By Lucio S.B. No. 427
77R3810 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health benefit plan coverage for the treatment of
1-3 autism and pervasive developmental disorders.
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 21.53X to read as follows:
1-7 Art. 21.53X. INDIVIDUAL OR GROUP HEALTH BENEFIT PLAN
1-8 COVERAGE FOR AUTISM AND PERVASIVE DEVELOPMENTAL DISORDERS
1-9 Sec. 1. DEFINITION. In this article, "enrollee" means a
1-10 person entitled to coverage under a health benefit plan.
1-11 Sec. 2. APPLICABILITY OF ARTICLE. (a) This article
1-12 applies only to a health benefit plan that provides benefits for
1-13 medical or surgical expenses incurred as a result of a health
1-14 condition, accident, or sickness, including an individual, group,
1-15 blanket, or franchise insurance policy or insurance agreement, a
1-16 group hospital service contract, or an individual or group evidence
1-17 of coverage or similar coverage document that is offered by:
1-18 (1) an insurance company;
1-19 (2) a group hospital service corporation operating
1-20 under Chapter 20 of this code;
1-21 (3) a fraternal benefit society operating under
1-22 Chapter 10 of this code;
1-23 (4) a stipulated premium insurance company operating
1-24 under Chapter 22 of this code;
2-1 (5) a reciprocal exchange operating under Chapter 19
2-2 of this code;
2-3 (6) a health maintenance organization operating under
2-4 the Texas Health Maintenance Organization Act (Chapter 20A,
2-5 Vernon's Texas Insurance Code);
2-6 (7) a multiple employer welfare arrangement that holds
2-7 a certificate of authority under Article 3.95-2 of this code; or
2-8 (8) an approved nonprofit health corporation that
2-9 holds a certificate of authority under Article 21.52F of this code.
2-10 (b) Notwithstanding Section 172.014, Local Government Code,
2-11 or any other law, this article applies to health and accident
2-12 coverage provided by a risk pool created under Chapter 172, Local
2-13 Government Code.
2-14 (c) This article does not apply to:
2-15 (1) a plan that provides coverage:
2-16 (A) only for benefits for a specified disease or
2-17 for another limited benefit;
2-18 (B) only for accidental death or dismemberment;
2-19 (C) for wages or payments in lieu of wages for a
2-20 period during which an employee is absent from work because of
2-21 sickness or injury;
2-22 (D) as a supplement to a liability insurance
2-23 policy;
2-24 (E) only for dental or vision care; or
2-25 (F) only for indemnity for hospital confinement;
2-26 (2) a small employer health benefit plan written under
2-27 Chapter 26 of this code;
3-1 (3) a Medicare supplemental policy as defined by
3-2 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-3 as amended;
3-4 (4) a workers' compensation insurance policy;
3-5 (5) medical payment insurance coverage provided under
3-6 a motor vehicle insurance policy; or
3-7 (6) a long-term care insurance policy, including a
3-8 nursing home fixed indemnity policy, unless the commissioner
3-9 determines that the policy provides benefit coverage so
3-10 comprehensive that the policy is a health benefit plan as described
3-11 by Subsection (a) of this section.
3-12 Sec. 3. COVERAGE REQUIRED. (a) In addition to any coverage
3-13 a health benefit plan is required to provide under Article 3.51-14
3-14 of this code, a health benefit plan must provide each enrollee with
3-15 coverage for any medically necessary treatment, equipment, or
3-16 therapy for the treatment of autism or a pervasive developmental
3-17 disorder.
3-18 (b) Coverage provided under this article shall be provided
3-19 in a manner determined to be appropriate in consultation with the
3-20 attending physician and the enrollee.
3-21 Sec. 4. DEDUCTIBLE, COPAYMENT, OR COINSURANCE REQUIREMENT
3-22 PERMITTED; DOLLAR LIMIT PROHIBITED. (a) Coverage required by this
3-23 article may be subject to annual deductibles, copayments, or
3-24 coinsurance requirements that are consistent with annual
3-25 deductibles, copayments, or coinsurance requirements for other
3-26 coverage provided under the health benefit plan.
3-27 (b) The coverage required by this article may not be subject
4-1 to dollar limitations other than the health benefit plan's lifetime
4-2 maximum benefits.
4-3 Sec. 5. RULES. The commissioner shall adopt rules as
4-4 necessary to administer this article.
4-5 SECTION 2. This Act takes effect September 1, 2001, and
4-6 applies only to a health benefit plan delivered, issued for
4-7 delivery, or renewed on or after January 1, 2002. A health benefit
4-8 plan delivered, issued for delivery, or renewed before January 1,
4-9 2002, is governed by the law as it existed immediately before the
4-10 effective date of this Act, and that law is continued in effect for
4-11 that purpose.