1-1 By: Van de Putte S.B. No. 806
1-2 (In the Senate - Filed February 20, 2001; February 22, 2001,
1-3 read first time and referred to Committee on Business and Commerce;
1-4 April 27, 2001, reported favorably by the following vote: Yeas 5,
1-5 Nays 0; April 27, 2001, sent to printer.)
1-6 A BILL TO BE ENTITLED
1-7 AN ACT
1-8 relating to health benefit plan coverage for certain mental
1-9 disorders in children.
1-10 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-11 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-12 amended by adding Article 21.53R to read as follows:
1-13 Art. 21.53R. COVERAGE FOR CERTAIN MENTAL DISORDERS IN
1-14 CHILDREN
1-15 Sec. 1. DEFINITIONS. In this article:
1-16 (1) "Child" means a person younger than 19 years of
1-17 age.
1-18 (2) "Mental disorder" means a disorder identified in
1-19 the Diagnostic and Statistical Manual of Mental Disorders, fourth
1-20 edition, other than a primary substance abuse disorder or a
1-21 developmental disorder, that results in a significant impairment of
1-22 a child's functioning in the child's community, family, school, or
1-23 peer group.
1-24 Sec. 2. APPLICABILITY OF ARTICLE. (a) This article applies
1-25 only to a health benefit plan that provides benefits for medical or
1-26 surgical expenses incurred as a result of a health condition,
1-27 accident, or sickness, including an individual, group, blanket, or
1-28 franchise insurance policy or insurance agreement, a group hospital
1-29 service contract, or an individual or group evidence of coverage or
1-30 similar coverage document that is offered by:
1-31 (1) an insurance company;
1-32 (2) a group hospital service corporation operating
1-33 under Chapter 20 of this code;
1-34 (3) a fraternal benefit society operating under
1-35 Chapter 10 of this code;
1-36 (4) a stipulated premium insurance company operating
1-37 under Chapter 22 of this code;
1-38 (5) a reciprocal exchange operating under Chapter 19
1-39 of this code;
1-40 (6) a health maintenance organization operating under
1-41 the Texas Health Maintenance Organization Act (Chapter 20A,
1-42 Vernon's Texas Insurance Code);
1-43 (7) a multiple employer welfare arrangement that holds
1-44 a certificate of authority under Article 3.95-2 of this code; or
1-45 (8) an approved nonprofit health corporation that
1-46 holds a certificate of authority under Article 21.52F of this code.
1-47 (b) This article applies to a small employer health benefit
1-48 plan written under Chapter 26 of this code.
1-49 (c) This article does not apply to:
1-50 (1) a plan that provides coverage:
1-51 (A) only for benefits for a specified disease or
1-52 for another limited benefit;
1-53 (B) only for accidental death or dismemberment;
1-54 (C) for wages or payments in lieu of wages for a
1-55 period during which an employee is absent from work because of
1-56 sickness or injury;
1-57 (D) as a supplement to a liability insurance
1-58 policy;
1-59 (E) for credit insurance;
1-60 (F) only for dental or vision care;
1-61 (G) only for hospital expenses; or
1-62 (H) only for indemnity for hospital confinement;
1-63 (2) a Medicare supplemental policy as defined by
1-64 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
2-1 as amended;
2-2 (3) a workers' compensation insurance policy;
2-3 (4) medical payment insurance coverage provided under
2-4 a motor vehicle insurance policy; or
2-5 (5) a long-term care insurance policy, including a
2-6 nursing home fixed indemnity policy, unless the commissioner
2-7 determines that the policy provides benefit coverage so
2-8 comprehensive that the policy is a health benefit plan as described
2-9 by Subsection (a) of this section.
2-10 Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan must
2-11 provide coverage for an enrollee who is a child for the diagnosis
2-12 and treatment of a mental disorder. Except as provided by this
2-13 article, a health benefit plan must provide coverage required under
2-14 this subsection under the same terms and conditions as coverage for
2-15 diagnosis and treatment of physical illness.
2-16 (b) Coverage required under this article may be provided or
2-17 offered through a managed care plan.
2-18 Sec. 4. COVERAGE OF INPATIENT STAYS AND OUTPATIENT VISITS.
2-19 Except as provided by this section, a health benefit plan must
2-20 cover inpatient stays and outpatient visits under this article
2-21 under the same terms and conditions as the plan covers inpatient
2-22 stays and outpatient visits for treatment of a physical illness.
2-23 Coverage required by this article may not be subject to an annual
2-24 or lifetime limit on the number of days of inpatient treatment or
2-25 the number of outpatient visits covered under the plan.
2-26 Sec. 5. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS; COINSURANCE.
2-27 Coverage provided under this article must be subject to the same
2-28 amount limits, deductibles, copayments, and coinsurance factors as
2-29 coverage for physical illness.
2-30 Sec. 6. RULES. The commissioner shall adopt rules as
2-31 necessary to implement this article.
2-32 SECTION 2. Subdivision (1), Section 1, Article 3.51-14,
2-33 Insurance Code, is amended to read as follows:
2-34 (1) "Serious mental illness" means the following
2-35 psychiatric illnesses as defined by the American Psychiatric
2-36 Association in the Diagnostic and Statistical Manual (DSM):
2-37 (A) schizophrenia;
2-38 (B) paranoid and other psychotic disorders;
2-39 (C) bipolar disorders (hypomanic, manic,
2-40 depressive, and mixed);
2-41 (D) major depressive disorders (single episode
2-42 or recurrent);
2-43 (E) schizo-affective disorders (bipolar or
2-44 depressive);
2-45 (F) pervasive developmental disorders; and
2-46 (G) obsessive-compulsive disorders[; and]
2-47 [(H) depression in childhood and adolescence].
2-48 SECTION 3. Subsection (a), Section 3, Article 3.51-14,
2-49 Insurance Code, is amended to read as follows:
2-50 (a) Except as provided by Section 4 of this article or
2-51 Article 21.53R of this code, a group health benefit plan:
2-52 (1) must provide coverage, based on medical necessity,
2-53 for the following treatment of serious mental illness in each
2-54 calendar year:
2-55 (A) 45 days of inpatient treatment; and
2-56 (B) 60 visits for outpatient treatment,
2-57 including group and individual outpatient treatment;
2-58 (2) may not include a lifetime limit on the number of
2-59 days of inpatient treatment or the number of outpatient visits
2-60 covered under the plan; and
2-61 (3) must include the same amount limits, deductibles,
2-62 copayments, and coinsurance factors for serious mental illness as
2-63 for physical illness.
2-64 SECTION 4. This Act takes effect September 1, 2001, and
2-65 applies only to a health benefit plan delivered, issued for
2-66 delivery, or renewed on or after January 1, 2002. A health benefit
2-67 plan delivered, issued for delivery, or renewed before January 1,
2-68 2002, is governed by the law as it existed immediately before the
2-69 effective date of this Act, and that law is continued in effect for
3-1 that purpose.
3-2 * * * * *