By: Whitmire S.B. No. 1608
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
AN ACT
1-1 relating to coverage for reconstructive breast surgery after
1-2 mastectomy.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Article 21.53D, Insurance Code, relating to
1-5 coverage for reconstructive breast surgery after mastectomy, is
1-6 amended as follows
1-7 Sec. 1. Definitions. In this article:
1-8 (1) "Health benefit plan" means a plan described by Section
1-9 2 of this article.
1-10 (2) "Breast reconstruction" means reconstruction of a breast
1-11 incident to mastectomy to restore or achieve breast symmetry. The
1-12 term includes surgical reconstruction of a breast on which
1-13 mastectomy surgery has been performed and surgical reconstruction
1-14 of a breast on which mastectomy surgery has not been performed.
1-15 (3) "Enrollee" means an individual enrolled in a health
1-16 benefit plan including covered dependents.
1-17 Sec. 2. Scope of Article. (a) This article applies to a
1-18 health benefit plan that[: (1)] provides benefits for medical or
1-19 surgical expenses incurred as a result of a health condition,
1-20 accident, or sickness, including an individual, group, blanket, or
1-21 franchise insurance policy or insurance agreement, a group hospital
1-22 service contract, or an individual or group evidence of coverage
2-1 that is offered by:
2-2 [(A) an individual, group, blanket, or franchise insurance
2-3 policy or insurance agreement, a group hospital service contract,
2-4 or an individual or group evidence of coverage that is offered by:]
2-5 (1) [(i)] an insurance company;
2-6 (2) [(ii)] a group hospital service corporation operating
2-7 under Chapter 20 of this code;
2-8 (3) [(iii)] a fraternal benefit society operating under
2-9 Chapter 10 of this code;
2-10 (4) [(iv)] a stipulated premium insurance company operating
2-11 under Chapter 22 of this code; [or]
2-12 (5) [(v)] a health maintenance organization operating under
2-13 the Texas Health Maintenance Organization Act (Chapter 20A,
2-14 Vernon's Texas Insurance Code);
2-15 (6) a reciprocal exchange operating under Chapter 19 of this
2-16 Code;
2-17 (7) a multiple employer welfare arrangement that holds a
2-18 certificate of authority under Article 3.95-2 of this Code; or
2-19 (8) an approved nonprofit health corporation that holds a
2-20 certificate of authority issued by the commissioner under Article
2-21 21.52F of this Code.
2-22 [(B) to the extent permitted by the Employee Retirement
2-23 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
2-24 health benefit plan that is offered by:]
2-25 [(i) a multiple employer welfare arrangement as defined by
2-26 Section 3, Employee Retirement Income Security Act of 1974 (29
3-1 U.S.C. Section 1002); or]
3-2 [(ii) another analogous benefit arrangement; or]
3-3 [(2) is offered by an approved nonprofit health corporation
3-4 that is certified under Section 5.01(a), Medical Practice Act
3-5 (Article 4495b, Vernon's Texas Civil Statutes), and that holds a
3-6 certificate of authority issued by the commissioner under Article
3-7 21.52F of this code.]
3-8 (b) This article does not apply to:
3-9 (1) a plan that provides coverage:
3-10 (A) only for a specified disease or limited benefit except
3-11 for cancer;
3-12 (B) only for accidental death or dismemberment;
3-13 (C) only for wages or payments in lieu of wages for a period
3-14 during which an employee is absent from work because of sickness or
3-15 injury;
3-16 (D) [for specified accident, hospital indemnity, or other
3-17 limited benefits health insurance policies] only for indemnity for
3-18 hospital confinement;
3-19 (E) only for credit insurance;
3-20 (F) only for dental or vision care;
3-21 (G) [for hospital confinement indemnity coverage only] only
3-22 for hospital expenses; or
3-23 (H) as a supplement to liability insurance;
3-24 [(2) a small employer plan written under Chapter 26 of this
3-25 code;]
3-26 (2) [(3)] a Medicare supplemental policy as defined by Section
4-1 1882(g) (1), Social Security Act (42 U.S.C. Section 1395ss);
4-2 (3) [(4)] workers' compensation insurance coverage;
4-3 (4) [(5)] medical payment insurance issued as part of a motor
4-4 vehicle insurance policy; or
4-5 (5) [(6)] a long-term care policy, including a nursing home
4-6 fixed indemnity policy, unless the commissioner determines that the
4-7 policy provides benefit coverage so comprehensive that the policy
4-8 is a health benefit plan as described by Subsection (a) of this
4-9 section.
4-10 Sec. 3. Coverage Required. (a) A health benefit plan that
4-11 provides coverage for Mastectomy must provide coverage for breast
4-12 reconstruction for:[.] [The coverage may be subject to the same
4-13 deductible or copayment applicable to mastectomy.]
4-14 (1) reconstruction of the breast on which the mastectomy has
4-15 been performed;
4-16 (2) surgery and reconstruction of the other breast to
4-17 achieve a symmetrical appearance; and
4-18 (3) prostheses and physical complications at all stages of
4-19 mastectomy including lymphedemas;
4-20 (b) The coverage described in this section shall be provided
4-21 in the manner determined to be appropriate in consultation with the
4-22 attending physician and the enrollee.
4-23 (c) The coverage described in this section may be subject to
4-24 annual deductibles, copayments and coinsurance provisions so long
4-25 as they are consistent with annual deductibles, copayments and
4-26 coinsurance provisions established for other benefits under the
5-1 health benefit plan.
5-2 (d) The benefits required by this subchapter shall not be
5-3 subject to dollar limitations other than the health benefit plan's
5-4 lifetime maximum benefits.
5-5 Sec. 4. Prohibitions. (a) A health benefit plan may
5-6 not: [offer a financial incentive for a patient to forgo breast
5-7 reconstruction or to waive the coverage required by Section 3 of
5-8 this article.]
5-9 (1) condition, limit or deny eligibility or continued
5-10 eligibility to an enrollee, to enroll or to renew coverage under
5-11 the terms of the health benefit plan, solely for the purpose of
5-12 avoiding the requirements of this article;
5-13 (2) provide monetary payments or rebates to individuals to
5-14 encourage enrollees to accept less than the minimum protections
5-15 required under this article;
5-16 (3) penalize or otherwise reduce or limit the reimbursement
5-17 or payment of an attending physician or provider because such
5-18 attending physician or provider provided care to an enrollee in
5-19 accordance with this article; and
5-20 (4) provide financial incentives or other benefits to an
5-21 attending physician or provider to induce such attending physician
5-22 or provider to provide care to an enrollee in a manner inconsistent
5-23 with this article.
5-24 (b) Nothing in this section shall be construed to prevent a
5-25 health benefit plan for negotiating the level and type of
5-26 reimbursement with a physician or provider for care provided in
6-1 accordance with this article.
6-2 Sec. 5. Notice. A health benefit plan that provides
6-3 coverage under this article shall provide notice to each enrollee
6-4 regarding the coverage in accordance with rules adopted by the
6-5 commissioner.
6-6 Sec. 6. If any provision of this Article or if application
6-7 of this Article to any person or circumstance is held invalid, the
6-8 invalidity does not affect other provisions or applications of this
6-9 Article that can be given effect without the invalid provisions or
6-10 applications, and to this end the provisions of this Article are
6-11 declared to be severable.
6-12 Sec. [5] 7. Rules. The commissioner may adopt rules to
6-13 implement this article and to meet the minimum requirements of
6-14 federal law.
6-15 SECTION 2. This Act shall apply to health benefit plans
6-16 currently in effect and to health benefit plans issued or delivered
6-17 on or after the date of enactment of this Act.
6-18 SECTION 3. The importance of this legislation and the
6-19 crowded condition of the calendars in both houses create an
6-20 emergency and an imperative public necessity that the
6-21 constitutional rule requiring bills to be read on three several
6-22 days in each house be suspended, and this rule is hereby suspended.