By Farabee                                            H.B. No. 1764
         Line and page numbers may not match official copy.
         Bill not drafted by TLC or Senate E&E.
                                A BILL TO BE ENTITLED
 1-1                                   AN ACT
 1-2     relating to coverage for reconstructive breast surgery after
 1-3     mastectomy.
 1-4           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
 1-5           SECTION 1.  Article 21.53D, Insurance Code, relating to
 1-6     coverage for reconstructive breast surgery after mastectomy, is
 1-7     amended as follows
 1-8           Sec. 1.  Definitions.  In this article:
 1-9                 (1)  "Health benefit plan" means a plan described by
1-10     Section 2 of this article.
1-11                 (2)  "Breast reconstruction" means reconstruction of a
1-12     breast incident to mastectomy to restore or achieve breast
1-13     symmetry.  The term includes surgical reconstruction of a breast on
1-14     which mastectomy surgery has been performed and surgical
1-15     reconstruction of a breast on which mastectomy surgery has not been
1-16     performed.
1-17                 (3)  "Enrollee" means an individual enrolled in a
1-18     health benefit plan including covered dependents.
1-19           Sec. 2.  Scope of Article.  (a)  This article applies to a
1-20     health benefit plan that[:  (1)]  provides benefits for medical or
1-21     surgical expenses incurred as a result of a health condition,
 2-1     accident, or sickness, including an individual, group, blanket, or
 2-2     franchise insurance policy or insurance agreement, a group hospital
 2-3     service contract, or an individual or group evidence of coverage
 2-4     that is offered by:
 2-5                       [(A)  an individual, group, blanket, or franchise
 2-6     insurance policy or insurance agreement, a group hospital service
 2-7     contract, or an individual or group evidence of coverage that is
 2-8     offered by:]
 2-9                 (1) [(i)]  an insurance company;
2-10                 (2) [(ii)]  a group hospital service corporation
2-11     operating under Chapter 20 of this code;
2-12                 (3) [(iii)]  a fraternal benefit society operating
2-13     under Chapter 10 of this code;
2-14                 (4) [(iv)]  a stipulated premium insurance company
2-15     operating under Chapter 22 of this code; [or]
2-16                 (5) [(v)]  a health maintenance organization operating
2-17     under the Texas Health Maintenance Organization Act (Chapter 20A,
2-18     Vernon's Texas Insurance Code);
2-19                 (6)  a reciprocal exchange operating under Chapter 19
2-20     of this Code;
2-21                 (7)  a multiple employer welfare arrangement that holds
2-22     a certificate of authority under Article 3.95-2 of this Code; or
2-23                 (8)  an approved nonprofit health corporation that
2-24     holds a certificate of authority issued by the commissioner under
2-25     Article 21.52F of this Code.
 3-1                       [(B)  to the extent permitted by the Employee
 3-2     Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
 3-3     seq.), a health benefit plan that is offered by:]
 3-4                             [(i)  a multiple employer welfare
 3-5     arrangement as defined by Section 3, Employee Retirement Income
 3-6     Security Act of 1974 (29 U.S.C. Section 1002); or]
 3-7                             [(ii)  another analogous benefit
 3-8     arrangement; or]
 3-9                 [(2)  is offered by an approved nonprofit health
3-10     corporation that is certified under Section 5.01(a), Medical
3-11     Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-12     that holds a certificate of authority issued by the commissioner
3-13     under Article 21.52F of this code.]
3-14           (b)  This article does not apply to:
3-15                 (1)  a plan that provides coverage:
3-16                       (A)  only for a specified disease or limited
3-17     benefit except for cancer;
3-18                       (B)  only for accidental death or dismemberment;
3-19                       (C)  only for wages or payments in lieu of wages
3-20     for a period during which an employee is absent from work because
3-21     of sickness or injury;
3-22                       (D)  [for specified accident, hospital indemnity,
3-23     or other limited benefits health insurance policies] only for
3-24     indemnity for hospital confinement;
3-25                       (E)  only for credit insurance;
 4-1                       (F)  only for dental or vision care;
 4-2                       (G)  [for hospital confinement indemnity coverage
 4-3     only] only for hospital expenses; or
 4-4                       (H)  as a supplement to liability insurance;
 4-5                 [(2)  a small employer plan written under Chapter 26 of
 4-6     this code;]
 4-7                 (2) [(3)]  a Medicare supplemental policy as defined by
 4-8     Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
 4-9                 (3) [(4)]  workers' compensation insurance coverage;
4-10                 (4) [(5)]  medical payment insurance issued as part of
4-11     a motor vehicle insurance policy; or
4-12                 (5) [(6)]  a long-term care policy, including a nursing
4-13     home fixed indemnity policy, unless the commissioner determines
4-14     that the policy provides benefit coverage so comprehensive that the
4-15     policy is a health benefit plan as described by Subsection (a) of
4-16     this section.
4-17           Sec. 3.  Coverage Required.  (a)  A health benefit plan that
4-18     provides coverage for Mastectomy must provide coverage for breast
4-19     reconstruction for:[.  The coverage may be subject to the same
4-20     deductible or copayment applicable to mastectomy.]
4-21                 (1)  reconstruction of the breast on which the
4-22     mastectomy has been performed;
4-23                 (2)  surgery and reconstruction of the other breast to
4-24     achieve a symmetrical appearance; and
4-25                 (3)  prostheses and physical complications at all
 5-1     stages of mastectomy including lymphedemas;
 5-2           (b)  The coverage described in this section shall be provided
 5-3     in the manner determined to be appropriate in consultation with the
 5-4     attending physician and the enrollee.
 5-5           (c)  The coverage described in this section may be subject to
 5-6     annual deductibles, copayments and coinsurance provisions so long
 5-7     as they are consistent with annual deductibles, copayments and
 5-8     coinsurance provisions established for other benefits under the
 5-9     health benefit plan.
5-10           (d)  The benefits required by this subchapter shall not be
5-11     subject to dollar limitations other than the health benefit plan's
5-12     lifetime maximum benefits.
5-13           Sec. 4.  PROHIBITIONS.  (a)  A health benefit plan may not:
5-14     [offer a financial incentive for a patient to forgo breast
5-15     reconstruction or to waive the coverage required by Section 3 of
5-16     this article.]
5-17                 (1)  condition, limit or deny eligibility or continued
5-18     eligibility to an enrollee, to enroll or to renew coverage under
5-19     the terms of the health benefit plan, solely for the purpose of
5-20     avoiding the requirements of this article;
5-21                 (2)  provide monetary payments or rebates to
5-22     individuals to encourage enrollees to accept less than the minimum
5-23     protections required under this article;
5-24                 (3)  penalize or otherwise reduce or limit the
5-25     reimbursement or payment of an attending physical or provider
 6-1     because such attending physician or provider provided care to an
 6-2     enrollee in accordance with this article; and
 6-3                 (4)  provide financial incentives or other benefits to
 6-4     an attending physician or provider to induce such attending
 6-5     physician or provider to provide care to an enrollee in a manner
 6-6     inconsistent with this article.
 6-7           (b)  Nothing in this section shall be construed to prevent a
 6-8     health benefit plan from negotiating the level and type of
 6-9     reimbursement with a physician or provider for care provided in
6-10     accordance with this article.
6-11           Sec. 5.  NOTICE.  A health benefit plan that provides
6-12     coverage under this article shall provide notice to each enrollee
6-13     regarding the coverage in accordance with rules adopted by the
6-14     commissioner.
6-15           Sec. 6.  If any provision of this Article or if application
6-16     of this Article to any person or circumstance is held invalid, the
6-17     invalidity does not affect other provisions or applications of this
6-18     Article that can be given effect without the invalid provisions or
6-19     applications, and to this end the provisions of this Article are
6-20     declared to be severable.
6-21           Sec. [5] 7.  Rules.  The commissioner may adopt rules to
6-22     implement this article and to meet the minimum requirements of
6-23     federal law.
6-24           SECTION 2.  This Act shall apply to health benefit plans
6-25     currently in effect and to health benefit plans issued or delivered
 7-1     on or after the date of enactment of this Act.
 7-2           SECTION 3.  The importance of this legislation and the
 7-3     crowded condition of the calendars in both houses create an
 7-4     emergency and an imperative public necessity that the
 7-5     constitutional rule requiring bills to be read on three several
 7-6     days in each house be suspended, and this rule is hereby suspended.