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By: Lucio S.B. No. 35
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for an enrollee with
autism or a pervasive developmental disorder.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
amended by adding Article 21.53X to read as follows:
Art. 21.53X. INDIVIDUAL HEALTH BENEFIT PLAN COVERAGE FOR
ENROLLEE WITH AUTISM OR PERVASIVE DEVELOPMENTAL DISORDER
Sec. 1. DEFINITION. In this article, "enrollee" means an
individual who is enrolled in a health benefit plan, including a
covered dependent.
Sec. 2. APPLICABILITY OF ARTICLE. (a) This article
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual
insurance policy or insurance agreement, an individual evidence of
coverage, or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842 of this code;
(3) a fraternal benefit society operating under
Chapter 885 of this code;
(4) a stipulated premium insurance company operating
under Chapter 884 of this code;
(5) a reciprocal exchange operating under Chapter 942
of this code;
(6) a Lloyd's plan operating under Chapter 941 of this
code;
(7) a health maintenance organization operating under
Chapter 843 of this code;
(8) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846 of this code; or
(9) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844 of this code.
(b) Notwithstanding Section 172.014, Local Government Code,
or any other law, this article applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(c) This article does not apply to:
(1) a plan that provides coverage:
(A) only for benefits for a specified disease or
for another limited benefit, other than a plan that provides
benefits for mental health or similar services;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a
period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) only for dental or vision care; or
(F) only for indemnity for hospital confinement;
(2) a small employer health benefit plan written under
Chapter 26 of this code;
(3) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
as amended;
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(6) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Subsection (a) of this section.
Sec. 3. EXCLUSION OF COVERAGE AND DENIAL OF BENEFITS
PROHIBITED. A health benefit plan may not exclude coverage or deny
benefits otherwise available to an enrollee for treatment,
equipment, or therapy based on the enrollee's having autism or a
pervasive developmental disorder.
Sec. 4. RULES. The commissioner shall adopt rules as
necessary to administer this article.
SECTION 2. Subdivision (1), Section 1, Article 3.51-14,
Insurance Code, is amended to read as follows:
(1) "Serious mental illness" means the following
psychiatric illnesses as defined by the American Psychiatric
Association in the Diagnostic and Statistical Manual (DSM):
(A) schizophrenia;
(B) paranoid and other psychotic disorders;
(C) bipolar disorders (hypomanic, manic,
depressive, and mixed);
(D) major depressive disorders (single episode
or recurrent);
(E) schizo-affective disorders (bipolar or
depressive);
(F) pervasive developmental disorders, including
autism;
(G) obsessive-compulsive disorders; and
(H) depression in childhood and adolescence.
SECTION 3. Section 2, Article 3.51-14, Insurance Code, is
amended to read as follows:
Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
a group health benefit plan that provides benefits for medical or
surgical expenses incurred as a result of a health condition,
accident, or sickness, including:
(1) a group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or a group
evidence of coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 20 of this code;
(C) a health maintenance organization operating
under the Texas Health Maintenance Organization Act (Chapter 20A,
Vernon's Texas Insurance Code);
(D) a fraternal benefit society operating under
Chapter 10 of this code; [or]
(E) a stipulated premium insurance company
operating under Chapter 22 of this code;
(F) a reciprocal exchange operating under
Chapter 942 of this code;
(G) a Lloyd's plan operating under Chapter 941 of
this code; or
(H) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844 of this
code; and
(2) to the extent permitted by the Employee Retirement
Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a
group health benefit plan that is offered under:
(A) a multiple employer welfare arrangement as
defined by Section 3, Employee Retirement Income Security Act of
1974 (29 U.S.C. Section 1002); or
(B) another analogous benefit arrangement.
(b) This article does not apply to coverage under:
(1) [a blanket accident and health insurance policy as
that term is defined under Section 2, Article 3.51-6, of this code;
[(2)] a short-term travel policy;
(2) [(3)] an accident-only policy;
(3) [(4)] a limited or specified-disease policy,
other than a plan that provides benefits for mental health care or
similar services;
(4) [(5)] with the exception of Section 1 of this
article which shall apply, a plan offered under the Texas Employees
Uniform Group Insurance Benefits Act (Article 3.50-2, Vernon's
Texas Insurance Code) or the Texas State College and University
Employees Uniform Insurance Benefits Act (Article 3.50-3, Vernon's
Texas Insurance Code);
(5) [(6)] a plan offered under or in accordance with
Article 3.51-5A of this code; or
(6) [(7)] a medicare supplement policy, as that term
is defined under Section 1(b)(3), Article 3.74, of this code.
SECTION 4. Subsection (a), Section 3, Article 3.51-14,
Insurance Code, is amended to read as follows:
(a) Except as provided by Section 4 of this article, a group
health benefit plan:
(1) must provide coverage, based on medical necessity,
for the following treatment of serious mental illness in each
calendar year:
(A) 45 days of inpatient treatment; and
(B) 60 visits for outpatient treatment,
including group and individual outpatient treatment;
(2) may not include a lifetime limit on the number of
days of inpatient treatment or the number of outpatient visits
covered under the plan; [and]
(3) must include equipment and therapy in the coverage
of treatment of pervasive developmental disorder; and
(4) must include the same amount limits, deductibles,
copayments, and coinsurance factors for serious mental illness as
for physical illness.
SECTION 5. Article 3.51-14, Insurance Code, is amended by
adding Section 6 to read as follows:
Sec. 6. RULES. The commissioner shall adopt rules as
necessary to administer this article.
SECTION 6. This Act takes effect September 1, 2003, and
applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2004. A health benefit
plan delivered, issued for delivery, or renewed before January 1,
2004, is governed by the law as it existed immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.