By Shapiro S.B. No. 572
76R1605 DB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to comprehensive coverage under certain health benefit
1-3 plans for the diagnosis and treatment of infertility.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53U to read as follows:
1-7 Art. 21.53U. COMPREHENSIVE COVERAGE FOR DIAGNOSIS AND
1-8 TREATMENT OF INFERTILITY
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Enrollee" means an individual enrolled in a
1-11 health benefit plan.
1-12 (2) "Health benefit plan" means a plan described by
1-13 Section 2(a) of this article.
1-14 (3) "Infertility" means the inability to:
1-15 (A) conceive after one year of unprotected
1-16 sexual intercourse; or
1-17 (B) sustain a successful pregnancy.
1-18 (4) "Infertility services" means health care benefits
1-19 provided to an enrollee to medically treat infertility. The term
1-20 includes:
1-21 (A) drug therapy;
1-22 (B) in vitro fertilization, regardless of the
1-23 source of the gametes;
1-24 (C) embryo transfer;
2-1 (D) artificial insemination;
2-2 (E) cryogenic preservation of gametes or
2-3 embryos;
2-4 (F) intracytoplasmic sperm injection;
2-5 (G) gamete intrafallopian tube transfer;
2-6 (H) zygote intrafallopian tube transfer;
2-7 (I) all associated blood and imaging tests; and
2-8 (J) any other medically indicated
2-9 nonexperimental service or procedure that is used to treat
2-10 infertility or induce pregnancy.
2-11 (5) "Reproductive health services" means benefits
2-12 provided under a health benefit plan for pregnancy-related services
2-13 and services associated with the diagnosis and treatment of
2-14 infertility.
2-15 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
2-16 a health benefit plan that:
2-17 (1) provides benefits for medical or surgical expenses
2-18 incurred as a result of a health condition, accident, or sickness,
2-19 including:
2-20 (A) an individual, group, blanket, or franchise
2-21 insurance policy or insurance agreement, a group hospital service
2-22 contract, or an individual or group evidence of coverage that is
2-23 offered by:
2-24 (i) an insurance company;
2-25 (ii) a group hospital service corporation
2-26 operating under Chapter 20 of this code;
2-27 (iii) a fraternal benefit society
3-1 operating under Chapter 10 of this code;
3-2 (iv) a stipulated premium insurance
3-3 company operating under Chapter 22 of this code; or
3-4 (v) a health maintenance organization
3-5 operating under the Texas Health Maintenance Organization Act
3-6 (Chapter 20A, Vernon's Texas Insurance Code); or
3-7 (B) to the extent permitted by the Employee
3-8 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
3-9 seq.), a health benefit plan that is offered by:
3-10 (i) a multiple employer welfare
3-11 arrangement as defined by Section 3, Employee Retirement Income
3-12 Security Act of 1974 (29 U.S.C. Section 1002);
3-13 (ii) any other entity not licensed under
3-14 this code or another insurance law of this state that contracts
3-15 directly for health care services on a risk-sharing basis,
3-16 including an entity that contracts for health care services on a
3-17 capitation basis; or
3-18 (iii) another analogous benefit
3-19 arrangement; or
3-20 (2) is offered by an approved nonprofit health
3-21 corporation that is certified under Section 5.01(a), Medical
3-22 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
3-23 that holds a certificate of authority issued by the commissioner
3-24 under Article 21.52F of this code.
3-25 (b) This article does not apply to:
3-26 (1) a plan that provides coverage:
3-27 (A) only for a specified disease or other
4-1 limited benefit;
4-2 (B) only for accidental death or dismemberment;
4-3 (C) for wages or payments in lieu of wages for a
4-4 period during which an employee is absent from work because of
4-5 sickness or injury;
4-6 (D) as a supplement to liability insurance;
4-7 (E) for credit insurance;
4-8 (F) only for dental or vision care; or
4-9 (G) only for indemnity for hospital confinement
4-10 or other hospital expenses;
4-11 (2) a small employer health benefit plan written under
4-12 Chapter 26 of this code;
4-13 (3) a Medicare supplemental policy as defined by
4-14 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
4-15 (4) workers' compensation insurance coverage;
4-16 (5) medical payment insurance issued as part of a
4-17 motor vehicle insurance policy; or
4-18 (6) a long-term care policy, including a nursing home
4-19 fixed indemnity policy, unless the commissioner determines that the
4-20 policy provides benefit coverage so comprehensive that the policy
4-21 is a health benefit plan as described by Subsection (a) of this
4-22 section.
4-23 Sec. 3. APPLICATION. This article does not apply to a
4-24 health benefit plan issued to an employer who has fewer than 25
4-25 employees.
4-26 Sec. 4. COVERAGE REQUIRED. (a) A health benefit plan that
4-27 provides coverage for pregnancy-related services must provide
5-1 coverage to an enrollee for:
5-2 (1) diagnostic testing associated with the treatment
5-3 of infertility; and
5-4 (2) infertility services.
5-5 (b) Benefits for the diagnostic testing and infertility
5-6 services must be provided to the same extent as the benefits that
5-7 are provided under the health benefit plan for other
5-8 pregnancy-related services.
5-9 Sec. 5. LIMITATIONS; REQUIRED CONDITIONS. (a) Coverage for
5-10 diagnostic testing under this article is required only if the
5-11 patient for the procedure is an enrollee or is otherwise covered
5-12 under the health benefit plan.
5-13 (b) Coverage for in vitro fertilization, gamete
5-14 intrafallopian tube transfer, or zygote intrafallopian tube
5-15 transfer is required only if:
5-16 (1) the patient for the procedure is an enrollee or is
5-17 otherwise covered under the health benefit plan;
5-18 (2) the patient has been unable or would be unable in
5-19 all medical probability to achieve or sustain a pregnancy to live
5-20 birth through reasonable, less costly, and medically appropriate
5-21 infertility treatments for which coverage is available under the
5-22 health benefit plan; and
5-23 (3) the procedure is performed at a medical facility
5-24 that conforms to guidelines for in vitro fertilization clinics or
5-25 programs established by:
5-26 (A) the American College of Obstetricians and
5-27 Gynecologists;
6-1 (B) the American Society for Reproductive
6-2 Medicine; or
6-3 (C) another nationally recognized organization
6-4 of obstetricians and gynecologists.
6-5 (c) In addition to the conditions imposed under Subsections
6-6 (a) and (b) of this section, an enrollee is not entitled to more
6-7 than three completed oocyte retrievals, except that if a live birth
6-8 follows a completed oocyte retrieval, two more completed oocyte
6-9 retrievals shall be covered.
6-10 Sec. 6. REQUIRED NOTICE. (a) A health benefit plan that
6-11 offers reproductive health services shall provide written notice to
6-12 each enrollee in the plan of the coverage provided for those
6-13 services. The plan shall provide the notice in accordance with
6-14 rules adopted by the commissioner.
6-15 (b) The notice required under this section must be
6-16 prominently positioned in any literature or correspondence made
6-17 available or distributed by the health benefit plan to enrollees.
6-18 Sec. 7. EXEMPTION. An insurer that is owned by or that is
6-19 part of an entity, group, or order that is directly affiliated with
6-20 a bona fide religious denomination that includes as an integral
6-21 part of its beliefs and practices the tenet that a specific
6-22 infertility service is contrary to the moral principles that the
6-23 religious denomination considers to be an essential part of its
6-24 beliefs is exempt from the requirement to offer coverage for that
6-25 particular infertility service.
6-26 SECTION 2. Section 3A, Article 3.51-6, Insurance Code, is
6-27 repealed.
7-1 SECTION 3. (a) Except as provided by Subsection (b) of this
7-2 section, this Act takes effect September 1, 1999, and applies only
7-3 to an insurance policy or an evidence of coverage that is
7-4 delivered, issued for delivery, or renewed on or after January 1,
7-5 2000. A policy or evidence of coverage that is delivered, issued
7-6 for delivery, or renewed before January 1, 2000, is governed by the
7-7 law as it existed immediately before the effective date of this
7-8 Act, and that law is continued in effect for that purpose.
7-9 (b) Section 2 of this Act takes effect January 1, 2000.
7-10 SECTION 4. The importance of this legislation and the
7-11 crowded condition of the calendars in both houses create an
7-12 emergency and an imperative public necessity that the
7-13 constitutional rule requiring bills to be read on three several
7-14 days in each house be suspended, and this rule is hereby suspended.