By: Van de Putte S.B. No. 116
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for certain mental
disorders in children.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
amended by adding Article 21.53R to read as follows:
Art. 21.53R. COVERAGE FOR CERTAIN MENTAL DISORDERS IN
CHILDREN
Sec. 1. DEFINITIONS. In this article:
(1) "Child" means a person younger than 19 years of
age.
(2) "Mental disorder" means a disorder identified in
the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition, or in a subsequent edition of that manual that the
commissioner by rule adopts to take the place of the fourth edition
or any subsequent edition for the purposes of this subdivision,
other than a primary substance abuse disorder or a developmental
disorder, that results in a significant impairment of a child's
functioning in the child's community, family, school, or peer
group.
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, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group 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;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium insurance company operating
under Chapter 884;
(5) an exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This article applies to a small employer health benefit
plan written under Chapter 26.
(c) This article does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or other limited
benefit;
(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 Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
as amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy;
(5) a credit insurance policy; or
(6) a long-term care 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).
Sec. 3. COVERAGE REQUIRED. (a) A health benefit plan must
provide coverage for an enrollee who is a child for the diagnosis
and treatment of a mental disorder. Except as provided by this
article, a health benefit plan must provide coverage required under
this subsection under the same terms and conditions as coverage for
diagnosis and treatment of physical illness.
(b) Coverage required under this article may be provided or
offered through a managed care plan.
Sec. 4. COVERAGE OF INPATIENT STAYS AND OUTPATIENT
VISITS. Except as provided by this section, a health benefit plan
must cover inpatient stays and outpatient visits under this article
under the same terms and conditions as the plan covers inpatient
stays and outpatient visits for treatment of a physical illness.
Coverage required by this article may not be subject to an annual or
lifetime limit on the number of days of inpatient treatment or the
number of outpatient visits covered under the plan.
Sec. 5. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS;
COINSURANCE. Coverage provided under this article must be subject
to the same amount limits, deductibles, copayments, and coinsurance
factors as coverage for physical illness.
Sec. 6. RULES. The commissioner shall adopt rules as
necessary to implement this article.
SECTION 2. Section 1(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; and
(G) obsessive-compulsive disorders[; and
[(H) depression in childhood and adolescence].
SECTION 3. Section 3(a), Article 3.51-14, Insurance Code,
is amended to read as follows:
(a) Except as provided by Section 4 of this article or
Article 21.53R of this code, 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 the same amount limits, deductibles,
copayments, and coinsurance factors for serious mental illness as
for physical illness.
SECTION 4. (a) On or before September 1, 2008, the Sunset
Advisory Commission shall conduct a study to determine:
(1) to what extent the health benefit plan coverage
required by Article 21.53R, Insurance Code, as added by this Act,
and by the change in law made by this Act to Sections 1(1) and 3(a),
Article 3.51-14, Insurance Code, is being used by enrollees in
health benefit plans to which those articles apply; and
(2) the impact of the required coverage on the cost of
those health benefit plans.
(b) The Sunset Advisory Commission shall report its
findings under this section to the legislature on or before January
1, 2009.
(c) The Texas Department of Insurance and any other state
agency shall cooperate with the Sunset Advisory Commission as
necessary to implement this section.
SECTION 5. 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.