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79R5544 DLF-D
By: Coleman H.B. No. 1784
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for an enrollee with
certain mental disorders.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. AMENDMENTS TO SUBCHAPTER A, CHAPTER 1355,
INSURANCE CODE
SECTION 1.01. Subchapter A, Chapter 1355, Insurance Code,
as effective April 1, 2005, is amended to read as follows:
SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR
CERTAIN [SERIOUS] MENTAL DISORDERS [ILLNESSES]
Sec. 1355.001. DEFINITIONS. In this subchapter, "mental
disorder"[:
[(1) "Serious mental illness"] means a disorder [the
following psychiatric illnesses] as defined by the American
Psychiatric Association in the Diagnostic and Statistical Manual of
Mental Disorders, fourth edition, or in a subsequent edition of
that manual that the commissioner adopts to take the place of the
fourth edition or any subsequent edition for the purposes of this
subdivision, that results in an impairment of a person's
functioning in the person's community, employment, family, school,
or social group [(DSM):
[(A) bipolar disorders (hypomanic, manic,
depressive, and mixed);
[(B) depression in childhood and adolescence;
[(C) major depressive disorders (single episode
or recurrent);
[(D) obsessive-compulsive disorders;
[(E) paranoid and other psychotic disorders;
[(F) pervasive developmental disorders;
[(G) schizo-affective disorders (bipolar or
depressive); and
[(H) schizophrenia].
[(2) "Small employer" has the meaning assigned by
Section 1501.002.]
Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter 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 an
individual, [:
[(1) a] group, blanket, or franchise insurance policy
or [, group] insurance agreement, a group hospital service
contract, an individual or group evidence of coverage, or a similar
coverage document, that is offered by:
(1) [(A)] an insurance company;
(2) [(B)] a group hospital service corporation
operating under Chapter 842;
(3) [(C)] a fraternal benefit society operating under
Chapter 885;
(4) [(D)] a stipulated premium company operating
under Chapter 884; [or]
(5) [(E)] a health maintenance organization operating
under Chapter 843;
(6) a reciprocal exchange operating under Chapter 942;
(7) a Lloyd's plan operating under Chapter 941;
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844; or [and]
(9) [(2) to the extent permitted by the Employee
Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
seq.), a plan offered under:
[(A)] a multiple employer welfare arrangement
that holds a certificate of authority under Chapter 846 [as defined
by Section 3 of that Act; or
[(B) another analogous benefit arrangement].
(b) This subchapter applies to a small employer health
benefit plan written under Chapter 1501.
Sec. 1355.003. EXCEPTION. [(a)] This subchapter does not
apply to [coverage under]:
(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;
(F) only for hospital expenses; or
(G) 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);
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
an automobile insurance policy;
(5) a credit 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 Section 1355.002 [a blanket accident and health insurance
policy, as described by Chapter 1251;
[(2) a short-term travel policy;
[(3) an accident-only policy;
[(4) a limited or specified-disease policy that does
not provide benefits for mental health care or similar services;
[(5) except as provided by Subsection (b), a plan
offered under Chapter 1551 or Chapter 1601;
[(6) a plan offered in accordance with Section
1355.151; or
[(7) a Medicare supplement benefit plan, as defined by
Section 1652.002].
[(b) For the purposes of a plan described by Subsection
(a)(5), "serious mental illness" has the meaning assigned by
Section 1355.001.]
Sec. 1355.004. REQUIRED COVERAGE [FOR SERIOUS MENTAL
ILLNESS]. [(a)] A [group] health benefit plan[:
[(1)] must provide coverage for the diagnosis and
treatment of a mental disorder, under the same terms and conditions
as coverage provided for the diagnosis and treatment of physical
illness[, based on medical necessity, for not less than the
following treatments 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 limitation on the
number of days of inpatient treatment or the number of visits for
outpatient treatment covered under the plan; and
[(3) must include the same amount limitations,
deductibles, copayments, and coinsurance factors for serious
mental illness as the plan includes for physical illness].
[(b) A group health benefit plan issuer:
[(1) may not count an outpatient visit for medication
management against the number of outpatient visits required to be
covered under Subsection (a)(1)(B); and
[(2) must provide coverage for an outpatient visit
described by Subsection (a)(1)(B) under the same terms as the
coverage the issuer provides for an outpatient visit for the
treatment of physical illness.]
Sec. 1355.005. COVERAGE OF INPATIENT STAYS AND OUTPATIENT
VISITS. A health benefit plan must cover inpatient stays and
outpatient visits under this subchapter under the same terms and
conditions as the plan covers inpatient stays and outpatient visits
for treatment of a physical illness. [MANAGED CARE PLAN
AUTHORIZED. A group health benefit plan issuer may provide or
offer coverage required by Section 1355.004 through a managed care
plan.]
Sec. 1355.006. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS;
COINSURANCE. Coverage provided under this subchapter must be
subject to the same amount limits, deductibles, copayments, and
coinsurance factors as coverage for physical illness. [COVERAGE FOR
CERTAIN CONDITIONS RELATED TO CONTROLLED SUBSTANCE OR MARIHUANA NOT
REQUIRED. (a) In this section, "controlled substance" and
"marihuana" have the meanings assigned by Section 481.002, Health
and Safety Code.
[(b) This subchapter does not require a group health benefit
plan to provide coverage for the treatment of:
[(1) addiction to a controlled substance or marihuana
that is used in violation of law; or
[(2) mental illness that results from the use of a
controlled substance or marihuana in violation of law.]
Sec. 1355.007. RULES. The commissioner shall adopt rules
as necessary to implement this article. [SMALL EMPLOYER
COVERAGE. An issuer of a group health benefit plan to a small
employer must offer the coverage described by Section 1355.004 to
the employer but is not required to provide the coverage if the
employer rejects the coverage.]
ARTICLE 2. CONFORMING AMENDMENTS
SECTION 2.01. Section 1355.151, Insurance Code, as
effective April 1, 2005, is amended to read as follows:
Sec. 1355.151. PROHIBITION ON EXCLUSION OR LIMITATION OF
CERTAIN COVERAGES. (a) In this section, "mental disorder"
["serious mental illness"] has the meaning assigned by Section
1355.001.
(b) A political subdivision that provides group health
insurance coverage, health maintenance organization coverage, or
self-insured health care coverage to the political subdivision's
officers or employees may not contract for or provide coverage that
is less extensive for a mental disorder [serious mental illness]
than the coverage provided for any [other] physical illness.
SECTION 2.02. Section 1551.003, Insurance Code, is amended
by adding Subsection (10-a) to read as follows:
(10-a) "Mental disorder" has the meaning assigned by
Section 1355.001.
SECTION 2.03. Section 1551.205, Insurance Code, is amended
to read as follows:
Sec. 1551.205. LIMITATIONS. The board of trustees may not
contract for or provide a coverage plan that:
(1) excludes or limits coverage or services for
acquired immune deficiency syndrome, as defined by the Centers for
Disease Control and Prevention of the United States Public Health
Service, or human immunodeficiency virus infection;
(2) provides coverage for a mental disorder [serious
mental illness] that is less extensive than the coverage provided
for any physical illness; or
(3) may provide coverage for prescription drugs to
assist in stopping smoking at a lower benefit level than is provided
for other prescription drugs.
SECTION 2.04. Section 1601.109, Insurance Code, is amended
to read as follows:
Sec. 1601.109. COVERAGE FOR AIDS, HIV, OR [SERIOUS] MENTAL
DISORDER [ILLNESS]. (a) In this section, "mental disorder"
["serious mental illness"] has the meaning assigned by Section
1355.001 [1, Article 3.51-14].
(b) A system may not contract for or provide for group
insurance or HMO coverage or provide self-insured coverage, that:
(1) excludes or limits coverage or services for
acquired immune deficiency syndrome, as defined by the Centers for
Disease Control and Prevention of the United States Public Health
Service, or human immunodeficiency virus infection; or
(2) provides coverage for a mental disorder [serious
mental illness] that is less extensive than the coverage provided
for any [other] physical illness.
SECTION 2.05. Section 3(b), Article 3.80, Insurance Code,
is amended to read as follows:
(b) For purposes of this article, "state-mandated health
benefits" does not include benefits that are mandated by federal
law or standard provisions or rights required under this code or
other laws of this state to be provided in an individual, blanket,
or group policy for accident and health insurance that are
unrelated to specific health illnesses, injuries, or conditions of
an insured, including provisions related to:
(1) continuation of coverage under:
(A) Subchapters F and G, Chapter 1251 [Section
1(d)(3) and Section 3B, Article 3.51-6] of this code;
(B) Section 1201.059 of this code [2(C), Chapter
397, Acts of the 54th Legislature, Regular Session, 1955 (Article
3.70-2, Vernon's Texas Insurance Code)]; and
(C) Subchapter B, Chapter 1253 [Article 3.51-8]
of this code[; and
[(D) Section 3C, Article 3.51-6 of this code, as
added by Section 10, Chapter 1041, Acts of the 71st Legislature,
Regular Session, 1989];
(2) termination of coverage under Sections 1202.051
and 1501.108 [Articles 3.70-1A, 26.23, and 26.86] of this code;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105 [Section 1(H),
Chapter 397, Acts of the 54th Legislature, Regular Session, 1955
(Article 3.70-1, Vernon's Texas Insurance Code), and Articles 26.49
and 26.90] of this code;
(4) coverage of children, including newborn or adopted
children, under:
(A) Subchapter D, Chapter 1251 [Sections 1, 3D,
and 3E, Article 3.51-6] of this code;
(B) Sections 1201.053, 1201.061,
1201.063-1201.065, and Subchapter A, Chapter 1367, of this code
[2(A), (E), (K), and (M), Chapter 397, Acts of the 54th Legislature,
Regular Session, 1955 (Article 3.70-2, Vernon's Texas Insurance
Code)];
(C) Chapter 1504 [Subchapter J, Chapter 3] of
this code;
(D) Chapter 1503 [Article 21.24-2] of this code;
(E) Section 1501.157 [Article 26.21(n)] of this
code;
(F) Section 1501.158 [Article 26.21A] of this
code; and
(G) Sections 1501.607-1501.609 [Article 26.84]
of this code;
(5) services of practitioners under:
(A) Subchapters A, B, and C, Chapter 1451
[Article 21.52] of this code; or
(B) Section 1301.052 [Article 3.70-3C] of this
code[, as added by Chapter 1260, Acts of the 75th Legislature,
Regular Session, 1997; or
[(C) Section 2(B), Chapter 397, Acts of the 54th
Legislature, Regular Session, 1955 (Article 3.70-2, Vernon's Texas
Insurance Code)];
(6) supplies and services associated with the
treatment of diabetes under Subchapter B, Chapter 1358 [Article
21.53G] of this code;
(7) coverage for a mental disorder [serious mental
illness] under Subchapter A, Chapter 1355 [Article 3.51-14 of this
code if the standard health benefit plan is issued to a large
employer as defined by Article 26.02 of this code];
(8) coverage for childhood immunizations and hearing
screening as required by:
(A) Subchapters B and C, Chapter 1367 [Article
21.53F] of this code, other than Section 1367.053(c); and
(B) Chapter 1353 [as added by Chapter 683, Acts
of the 75th Legislature, Regular Session, 1997, and Article 21.53K]
of this code;
(9) coverage for reconstructive surgery for certain
craniofacial abnormalities of children as required by Subchapter D,
Chapter 1367 [Article 21.53W] of this code;
(10) coverage for the dietary treatment of
phenylketonuria as required by Chapter 1359 [Article 3.79] of this
code;
(11) coverage for referral to a non-network physician
or provider when medically necessary covered services are not
available through network physicians or providers, as required by
Section 1271.055 [Article 20A.09(a)(3)(C)] of this code; and
(12) coverage for cancer screenings under the
following chapters [articles] of this code:
(A) Chapter 1356 [Article 3.70-2(H), as added by
Chapter 1091, Acts of the 70th Legislature, Regular Session, 1987];
(B) Chapter 1362 [Article 21.53F, as added by
Chapter 1287, Acts of the 75th Legislature, Regular Session, 1997];
and
(C) Chapter 1363 [Article 21.53S].
SECTION 2.06. Subsection (d), Article 20A.09N, Insurance
Code, is amended to read as follows:
(d) For purposes of this section, "state-mandated health
benefits" does not include coverage that is mandated by federal law
or standard provisions or rights required under the Insurance Code
or other law of this state to be provided in an evidence of coverage
that are unrelated to specific health illnesses, injuries, or
conditions of an insured, including provisions related to:
(1) continuation of coverage under Subchapter G,
Chapter 1251 [Section 3B, Article 3.51-6], Insurance Code;
(2) termination of coverage under Sections 1202.051
and 1501.108 [Articles 3.70-1A, 26.23, and 26.86], Insurance Code;
(3) preexisting conditions under Subchapter D,
Chapter 1201, Insurance Code, and Sections 1501.102-1501.105,
[Section 1(H), Chapter 397, Acts of the 54th Legislature, Regular
Session, 1955 (Article 3.70-1, Vernon's Texas Insurance Code), and
Articles 26.49 and 26.90,] Insurance Code;
(4) coverage of children, including newborn or adopted
children, under:
(A) Chapter 1504 [Subchapter J, Chapter 3],
Insurance Code;
(B) Chapter 1503 [Article 21.24-2], Insurance
Code;
(C) Section 1501.157 [Article 26.21(n)],
Insurance Code;
(D) Section 1501.158 [Article 26.21A], Insurance
Code; and
(E) Sections 1501.607-1501.609 [Article 26.84],
Insurance Code;
(5) services of providers under Section 843.304,
Insurance Code [of this code];
(6) coverage for a mental disorder [serious mental
health illness] under Subchapter A, Chapter 1355 [Article 3.51-14],
Insurance Code [, if the standard health benefit plan is issued to a
large employer as defined in Article 26.02, Insurance Code]; and
(7) coverage for cancer screenings under the following
chapters [articles] of the Insurance Code [this code]:
(A) Chapter 1356, Insurance Code [Article
3.70-2(H), as added by Chapter 1091, Acts of the 70th Legislature,
Regular Session, 1987];
(B) Chapter 1362, Insurance Code [Article
21.53F, as added by Chapter 1287, Acts of the 75th Legislature,
Regular Session, 1997]; and
(C) Chapter 1363, Insurance Code [Article
21.53S].
SECTION 2.07. Section 1551.003(12), Insurance Code, is
repealed.
ARTICLE 3. TRANSITION; EFFECTIVE DATE
SECTION 3.01. The change in law made by this Act applies
only to a health benefit plan delivered, issued for delivery, or
renewed on or after January 1, 2006. A health benefit plan
delivered, issued for delivery, or renewed before January 1, 2006,
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.
SECTION 3.02. To the extent of any conflict, this Act
prevails over another Act of the 79th Legislature, Regular Session,
2005, relating to nonsubstantive additions to and corrections in
enacted codes (the General Code Update bill).
SECTION 3.03. This Act takes effect September 1, 2005.