Amend HB 1919 (Senate committee printing) by adding the
following appropriately numbered SECTIONS to the bill and
renumbering subsequent SECTIONS accordingly:
SECTION __. The heading to Subchapter A, Chapter 1355,
Insurance Code, is amended to read as follows:
SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR
CERTAIN MENTAL DISORDERS AND SERIOUS MENTAL ILLNESSES
SECTION __. Subchapter A, Chapter 1355, Insurance Code, is
amended by amending Section 1355.001 and by adding Section
1355.0015 to read as follows:
Sec. 1355.001. PURPOSE. The legislature recognizes that
mental illnesses are biologically based and treatable and that,
with appropriate care, individuals with mental illness can live
productive and successful lives. The purpose of this subchapter is
to ensure that this recognition is reflected in group health
benefit plans by requiring that the benefits provided for mental
disorders be equal to those provided for other medical and surgical
conditions.
Sec. 1355.0015. 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 (DSM), 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 of Mental Disorders (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 __. Section 1355.002, Insurance Code, 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 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; 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 __. Subsections (a) and (b), Section 1355.003,
Insurance Code, 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;
(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 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)(10) [(a)(5)], "serious mental illness" has the meaning assigned
by Section 1355.0015.
SECTION ____. Subchapter A, Chapter 1355, Insurance Code,
is amended by adding Sections 1355.0031 through 1355.0035 to read
as follows:
Sec. 1355.0031. COVERAGE EQUITY REQUIRED. (a) Except as
provided by Subsection (c), a group health benefit plan that
provides coverage for any mental disorder must provide coverage for
the diagnosis and medically necessary treatment of that mental
disorder under terms at least as favorable as the coverage provided
under the health benefit plan for the diagnosis and treatment of
medical and surgical conditions.
(b) A group health benefit plan may not establish separate
cost-sharing requirements that are only applicable to coverage for
mental disorders.
(c) A group health benefit plan that is a standard health
benefit plan under Chapter 1507, except for a plan issued to a small
employer, is required to provide coverage for a mental disorder
only if the mental disorder is a serious mental illness, and only to
the extent required by Sections 1355.004(b) and (c) and Sections
1507.003 and 1507.053.
Sec. 1355.0032. TREATMENT LIMITATIONS; FINANCIAL
REQUIREMENTS. (a) For purposes of this section:
(1) "Financial requirements" include requirements
relating to deductibles, copayments, coinsurance, out-of-pocket
expenses, and annual and lifetime limits.
(2) "Treatment limitations" include limitations on
the frequency of treatments, number of visits, days of coverage, or
other similar limits on the scope and duration of coverage.
(b) A group health benefit plan that provides coverage for
the diagnosis and medically necessary treatment of mental disorders
may not impose treatment limitations or financial requirements on
the provision of benefits under that coverage if identical
limitations or requirements are not imposed on coverage for the
diagnosis and treatment of medical and surgical conditions covered
by the plan.
(c) This section does not prohibit a group health benefit
plan issuer from negotiating separate reimbursement or provider
payment rates and service delivery systems for different benefits
that are consistent with the requirements under Subsection (b)
regarding treatment limitations and financial requirements.
(d) This section does not prohibit a group health benefit
plan issuer from managing the provision of benefits for treatment
of mental disorders as necessary to provide services for covered
benefits, including:
(1) use of any utilization review, authorization, or
other similar management practices;
(2) application of medical necessity and
appropriateness criteria applicable to behavioral health; and
(3) contracting with and using a network of providers.
(e) This section does not prohibit a group health benefit
plan from complying with the requirements of this subchapter in a
manner that takes into consideration similar treatment settings or
similar treatments.
Sec. 1355.0033. OUT-OF-NETWORK COVERAGE. (a) If a group
health benefit plan offers out-of-network coverage for medical and
surgical benefits under the plan, the group health benefit plan
must also offer out-of-network coverage for benefits for treatment
of mental disorders.
(b) If the group health benefit plan provides benefits for
medical and surgical conditions and treatment of mental disorders,
and provides those benefits on both an in-network and
out-of-network basis under the terms of the plan, the group health
benefit plan must ensure that the requirements of this subchapter
are applied to both in-network and out-of-network services by
comparing in-network medical and surgical benefits to in-network
benefits for treatment of mental disorders and out-of-network
medical and surgical benefits to out-of-network benefits for
treatment of mental disorders.
(c) This section may not be construed as requiring that a
group health benefit plan eliminate an out-of-network provider
option from the plan under the terms of the plan.
Sec. 1355.0034. SMALL EMPLOYER PLANS. An issuer of a group
health benefit plan to a small employer under Chapter 1501 must
offer coverage for mental disorders that are not classified as
serious mental illnesses that is equal to that provided under the
plan for other medical and surgical care, but is not required to
provide the coverage if the employer rejects the coverage.
Sec. 1355.0035. COST EXEMPTION. (a) If the issuer of a
group health benefit plan experiences increased actual total costs
of coverage, as a result of compliance with the coverage equity
requirements adopted under Sections 1355.0031-1355.0034, that
exceed two percent during the first year of operation of the plan,
that plan is exempt in the manner prescribed by this section from
application of those equity requirements for the following second
plan year if the group health benefit plan issuer complies with the
requirements of this section.
(b) If the issuer of a group health benefit plan experiences
increased actual total costs of coverage, as a result of compliance
with the coverage equity requirements adopted under Sections
1355.0031-1355.0034, that exceed one percent during a year of
operation after the first plan year, that plan is exempt in the
manner prescribed by this section from application of those equity
requirements for the following plan year if the group health
benefit plan issuer complies with the requirements of this section.
(c) A group health benefit plan issuer that seeks an
exemption under Subsection (a) or (b) must apply to the department
in the manner prescribed by the commissioner. A group health
benefit plan issuer is only eligible to seek a cost exemption under
this section after the group health benefit plan has complied with
the coverage equity requirements of this subchapter for at least
the first six months of the plan year in which application is made.
(d) To qualify for the cost exemption under Subsection (a)
or (b), a group health benefit plan issuer must submit the
application required under Subsection (c), accompanied by the
written certification of a qualified actuary who is a member in good
standing of the American Academy of Actuaries that the increase in
costs described by Subsection (a) or (b) is solely the result of
compliance with the coverage equity requirements of this
subchapter.
(e) The department shall review the actuarial assessment
submitted under Subsection (d). Based on the department review of
the assessment, the commissioner shall inform the issuer of the
group health benefit plan in writing as to whether or not the
assessment satisfactorily demonstrates that the cost exemption is
justified under Subsection (a) or (b). On receipt of a
determination from the commissioner that the cost exemption is
justified, the group health benefit plan is exempt from the
coverage equity requirements of this subchapter as provided by this
section.
(f) Notwithstanding Subsection (a) or (b), an employer may
elect to continue to apply the coverage equity requirements adopted
under this subchapter with respect to the group health benefit plan
regardless of any increase in total costs.
SECTION __. Sections 1355.004, 1355.005, and 1355.007,
Insurance Code, are amended to read as follows:
Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS MENTAL
ILLNESS. (a) Except as provided by Subsections (b) and (c), a [A]
group health benefit plan[:
[(1)] must provide coverage, based on medical
necessity, for the diagnosis and medically necessary treatment [not
less than the following treatments] of serious mental illness under
terms at least as favorable as the coverage provided under the
health benefit plan for the diagnosis and treatment of medical and
surgical conditions.
(b) A group health benefit plan issuer that issues a
standard health benefit plan under Chapter 1507, except for a plan
issued to a small employer:
(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.
(c) [(b)] A group health benefit plan issuer that issues a
standard health benefit plan under Chapter 1507:
(1) may not count an outpatient visit for medication
management against the number of outpatient visits required to be
covered under Subsection (b)(1)(B) [(a)(1)(B)]; and
(2) must provide coverage for an outpatient visit
described by Subsection (b)(1)(B) [(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. MANAGED CARE PLAN AUTHORIZED. A group
health benefit plan issuer may provide or offer coverage required
by this subchapter [Section 1355.004] through a managed care plan.
Sec. 1355.007. SMALL EMPLOYER COVERAGE. An issuer of a
group health benefit plan to a small employer under Chapter 1501
must offer the coverage for serious mental illnesses described by
Section 1355.004(a) [1355.004] to the employer but is not required
to provide the coverage if the employer rejects the coverage.
SECTION __. Subchapter A, Chapter 1355, Insurance Code, is
amended by adding Section 1355.008 to read as follows:
Sec. 1355.008. RULES. The commissioner shall adopt rules
in the manner prescribed by Subchapter A, Chapter 36, as necessary
to administer this subchapter.
SECTION 8. 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, 2008. A group health benefit plan
delivered, issued for delivery, or renewed before January 1, 2008,
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 9. This Act takes effect September 1, 2007.