By: Carona S.B. No. 288
A BILL TO BE ENTITLED
AN ACT
1-1 relating to the definition under certain health benefit plans of
1-2 treatment for craniofacial abnormalities of a child.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-5 amended by adding Article 21.53W to read as follows:
1-6 Art. 21.53W. COVERAGE FOR CRANIOFACIAL ABNORMALITIES
1-7 Sec. 1. DEFINITIONS. In this article:
1-8 (1) "Enrollee" means an individual enrolled in a
1-9 health benefit plan.
1-10 (2) "Health benefit plan" means a plan described by
1-11 Section 2(a) of this article.
1-12 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
1-13 a health benefit plan that:
1-14 (1) provides benefits for medical or surgical expenses
1-15 incurred as a result of a health condition, accident, or sickness,
1-16 including:
1-17 (A) an individual, group, blanket, or franchise
1-18 insurance policy or insurance agreement, a group hospital service
1-19 contract, or an individual or group evidence of coverage that is
1-20 offered by:
1-21 (i) an insurance company;
1-22 (ii) a group hospital service corporation
1-23 operating under Chapter 20 of this code;
1-24 (iii) a fraternal benefit society
2-1 operating under Chapter 10 of this code;
2-2 (iv) a stipulated premium insurance
2-3 company operating under Chapter 22 of this code; or
2-4 (v) a health maintenance organization
2-5 operating under the Texas Health Maintenance Organization Act
2-6 (Chapter 20A, Vernon's Texas Insurance Code); or
2-7 (B) to the extent permitted by the Employee
2-8 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-9 seq.), a health benefit plan that is offered by:
2-10 (i) a multiple employer welfare
2-11 arrangement as defined by Section 3, Employee Retirement Income
2-12 Security Act of 1974 (29 U.S.C. Section 1002);
2-13 (ii) any other entity not licensed under
2-14 this code or another insurance law of this state that contracts
2-15 directly for health care services on a risk-sharing basis,
2-16 including an entity that contracts for health care services on a
2-17 capitation basis; or
2-18 (iii) another analogous benefit
2-19 arrangement; or
2-20 (2) is offered by an approved nonprofit health
2-21 corporation that is certified under Section 5.01(a), Medical
2-22 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-23 that holds a certificate of authority issued by the commissioner
2-24 under Article 21.52F of this code.
2-25 (b) This article does not apply to:
2-26 (1) a plan that provides coverage:
3-1 (A) only for a specified disease or other
3-2 limited benefit;
3-3 (B) only for accidental death or dismemberment;
3-4 (C) for wages or payments in lieu of wages for a
3-5 period during which an employee is absent from work because of
3-6 sickness or injury;
3-7 (D) as a supplement to liability insurance;
3-8 (E) for credit insurance;
3-9 (F) only for dental or vision care; or
3-10 (G) only for indemnity for hospital confinement
3-11 or other hospital expenses;
3-12 (2) a small employer health benefit plan written under
3-13 Chapter 26 of this code;
3-14 (3) a Medicare supplemental policy as defined by
3-15 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-16 (4) workers' compensation insurance coverage;
3-17 (5) medical payment insurance issued as part of a
3-18 motor vehicle insurance policy; or
3-19 (6) a long-term care policy, including a nursing home
3-20 fixed indemnity policy, unless the commissioner determines that the
3-21 policy provides benefit coverage so comprehensive that the policy
3-22 is a health benefit plan as described by Subsection (a) of this
3-23 section.
3-24 Sec. 3. COVERAGE. A health benefit plan that provides
3-25 benefits to a child who is younger than 18 years of age must define
3-26 reconstructive surgery for craniofacial abnormalities under the
4-1 plan to mean surgery to improve the function of, or to attempt to
4-2 create a normal appearance of, an abnormal structure caused by
4-3 congenital defects, developmental deformities, trauma, tumors,
4-4 infections, or disease.
4-5 Sec. 4. RULES. The commissioner shall adopt rules as
4-6 necessary to administer this article.
4-7 SECTION 2. This Act takes effect September 1, 1999, and
4-8 applies only to a health benefit plan that is delivered, issued for
4-9 delivery, or renewed on or after January 1, 2000. A health benefit
4-10 plan that is delivered, issued for delivery, or renewed before
4-11 January 1, 2000, is governed by the law as it existed immediately
4-12 before the effective date of this Act, and that law is continued in
4-13 effect for that purpose.
4-14 SECTION 3. The importance of this legislation and the
4-15 crowded condition of the calendars in both houses create an
4-16 emergency and an imperative public necessity that the
4-17 constitutional rule requiring bills to be read on three several
4-18 days in each house be suspended, and this rule is hereby suspended.