By Chavez H.B. No. 2099
77R2979 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health benefit plan coverage for serious mental illness
1-3 and serious emotional disturbances of a child.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 3.51-14, Insurance Code, is redesignated
1-6 as Article 21.53N, Insurance Code, and amended to read as follows:
1-7 Art. 21.53N [3.51-14]. HEALTH BENEFIT PLAN COVERAGE FOR
1-8 CERTAIN SERIOUS MENTAL ILLNESSES AND SERIOUS EMOTIONAL DISTURBANCES
1-9 Sec. 1. DEFINITIONS. In [For purposes of] this article:
1-10 (1) "Child" means a person who is under the age of 18
1-11 years.
1-12 (2) "Serious emotional disturbance" means a mental
1-13 disorder, other than a primary substance use disorder or a
1-14 developmental disorder, identified in the most recent edition of
1-15 the Diagnostic and Statistical Manual of Mental Disorders that
1-16 results in behavior inappropriate to the child's age according to
1-17 expected developmental norms.
1-18 (3) "Serious mental illness" means the following
1-19 psychiatric illnesses as defined by the American Psychiatric
1-20 Association in the Diagnostic and Statistical Manual (DSM):
1-21 (A) schizophrenia;
1-22 (B) paranoid and other psychotic disorders;
1-23 (C) bipolar disorders (hypomanic, manic,
1-24 depressive, and mixed);
2-1 (D) major depressive disorders (single episode
2-2 or recurrent);
2-3 (E) schizo-affective disorders (bipolar or
2-4 depressive);
2-5 (F) pervasive developmental disorders or autism;
2-6 (G) obsessive-compulsive disorders;
2-7 (H) anorexia nervosa;
2-8 (I) bulimia nervosa; and
2-9 (J) [(H)] depression in childhood and
2-10 adolescence.
2-11 [(2) "Group health benefit plan" means a plan
2-12 described by Section 2 of this article.]
2-13 [(3) "Small employer" has the meaning assigned by
2-14 Article 26.02 of this code.]
2-15 Sec. 2. APPLICABILITY [SCOPE] OF ARTICLE. (a) This article
2-16 applies only to a [group] health benefit plan that provides
2-17 benefits for medical or surgical expenses incurred as a result of a
2-18 health condition, accident, or sickness, including an individual,
2-19 group, blanket, or franchise insurance policy or insurance
2-20 agreement, a group hospital service contract, or an individual or
2-21 group evidence of coverage or similar coverage document that is
2-22 offered by:
2-23 (1) an insurance company;
2-24 (2) a group hospital service corporation operating
2-25 under Chapter 20 of this code;
2-26 (3) a fraternal benefit society operating under
2-27 Chapter 10 of this code;
3-1 (4) a stipulated premium insurance company operating
3-2 under Chapter 22 of this code;
3-3 (5) a reciprocal exchange operating under Chapter 19
3-4 of this code;
3-5 (6) a health maintenance organization operating under
3-6 the Texas Health Maintenance Organization Act (Chapter 20A,
3-7 Vernon's Texas Insurance Code);
3-8 (7) a multiple employer welfare arrangement that holds
3-9 a certificate of authority under Article 3.95-2 of this code; or
3-10 (8) an approved nonprofit health corporation that
3-11 holds a certificate of authority under Article 21.52F of this code.
3-12 (b) This article applies to a small employer health benefit
3-13 plan written under Chapter 26 of this code.
3-14 (c) This article does not apply to:
3-15 (1) a plan that provides coverage:
3-16 (A) only for benefits for a specified disease or
3-17 for another limited benefit;
3-18 (B) only for accidental death or dismemberment;
3-19 (C) for wages or payments in lieu of wages for a
3-20 period during which an employee is absent from work because of
3-21 sickness or injury;
3-22 (D) as a supplement to a liability insurance
3-23 policy;
3-24 (E) for credit insurance;
3-25 (F) only for dental or vision care;
3-26 (G) only for hospital expenses; or
3-27 (H) only for indemnity for hospital confinement;
4-1 (2) a Medicare supplemental policy as defined by
4-2 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
4-3 as amended;
4-4 (3) a workers' compensation insurance policy;
4-5 (4) medical payment insurance coverage provided under
4-6 a motor vehicle insurance policy; or
4-7 (5) a long-term care insurance policy, including a
4-8 nursing home fixed indemnity policy, unless the commissioner
4-9 determines that the policy provides benefit coverage so
4-10 comprehensive that the policy is a health benefit plan as described
4-11 by Subsection (a) of this section[:]
4-12 [(1) a group insurance policy or insurance agreement,
4-13 a group hospital service contract, or a group evidence of coverage
4-14 that is offered by:]
4-15 [(A) an insurance company;]
4-16 [(B) a group hospital service corporation
4-17 operating under Chapter 20 of this code;]
4-18 [(C) a health maintenance organization operating
4-19 under the Texas Health Maintenance Organization Act (Chapter 20A,
4-20 Vernon's Texas Insurance Code);]
4-21 [(D) a fraternal benefit society operating under
4-22 Chapter 10 of this code; or]
4-23 [(E) a stipulated premium insurance company
4-24 operating under Chapter 22 of this code; and]
4-25 [(2) to the extent permitted by the Employee
4-26 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
4-27 seq.), a group health benefit plan that is offered under:]
5-1 [(A) a multiple employer welfare arrangement as
5-2 defined by Section 3, Employee Retirement Income Security Act of
5-3 1974 (29 U.S.C. Section 1002); or]
5-4 [(B) another analogous benefit arrangement.]
5-5 [(b) This article does not apply to coverage under:]
5-6 [(1) a blanket accident and health insurance policy as
5-7 that term is defined under Section 2, Article 3.51-6, of this code;]
5-8 [(2) a short-term travel policy;]
5-9 [(3) an accident-only policy;]
5-10 [(4) a limited or specified-disease policy, other than
5-11 a plan that provides benefits for mental health care or similar
5-12 services;]
5-13 [(5) with the exception of Section 1 of this article
5-14 which shall apply, a plan offered under the Texas Employees Uniform
5-15 Group Insurance Benefits Act (Article 3.50-2, Vernon's Texas
5-16 Insurance Code) or the Texas State College and University Employees
5-17 Uniform Insurance Benefits Act (Article 3.50-3, Vernon's Texas
5-18 Insurance Code);]
5-19 [(6) a plan offered under or in accordance with
5-20 Article 3.51-5A of this code; or]
5-21 [(7) a medicare supplement policy, as that term is
5-22 defined under Section 1(b)(3), Article 3.74, of this code].
5-23 Sec. 3. COVERAGE REQUIRED [COVERAGE FOR SERIOUS MENTAL
5-24 ILLNESSES]. (a) A [Except as provided by Section 4 of this
5-25 article, a group] health benefit plan[:]
5-26 [(1)] must provide coverage[, based on medical
5-27 necessity,] for the diagnosis and medically necessary [following]
6-1 treatment of a serious mental illness or serious emotional
6-2 disturbance of a child under the same terms and conditions applied
6-3 to physical illness generally.
6-4 (b) Coverage required under this article must include [in
6-5 each calendar year]:
6-6 (1) [(A) 45 days of] inpatient treatment; [and]
6-7 (2) [(B) 60 visits for] outpatient treatment,
6-8 including group and individual outpatient treatment; and
6-9 (3) if the health benefit plan otherwise provides
6-10 coverage for prescription drugs, prescription drugs.
6-11 (c) A health benefit plan must provide the coverage required
6-12 under this article in the plan's entire service area. For the
6-13 purposes of this subsection, a health maintenance organization or
6-14 preferred provider plan is not precluded from requiring an enrollee
6-15 who resides or works in a geographic area served by specialized
6-16 health care service plans or mental health plans to obtain all or
6-17 part of the enrollee's mental health services within that
6-18 geographic area.
6-19 (d) A health benefit plan must provide the coverage required
6-20 under this article in emergency situations to the same extent as
6-21 coverage for emergency situations involving physical illness
6-22 generally.
6-23 Sec. 4. LIFETIME LIMITS ON INPATIENT TREATMENT OR OUTPATIENT
6-24 VISITS PROHIBITED. A health benefit plan [(2)] may not include a
6-25 lifetime limit on the number of days of inpatient treatment or the
6-26 number of outpatient visits covered under the plan.
6-27 Sec. 5. COST SHARING PERMITTED. Coverage provided under
7-1 this article may be subject to maximum lifetime benefits,[; and]
7-2 [(3) must include the same amount limits,]
7-3 deductibles, copayments, and coinsurance factors that are the same
7-4 as maximum lifetime benefits, deductibles, copayments, and
7-5 coinsurance factors [for serious mental illness as] for physical
7-6 illness under the health benefit plan.
7-7 Sec. 6. MANAGED CARE COMPONENT PERMITTED. [(b) An issuer
7-8 of a group health benefit plan may not count toward the number of
7-9 outpatient visits required to be covered under Subsection (a)(1) of
7-10 this section an outpatient visit for the purpose of medication
7-11 management and must cover that outpatient visit under the same
7-12 terms and conditions as it covers outpatient visits for treatment
7-13 of physical illness.]
7-14 [(c)] An issuer of a [group] health benefit plan may provide
7-15 or offer coverage required under this article [section] through a
7-16 single service health maintenance organization or other managed
7-17 care plan.
7-18 [Sec. 4. SMALL EMPLOYER COVERAGE. An issuer of a group
7-19 health benefit plan to a small employer must offer the coverage
7-20 described in Section 3 of this article but is not required to
7-21 provide the coverage if the small employer rejects the coverage.]
7-22 Sec. 7 [5]. CERTAIN BENEFITS PROHIBITED. (a) This article
7-23 may not be interpreted to require a [group] health benefit plan to
7-24 provide coverage for treatment of:
7-25 (1) addiction to a controlled substance or marihuana
7-26 that is used in violation of law; or
7-27 (2) mental illness resulting from the use of a
8-1 controlled substance or marihuana in violation of law.
8-2 (b) In this section, "controlled substance" and "marihuana"
8-3 have the meanings assigned by Section 481.002, Health and Safety
8-4 Code.
8-5 SECTION 2. This Act takes effect September 1, 2001, and
8-6 applies only to a health benefit plan delivered, issued for
8-7 delivery, or renewed on or after January 1, 2002. A health benefit
8-8 plan delivered, issued for delivery, or renewed before January 1,
8-9 2002, is governed by the law in effect immediately before the
8-10 effective date of this Act, and that law is continued in effect for
8-11 that purpose.