     Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-25     seq.), a health benefit plan that is offered by:]
2-26                             [(i)  a multiple employer welfare
2-27     arrangement as defined by Section 3, Employee Retirement Income
 3-1     Security Act of 1974 (29 U.S.C. Section 1002); or]
 3-2                             [(ii)  another analogous benefit
 3-3     arrangement; or]
 3-4                 [(2)  is offered by an approved nonprofit health
 3-5     corporation that is certified under Section 5.01(a), Medical
 3-6     Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
 3-7     that holds a certificate of authority issued by the commissioner
 3-8     under Article 21.52F of this code].
 3-9           (b)  This article does not apply to:
3-10                 (1)  a plan that provides coverage:
3-11                       (A)  only for a specified disease or other
3-12     limited benefit except for cancer;
3-13                       (B)  only for accidental death or dismemberment;
3-14                       (C)  only for wages or payments in lieu of wages
3-15     for a period during which an employee is absent from work because
3-16     of sickness or injury;
3-17                       (D)  only [for specified accident, hospital
3-18     indemnity, or other limited benefits health insurance policies;]
3-19                       [(E)]  for credit insurance;
3-20                       (E) [(F)]  only for dental or vision care;
3-21                       (F)  only for indemnity [(G)]  for hospital
3-22     confinement [indemnity coverage only]; or
3-23                       (G) [(H)]  as a supplement to liability
3-24     insurance;
3-25                 (2)  [a small employer plan written under Chapter 26 of
3-26     this code;]
3-27                 [(3)]  a Medicare supplemental policy as defined by
 4-1     Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
 4-2     as amended;
 4-3                 (3) [(4)]  workers' compensation insurance coverage;
 4-4                 (4) [(5)]  medical payment insurance issued as part of
 4-5     a motor vehicle insurance policy; or
 4-6                 (5) [(6)]  a long-term care policy, including a nursing
 4-7     home fixed indemnity policy, unless the commissioner determines
 4-8     that the policy provides benefit coverage so comprehensive that the
 4-9     policy is a health benefit plan as described by Subsection (a) of
4-10     this section.
4-11           Sec. 3.  COVERAGE REQUIRED.  (a) A health benefit plan that
4-12     provides coverage for mastectomy must provide coverage for:
4-13                 (1)  reconstruction of the breast on which the
4-14     mastectomy has been performed;
4-15                 (2)  surgery and reconstruction of the other breast to
4-16     achieve a symmetrical appearance; and
4-17                 (3)  prostheses and treatment of physical
4-18     complications, including lymphedemas, at all stages of mastectomy.
4-19           (b)  The coverage described by this section shall be provided
4-20     in a manner determined to be appropriate in consultation with the
4-21     attending physician and the enrollee.
4-22           (c)  The coverage described by this section may be subject to
4-23     annual deductibles, copayments, and coinsurance that are consistent
4-24     with annual deductibles, copayments, and coinsurance required for
4-25     other benefits under the health benefit plan.
4-26           (d)  The benefits required by this subchapter may not be
4-27     subject to dollar limitations other than the health benefit plan's
 5-1     lifetime maximum benefits [breast reconstruction.  The coverage may
 5-2     be subject to the same deductible or copayment applicable to
 5-3     mastectomy].
 5-4           Sec. 4.  PROHIBITIONS [PROHIBITION].  (a) A health benefit
 5-5     plan may not:
 5-6                 (1)  offer a financial incentive for a patient to forgo
 5-7     breast reconstruction or to waive the coverage required by Section
 5-8     3 of this article;
 5-9                 (2)  condition, limit, or deny the eligibility of an
5-10     enrollee to enroll in the health benefit plan or to renew coverage
5-11     under the terms of the plan solely for the purpose of avoiding the
5-12     requirements of this article; or
5-13                 (3)  reduce or limit the reimbursement or payment of,
5-14     or otherwise penalize, an attending physician or provider or
5-15     provide financial incentives or other benefits to an attending
5-16     physician or provider to induce the physician or provider to
5-17     provide care to an enrollee in a manner inconsistent with this
5-18     article.
5-19           (b)  This section may not be construed to prevent a health
5-20     benefit plan from negotiating with a physician or provider the
5-21     level and type of reimbursement that physician or provider will
5-22     receive for care provided in accordance with this article.
5-23           Sec. 5.  NOTICE. A health benefit plan that provides coverage
5-24     under this article shall provide notice of the availability of that
5-25     coverage to each enrollee in accordance with rules adopted by the
5-26     commissioner.
5-27           Sec. 6.  SEVERABILITY.  If any provision of this article or
 6-1     the application of this article to any person or circumstance is
 6-2     held invalid, the invalidity does not affect a provision or
 6-3     application of this article that can be given effect without the
 6-4     invalid provision or application, and to this end, the provisions
 6-5     of this article are declared to be severable.
 6-6           Sec. 7.  RULES.  The commissioner may adopt rules to
 6-7     implement this article and to meet the minimum requirements of
 6-8     federal law.
 6-9           SECTION 2.  This Act applies to a health benefit plan in
6-10     effect on the effective date of this Act or that is delivered, or
6-11     issued for delivery, on or after the effective date of this Act.
6-12           SECTION 3.  The importance of this legislation and the
6-13     crowded condition of the calendars in both houses create an
6-14     emergency and an imperative public necessity that the
6-15     constitutional rule requiring bills to be read on three several
6-16     days in each house be suspended, and this rule is hereby suspended,
6-17     and that this Act take effect and be in force from and after its
6-18     passage, and it is so enacted.
         _______________________________     _______________________________
             President of the Senate              Speaker of the House
               I certify that H.B. No. 1764 was passed by the House on April
         16, 1999, by a non-record vote; and that the House concurred in
         Senate amendments to H.B. No. 1764 on May 26, 1999, by the
         following vote:  Yeas 143, Nays 0, 3 present, not voting.
                                             _______________________________
                                                 Chief Clerk of the House
               I certify that H.B. No. 1764 was passed by the Senate, with
         amendments, on May 24, 1999, by the following vote:  Yeas 30, Nays
         0.
                                             _______________________________
                                                 Secretary of the Senate
         APPROVED:  _____________________
                            Date
                    _____________________
                          Governor