79R2264 PB-D
By: Lucio S.B. No. 208
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for an enrollee with
certain mental disorders, including autism or another pervasive
developmental disorder.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1355, Insurance Code, as effective April
1, 2005, is amended by adding Subchapter F to read as follows:
SUBCHAPTER F. INDIVIDUAL HEALTH BENEFIT PLAN COVERAGE FOR
ENROLLEE WITH AUTISM OR PERVASIVE DEVELOPMENTAL DISORDER
Sec. 1355.251. DEFINITION. In this subchapter, "enrollee"
means an individual who is enrolled in a health benefit plan,
including a covered dependent.
Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to an individual 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;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium insurance company operating
under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under
Chapter 843;
(8) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) Notwithstanding Section 172.014, Local Government Code,
or any other law, this subchapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
Sec. 1355.253. EXCEPTION. This subchapter 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 1501;
(3) a Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under
an automobile 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 1355.252.
Sec. 1355.254. 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. 1355.255. RULES. The commissioner shall adopt rules
as necessary to administer this subchapter.
SECTION 2. Section 1355.001(1), Insurance Code, as
effective April 1, 2005, 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) 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, including
autism;
(G) schizo-affective disorders (bipolar or
depressive); and
(H) schizophrenia.
SECTION 3. Section 1355.002, Insurance Code, as effective
April 1, 2005, is amended to read as follows:
Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. 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, blanket, or franchise 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 4. Section 1355.003(a), Insurance Code, as
effective April 1, 2005, is amended to read as follows:
(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;
(2) [(3)] an accident-only policy;
(3) [(4)] a limited or specified-disease policy that
does not provide benefits for mental health care or similar
services;
(4) [(5)] except as provided by Subsection (b), a plan
offered under Chapter 1551 or Chapter 1601;
(5) [(6)] a plan offered in accordance with Section
1355.151; or
(6) [(7)] a Medicare supplement benefit plan, as
defined by Section 1652.002.
SECTION 5. Section 1355.004(a), Insurance Code, as
effective April 1, 2005, is amended to read as follows:
(a) A group health benefit plan:
(1) must provide coverage, 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 equipment and therapy in the coverage
of treatment of pervasive developmental disorders; and
(4) must include the same amount limitations,
deductibles, copayments, and coinsurance factors for serious
mental illness as the plan includes for physical illness.
SECTION 6. 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 7. 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 8. This Act takes effect September 1, 2005.