By Van de Putte S.B. No. 806
77R4990 AJA-F
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, other than a primary substance abuse disorder or a
1-15 developmental disorder, that results in a significant impairment of
1-16 a child's functioning in the child's community, family, school, or
1-17 peer group.
1-18 Sec. 2. APPLICABILITY OF ARTICLE. (a) This article
1-19 applies only to a health benefit plan that provides benefits for
1-20 medical or surgical expenses incurred as a result of a health
1-21 condition, accident, or sickness, including an individual, group,
1-22 blanket, or franchise insurance policy or insurance agreement, a
1-23 group hospital service contract, or an individual or group evidence
1-24 of coverage or similar coverage document that is offered by:
2-1 (1) an insurance company;
2-2 (2) a group hospital service corporation operating
2-3 under Chapter 20 of this code;
2-4 (3) a fraternal benefit society operating under
2-5 Chapter 10 of this code;
2-6 (4) a stipulated premium insurance company operating
2-7 under Chapter 22 of this code;
2-8 (5) a reciprocal exchange operating under Chapter 19
2-9 of this code;
2-10 (6) a health maintenance organization operating under
2-11 the Texas Health Maintenance Organization Act (Chapter 20A,
2-12 Vernon's Texas Insurance Code);
2-13 (7) a multiple employer welfare arrangement that holds
2-14 a certificate of authority under Article 3.95-2 of this code; or
2-15 (8) an approved nonprofit health corporation that
2-16 holds a certificate of authority under Article 21.52F of this code.
2-17 (b) This article applies to a small employer health benefit
2-18 plan written under Chapter 26 of this code.
2-19 (c) This article does not apply to:
2-20 (1) a plan that provides coverage:
2-21 (A) only for benefits for a specified disease or
2-22 for another limited benefit;
2-23 (B) only for accidental death or dismemberment;
2-24 (C) for wages or payments in lieu of wages for a
2-25 period during which an employee is absent from work because of
2-26 sickness or injury;
2-27 (D) as a supplement to a liability insurance
3-1 policy;
3-2 (E) for credit insurance;
3-3 (F) only for dental or vision care;
3-4 (G) only for hospital expenses; or
3-5 (H) only for indemnity for hospital confinement;
3-6 (2) a Medicare supplemental policy as defined by
3-7 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-8 as amended;
3-9 (3) a workers' compensation insurance policy;
3-10 (4) medical payment insurance coverage provided under
3-11 a motor vehicle insurance policy; or
3-12 (5) a long-term care insurance policy, including a
3-13 nursing home fixed indemnity policy, unless the commissioner
3-14 determines that the policy provides benefit coverage so
3-15 comprehensive that the policy is a health benefit plan as described
3-16 by Subsection (a) of this section.
3-17 Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan must
3-18 provide coverage for an enrollee who is a child for the diagnosis
3-19 and treatment of a mental disorder. Except as provided by this
3-20 article, a health benefit plan must provide coverage required under
3-21 this subsection under the same terms and conditions as coverage for
3-22 diagnosis and treatment of physical illness.
3-23 (b) Coverage required under this article may be provided or
3-24 offered through a managed care plan.
3-25 Sec. 4. COVERAGE OF INPATIENT STAYS AND OUTPATIENT VISITS.
3-26 Except as provided by this section, a health benefit plan must
3-27 cover inpatient stays and outpatient visits under this article
4-1 under the same terms and conditions as the plan covers inpatient
4-2 stays and outpatient visits for treatment of a physical illness.
4-3 Coverage required by this article may not be subject to an annual
4-4 or lifetime limit on the number of days of inpatient treatment or
4-5 the number of outpatient visits covered under the plan.
4-6 Sec. 5. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS; COINSURANCE.
4-7 Coverage provided under this article must be subject to the same
4-8 amount limits, deductibles, copayments, and coinsurance factors as
4-9 coverage for physical illness.
4-10 Sec. 6. RULES. The commissioner shall adopt rules as
4-11 necessary to implement this article.
4-12 SECTION 2. Section 1(1), Article 3.51-14, Insurance Code, is
4-13 amended to read as follows:
4-14 (1) "Serious mental illness" means the following
4-15 psychiatric illnesses as defined by the American Psychiatric
4-16 Association in the Diagnostic and Statistical Manual (DSM):
4-17 (A) schizophrenia;
4-18 (B) paranoid and other psychotic disorders;
4-19 (C) bipolar disorders (hypomanic, manic,
4-20 depressive, and mixed);
4-21 (D) major depressive disorders (single episode
4-22 or recurrent);
4-23 (E) schizo-affective disorders (bipolar or
4-24 depressive);
4-25 (F) pervasive developmental disorders; and
4-26 (G) obsessive-compulsive disorders[; and]
4-27 [(H) depression in childhood and adolescence].
5-1 SECTION 3. Section 3(a), Article 3.51-14, Insurance Code, is
5-2 amended to read as follows:
5-3 (a) Except as provided by Section 4 of this article or
5-4 Article 21.53R of this code, a group health benefit plan:
5-5 (1) must provide coverage, based on medical necessity,
5-6 for the following treatment of serious mental illness in each
5-7 calendar year:
5-8 (A) 45 days of inpatient treatment; and
5-9 (B) 60 visits for outpatient treatment,
5-10 including group and individual outpatient treatment;
5-11 (2) may not include a lifetime limit on the number of
5-12 days of inpatient treatment or the number of outpatient visits
5-13 covered under the plan; and
5-14 (3) must include the same amount limits, deductibles,
5-15 copayments, and coinsurance factors for serious mental illness as
5-16 for physical illness.
5-17 SECTION 4. This Act takes effect September 1, 2001, and
5-18 applies only to a health benefit plan delivered, issued for
5-19 delivery, or renewed on or after January 1, 2002. A health benefit
5-20 plan delivered, issued for delivery, or renewed before January 1,
5-21 2002, is governed by the law as it existed immediately before the
5-22 effective date of this Act, and that law is continued in effect for
5-23 that purpose.