77R16434 AJA-F
By Van de Putte, et al. S.B. No. 806
Substitute the following for S.B. No. 806:
By Lewis of Tarrant C.S.S.B. No. 806
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health benefit plan coverage for certain mental
1-3 disorders in children.
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 21.53R to read as follows:
1-7 Art. 21.53R. COVERAGE FOR CERTAIN MENTAL DISORDERS IN
1-8 CHILDREN
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Child" means a person younger than 19 years of
1-11 age.
1-12 (2) "Mental disorder" means a disorder identified in
1-13 the Diagnostic and Statistical Manual of Mental Disorders, fourth
1-14 edition, or in a subsequent edition of that manual that the
1-15 commissioner by rule adopts to take the place of the fourth edition
1-16 or any subsequent edition for the purposes of this subdivision,
1-17 other than a primary substance abuse disorder or a developmental
1-18 disorder, that results in a significant impairment of a child's
1-19 functioning in the child's community, family, school, or peer
1-20 group.
1-21 Sec. 2. APPLICABILITY OF ARTICLE. (a) This article
1-22 applies only to a health benefit plan that provides benefits for
1-23 medical or surgical expenses incurred as a result of a health
1-24 condition, accident, or sickness, including an individual, group,
2-1 blanket, or franchise insurance policy or insurance agreement, a
2-2 group hospital service contract, or an individual or group evidence
2-3 of coverage or similar coverage document that is offered by:
2-4 (1) an insurance company;
2-5 (2) a group hospital service corporation operating
2-6 under Chapter 20 of this code;
2-7 (3) a fraternal benefit society operating under
2-8 Chapter 10 of this code;
2-9 (4) a stipulated premium insurance company operating
2-10 under Chapter 22 of this code;
2-11 (5) a reciprocal exchange operating under Chapter 19
2-12 of this code;
2-13 (6) a health maintenance organization operating under
2-14 the Texas Health Maintenance Organization Act (Chapter 20A,
2-15 Vernon's Texas Insurance Code);
2-16 (7) a multiple employer welfare arrangement that holds
2-17 a certificate of authority under Article 3.95-2 of this code; or
2-18 (8) an approved nonprofit health corporation that
2-19 holds a certificate of authority under Article 21.52F of this code.
2-20 (b) This article applies to a small employer health benefit
2-21 plan written under Chapter 26 of this code.
2-22 (c) This article does not apply to:
2-23 (1) a plan that provides coverage:
2-24 (A) only for benefits for a specified disease or
2-25 for another limited benefit;
2-26 (B) only for accidental death or dismemberment;
2-27 (C) for wages or payments in lieu of wages for a
3-1 period during which an employee is absent from work because of
3-2 sickness or injury;
3-3 (D) as a supplement to a liability insurance
3-4 policy;
3-5 (E) for credit insurance;
3-6 (F) only for dental or vision care;
3-7 (G) only for hospital expenses; or
3-8 (H) only for indemnity for hospital confinement;
3-9 (2) a Medicare supplemental policy as defined by
3-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-11 as amended;
3-12 (3) a workers' compensation insurance policy;
3-13 (4) medical payment insurance coverage provided under
3-14 a motor vehicle insurance policy; or
3-15 (5) a long-term care insurance policy, including a
3-16 nursing home fixed indemnity policy, unless the commissioner
3-17 determines that the policy provides benefit coverage so
3-18 comprehensive that the policy is a health benefit plan as described
3-19 by Subsection (a) of this section.
3-20 Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan must
3-21 provide coverage for an enrollee who is a child for the diagnosis
3-22 and treatment of a mental disorder. Except as provided by this
3-23 article, a health benefit plan must provide coverage required under
3-24 this subsection under the same terms and conditions as coverage for
3-25 diagnosis and treatment of physical illness.
3-26 (b) Coverage required under this article may be provided or
3-27 offered through a managed care plan.
4-1 Sec. 4. COVERAGE OF INPATIENT STAYS AND OUTPATIENT VISITS.
4-2 Except as provided by this section, a health benefit plan must
4-3 cover inpatient stays and outpatient visits under this article
4-4 under the same terms and conditions as the plan covers inpatient
4-5 stays and outpatient visits for treatment of a physical illness.
4-6 Coverage required by this article may not be subject to an annual
4-7 or lifetime limit on the number of days of inpatient treatment or
4-8 the number of outpatient visits covered under the plan.
4-9 Sec. 5. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS; COINSURANCE.
4-10 Coverage provided under this article must be subject to the same
4-11 amount limits, deductibles, copayments, and coinsurance factors as
4-12 coverage for physical illness.
4-13 Sec. 6. RULES. The commissioner shall adopt rules as
4-14 necessary to implement this article.
4-15 SECTION 2. Section 1(1), Article 3.51-14, Insurance Code, is
4-16 amended to read as follows:
4-17 (1) "Serious mental illness" means the following
4-18 psychiatric illnesses as defined by the American Psychiatric
4-19 Association in the Diagnostic and Statistical Manual (DSM):
4-20 (A) schizophrenia;
4-21 (B) paranoid and other psychotic disorders;
4-22 (C) bipolar disorders (hypomanic, manic,
4-23 depressive, and mixed);
4-24 (D) major depressive disorders (single episode
4-25 or recurrent);
4-26 (E) schizo-affective disorders (bipolar or
4-27 depressive);
5-1 (F) pervasive developmental disorders; and
5-2 (G) obsessive-compulsive disorders[; and]
5-3 [(H) depression in childhood and adolescence].
5-4 SECTION 3. Section 3(a), Article 3.51-14, Insurance Code, is
5-5 amended to read as follows:
5-6 (a) Except as provided by Section 4 of this article or
5-7 Article 21.53R of this code, a group health benefit plan:
5-8 (1) must provide coverage, based on medical necessity,
5-9 for the following treatment of serious mental illness in each
5-10 calendar year:
5-11 (A) 45 days of inpatient treatment; and
5-12 (B) 60 visits for outpatient treatment,
5-13 including group and individual outpatient treatment;
5-14 (2) may not include a lifetime limit on the number of
5-15 days of inpatient treatment or the number of outpatient visits
5-16 covered under the plan; and
5-17 (3) must include the same amount limits, deductibles,
5-18 copayments, and coinsurance factors for serious mental illness as
5-19 for physical illness.
5-20 SECTION 4. (a) On or before September 1, 2006, the Sunset
5-21 Advisory Commission shall conduct a study to determine:
5-22 (1) to what extent the health benefit plan coverage
5-23 required by Article 21.53R, Insurance Code, as added by this Act,
5-24 and by the change in law made by this Act to Sections 1(1) and
5-25 3(a), Article 3.51-14, Insurance Code, is being used by enrollees
5-26 in health benefit plans to which those articles apply; and
5-27 (2) the impact of the required coverage on the cost of
6-1 those health benefit plans.
6-2 (b) The Sunset Advisory Commission shall report its findings
6-3 under this section to the legislature on or before January 1, 2007.
6-4 (c) The Texas Department of Insurance and any other state
6-5 agency shall cooperate with the Sunset Advisory Commission as
6-6 necessary to implement this section.
6-7 SECTION 5. This Act takes effect September 1, 2001, and
6-8 applies only to a health benefit plan delivered, issued for
6-9 delivery, or renewed on or after January 1, 2002. A health benefit
6-10 plan delivered, issued for delivery, or renewed before January 1,
6-11 2002, is governed by the law as it existed immediately before the
6-12 effective date of this Act, and that law is continued in effect for
6-13 that purpose.