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.
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