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