79R1321 AJA-D
By: Van de Putte S.B. No. 215
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. Chapter 1367, Insurance Code, as effective April
1, 2005, is amended by adding Subchapter F to read as follows:
SUBCHAPTER F. CERTAIN MENTAL DISORDERS IN CHILDREN
Sec. 1367.251. DEFINITIONS. In this subchapter:
(1) "Child" means a person younger than 19 years of
age.
(2) "Mental disorder" means a disorder that is
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 and that results in a significant impairment of a
child's functioning in the child's community, family, school, or
peer group. The term does not include a primary substance abuse
disorder or a developmental disorder.
Sec. 1367.252. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a health benefit plan that:
(1) 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:
(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 insurance company
operating under Chapter 884;
(E) a reciprocal or interinsurance exchange
operating under Chapter 942;
(F) a health maintenance organization operating
under Chapter 843; or
(G) a multiple employer welfare arrangement
subject to regulation under Chapter 846; or
(2) is offered by an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844.
(b) This subchapter applies to a small employer health
benefit plan written under Chapter 1501.
Sec. 1367.253. EXCEPTION. This subchapter 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
an automobile 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 Section 1367.252.
Sec. 1367.254. 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 subchapter, 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 subchapter may be provided
or offered through a managed care plan.
Sec. 1367.255. 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
subchapter 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 subchapter 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. 1367.256. 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.
Sec. 1367.257. RULES. The commissioner shall adopt rules as
necessary to implement 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);
(C) [(D)] obsessive-compulsive disorders;
(D) [(E)] paranoid and other psychotic
disorders;
(E) [(F)] pervasive developmental disorders;
(F) [(G)] schizo-affective disorders (bipolar or
depressive); and
(G) [(H)] schizophrenia.
SECTION 3. Section 1355.004(a), Insurance Code, as
effective April 1, 2005, is amended to read as follows:
(a) Except as provided by Subchapter F, Chapter 1367, 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 the same amount limitations,
deductibles, copayments, and coinsurance factors for serious
mental illness as the plan includes for physical illness.
SECTION 4. (a) On or before September 1, 2010, the Sunset
Advisory Commission shall conduct a study to determine:
(1) to what extent the health benefit plan coverage
required by Subchapter F, Chapter 1367, Insurance Code, as added by
this Act, and by the change in law made by this Act to Chapter 1355,
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, 2011.
(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 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 6. This Act takes effect September 1, 2005.