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.