79R7975 PB-F
By: Nixon H.B. No. 1941
A BILL TO BE ENTITLED
AN ACT
relating to group 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 CHAPTER 1355, INSURANCE CODE
SECTION 1.01. The heading to 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 MENTAL DISORDERS AND SERIOUS MENTAL ILLNESSES
SECTION 1.02. Section 1355.001, Insurance Code, as
effective April 1, 2005, is amended to read as follows:
Sec. 1355.001. DEFINITIONS. In this subchapter:
(1) "Enrollee" means an individual who is enrolled in
a group health benefit plan, including a covered dependent.
(2) "Mental disorder" means a disorder defined by the
American Psychiatric Association in the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition, or a subsequent edition
of that manual that the commissioner by rule adopts to take the
place of the fourth edition, except that the term does not include:
(A) a mental disorder classified under that
manual as a "V-code" disorder;
(B) mental retardation;
(C) a learning disorder;
(D) a motor skill disorder; or
(E) a communication disorder.
(3) "Serious mental illness" means a mental disorder
that is one of the following psychiatric illnesses as defined by the
American Psychiatric Association in the Diagnostic and Statistical
Manual (DSM), fourth edition, or a subsequent edition of that
manual that the commissioner by rule adopts to take the place of the
fourth edition:
(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.
(4) [(2)] "Small employer" has the meaning assigned by
Section 1501.002.
SECTION 1.03. Section 1355.002, Insurance Code, as
effective April 1, 2005, is amended to read as follows:
Sec. 1355.002. CONSTRUCTION AND APPLICABILITY OF
SUBCHAPTER. (a) This subchapter may not be construed to limit any
medical treatment described in a billing code listed in the
International Classification of Diseases, ninth edition, of the
World Health Organization, or a subsequent edition of that
publication that the commissioner by rule adopts to take the place
of the ninth edition.
(b) 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:
(1) a group insurance policy, group insurance
agreement, group hospital service contract, or group evidence of
coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884; [or]
(E) a health maintenance organization operating
under Chapter 843;
(F) a reciprocal exchange operating under
Chapter 942;
(G) a Lloyd's plan operating under Chapter 941;
or
(H) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; and
(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].
SECTION 1.04. Section 1355.003, Insurance Code, as
effective April 1, 2005, is amended to read as follows:
Sec. 1355.003. EXCEPTION. [(a)] This subchapter does not
apply to coverage under:
(1) 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 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;
(5) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(6) a workers' compensation insurance policy;
(7) medical payment insurance coverage provided under
an automobile insurance policy;
(8) a credit insurance policy;
(9) 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 group health benefit plan as
described by Section 1355.002 [limited or specified-disease policy
that does not provide benefits for mental health care or similar
services];
(10) [(5)] except as provided by Section 1355.0035(b)
[Subsection (b)], a plan offered under Chapter 1551 or Chapter
1601; or
(11) [(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.]
SECTION 1.05. Chapter 1355, Insurance Code, as effective
April 1, 2005, is amended by adding Section 1355.0035 to read as
follows:
Sec. 1355.0035. REQUIRED COVERAGE FOR MENTAL DISORDERS.
(a) Except as provided by Subsections (b) and (c), a group health
benefit plan must provide coverage for the diagnosis and medically
necessary treatment of an enrollee's mental disorder under terms at
least as favorable as coverage provided to the enrollee for the
diagnosis and treatment of medical and surgical conditions.
(b) A group health benefit plan offered under Chapter 1551
or 1601 may limit coverage under this chapter to the coverage
required under Section 1355.004.
(c) This section does not apply to a consumer choice of
benefits health insurance plan under Chapter 1507 or Article 3.80
or 20A.09N.
SECTION 1.06. Section 1355.004, Insurance Code, as
effective April 1, 2005, is amended by adding Subsection (c) to read
as follows:
(c) This section does not apply to a group health benefit
plan required to provide coverage under Section 1355.0035(a).
SECTION 1.07. Section 1355.005, Insurance Code, as
effective April 1, 2005, is amended to read as follows:
Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A group
health benefit plan issuer may provide or offer coverage required
by Section 1355.0035 or 1355.004 through a managed care plan.
SECTION 1.08. Subchapter A, Chapter 1355, Insurance Code,
as effective April 1, 2005, is amended by adding Section 1355.0055
to read as follows:
Sec. 1355.0055. COVERAGE EQUITY. (a) A group health
benefit plan subject to Section 1355.0035 may not impose treatment
limitations or financial requirements on the provision of benefits
under this subchapter for a mental disorder if identical
limitations or requirements are not imposed on coverage of benefits
for other medical conditions.
(b) A deductible or out-of-pocket limit required under a
health benefit plan that is subject to Section 1355.0035 must be
comprehensive for coverage of both mental health and physical
health conditions.
SECTION 1.09. Subchapter A, Chapter 1355, Insurance Code,
as effective April 1, 2005, is amended by adding Section 1355.008 to
read as follows:
Sec. 1355.008. RULES. The commissioner shall adopt rules
as necessary to administer this subchapter.
SECTION 1.10. 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.
ARTICLE 2. CONFORMING AMENDMENTS
SECTION 2.01. Section 1551.003, Insurance Code, is amended
by adding Subdivision (10-a) to read as follows:
(10-a) "Mental disorder" has the meaning assigned by
Section 1355.001(2).
SECTION 2.02. 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 2.03. 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.
ARTICLE 3. TRANSITION; EFFECTIVE DATE
SECTION 3.01. The change in law made by this Act applies
only to a group health benefit plan delivered, issued for delivery,
or renewed on or after January 1, 2006. A group 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. This Act takes effect September 1, 2005.