1-1 By: Farabee, Van de Putte H.B. No. 1764
1-2 (Senate Sponsor - Whitmire)
1-3 (In the Senate - Received from the House April 19, 1999;
1-4 April 20, 1999, read first time and referred to Committee on
1-5 Economic Development; May 14, 1999, reported adversely, with
1-6 favorable Committee Substitute by the following vote: Yeas 4, Nays
1-7 0; May 14, 1999, sent to printer.)
1-8 COMMITTEE SUBSTITUTE FOR H.B. No. 1764 By: Armbrister
1-9 A BILL TO BE ENTITLED
1-10 AN ACT
1-11 relating to coverage by a health benefit plan of reconstructive
1-12 breast surgery after mastectomy.
1-13 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-14 SECTION 1. Article 21.53D, Insurance Code, as added by
1-15 Chapter 84, Acts of the 75th Legislature, Regular Session, 1997, is
1-16 redesignated as Article 21.53I and amended to read as follows:
1-17 Art. 21.53I [21.53D]. COVERAGE FOR RECONSTRUCTIVE SURGERY
1-18 AFTER MASTECTOMY
1-19 Sec. 1. DEFINITIONS. In this article:
1-20 (1) "Health benefit plan" means a plan described by
1-21 Section 2 of this article.
1-22 (2) "Breast reconstruction" means reconstruction of a
1-23 breast incident to mastectomy to restore or achieve breast
1-24 symmetry. The term includes surgical reconstruction of a breast on
1-25 which mastectomy surgery has been performed and surgical
1-26 reconstruction of a breast on which mastectomy surgery has not been
1-27 performed.
1-28 (3) "Enrollee" means a person entitled to coverage
1-29 under a health benefit plan.
1-30 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
1-31 a health benefit plan that[:]
1-32 [(1)] provides benefits for medical or surgical
1-33 expenses incurred as a result of a health condition, accident, or
1-34 sickness, including[:]
1-35 [(A)] an individual, group, blanket, or
1-36 franchise insurance policy or insurance agreement, a group hospital
1-37 service contract, or an individual or group evidence of coverage or
1-38 similar coverage document that is offered by:
1-39 (1) [(i)] an insurance company;
1-40 (2) [(ii)] a group hospital service corporation
1-41 operating under Chapter 20 of this code;
1-42 (3) [(iii)] a fraternal benefit society operating
1-43 under Chapter 10 of this code;
1-44 (4) [(iv)] a stipulated premium insurance company
1-45 operating under Chapter 22 of this code;
1-46 (5) a reciprocal exchange operating under Chapter 19
1-47 of this code;
1-48 (6) [or (v)] a health maintenance organization
1-49 operating under the Texas Health Maintenance Organization Act
1-50 (Chapter 20A, Vernon's Texas Insurance Code);
1-51 (7) a multiple employer welfare arrangement that holds
1-52 a certificate of authority under Article 3.95-2 of this code; or
1-53 (8) an approved nonprofit health corporation that
1-54 holds a certificate of authority issued by the commissioner under
1-55 Article 21.52F of this code
1-56 [(B) to the extent permitted by the Employee
1-57 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
1-58 seq.), a health benefit plan that is offered by:]
1-59 [(i) a multiple employer welfare
1-60 arrangement as defined by Section 3, Employee Retirement Income
1-61 Security Act of 1974 (29 U.S.C. Section 1002); or]
1-62 [(ii) another analogous benefit
1-63 arrangement; or]
1-64 [(2) is offered by an approved nonprofit health
2-1 corporation that is certified under Section 5.01(a), Medical
2-2 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-3 that holds a certificate of authority issued by the commissioner
2-4 under Article 21.52F of this code].
2-5 (b) This article does not apply to:
2-6 (1) a plan that provides coverage:
2-7 (A) only for a specified disease or other
2-8 limited benefit except for cancer;
2-9 (B) only for accidental death or dismemberment;
2-10 (C) only for wages or payments in lieu of wages
2-11 for a period during which an employee is absent from work because
2-12 of sickness or injury;
2-13 (D) only [for specified accident, hospital
2-14 indemnity, or other limited benefits health insurance policies;]
2-15 [(E)] for credit insurance;
2-16 (E) [(F)] only for dental or vision care;
2-17 (F) only for indemnity [(G)] for hospital
2-18 confinement [indemnity coverage only]; or
2-19 (G) [(H)] as a supplement to liability
2-20 insurance;
2-21 (2) [a small employer plan written under Chapter 26 of
2-22 this code;]
2-23 [(3)] a Medicare supplemental policy as defined by
2-24 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
2-25 as amended;
2-26 (3) [(4)] workers' compensation insurance coverage;
2-27 (4) [(5)] medical payment insurance issued as part of
2-28 a motor vehicle insurance policy; or
2-29 (5) [(6)] a long-term care policy, including a nursing
2-30 home fixed indemnity policy, unless the commissioner determines
2-31 that the policy provides benefit coverage so comprehensive that the
2-32 policy is a health benefit plan as described by Subsection (a) of
2-33 this section.
2-34 Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan that
2-35 provides coverage for mastectomy must provide coverage for:
2-36 (1) reconstruction of the breast on which the
2-37 mastectomy has been performed;
2-38 (2) surgery and reconstruction of the other breast to
2-39 achieve a symmetrical appearance; and
2-40 (3) prostheses and treatment of physical
2-41 complications, including lymphedemas, at all stages of mastectomy.
2-42 (b) The coverage described by this section shall be provided
2-43 in a manner determined to be appropriate in consultation with the
2-44 attending physician and the enrollee.
2-45 (c) The coverage described by this section may be subject to
2-46 annual deductibles, copayments, and coinsurance that are consistent
2-47 with annual deductibles, copayments, and coinsurance required for
2-48 other benefits under the health benefit plan.
2-49 (d) The benefits required by this subchapter may not be
2-50 subject to dollar limitations other than the health benefit plan's
2-51 lifetime maximum benefits [breast reconstruction. The coverage may
2-52 be subject to the same deductible or copayment applicable to
2-53 mastectomy].
2-54 Sec. 4. PROHIBITIONS [PROHIBITION]. (a) A health benefit
2-55 plan may not:
2-56 (1) offer a financial incentive for a patient to forgo
2-57 breast reconstruction or to waive the coverage required by Section
2-58 3 of this article;
2-59 (2) condition, limit, or deny the eligibility of an
2-60 enrollee to enroll in the health benefit plan or to renew coverage
2-61 under the terms of the plan solely for the purpose of avoiding the
2-62 requirements of this article; or
2-63 (3) reduce or limit the reimbursement or payment of,
2-64 or otherwise penalize, an attending physician or provider or
2-65 provide financial incentives or other benefits to an attending
2-66 physician or provider to induce the physician or provider to
2-67 provide care to an enrollee in a manner inconsistent with this
2-68 article.
2-69 (b) This section may not be construed to prevent a health
3-1 benefit plan from negotiating with a physician or provider the
3-2 level and type of reimbursement that physician or provider will
3-3 receive for care provided in accordance with this article.
3-4 Sec. 5. NOTICE. A health benefit plan that provides
3-5 coverage under this article shall provide notice of the
3-6 availability of that coverage to each enrollee in accordance with
3-7 rules adopted by the commissioner.
3-8 Sec. 6. SEVERABILITY. If any provision of this article or
3-9 the application of this article to any person or circumstance is
3-10 held invalid, the invalidity does not affect a provision or
3-11 application of this article that can be given effect without the
3-12 invalid provision or application, and to this end, the provisions
3-13 of this article are declared to be severable.
3-14 Sec. 7. RULES. The commissioner may adopt rules to
3-15 implement this article and to meet the minimum requirements of
3-16 federal law.
3-17 SECTION 2. This Act applies to a health benefit plan in
3-18 effect on the effective date of this Act or that is delivered, or
3-19 issued for delivery, on or after the effective date of this Act.
3-20 SECTION 3. The importance of this legislation and the
3-21 crowded condition of the calendars in both houses create an
3-22 emergency and an imperative public necessity that the
3-23 constitutional rule requiring bills to be read on three several
3-24 days in each house be suspended, and this rule is hereby suspended,
3-25 and that this Act take effect and be in force from and after its
3-26 passage, and it is so enacted.
3-27 * * * * *