80R5150 PB-D

By: Davis of Harris H.B. No. 1224

A BILL TO BE ENTITLED

AN ACT

relating to health benefit plan coverage for enrollees with autism spectrum disorder.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Chapter 1355, Insurance Code, is amended by adding Subchapter F to read as follows: SUBCHAPTER F. HEALTH BENEFIT PLAN COVERAGE FOR ENROLLEE WITH AUTISM SPECTRUM DISORDER

Sec. 1355.251. DEFINITIONS. In this subchapter:

(1) "Autism spectrum disorder" means a neurobiological disorder that includes autism, Asperger syndrome, or Pervasive Developmental Disorder--Not Otherwise Specified.

(2) "Enrollee" means an individual who is enrolled in a health benefit plan, including a covered dependent.

(3) "Neurobiological disorder" means an illness of the nervous system caused by genetic, metabolic, or other biological factors.

Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a 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, 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:

(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.

(c) This subchapter applies to basic coverage provided under Chapter 1551, a basic plan provided under Chapter 1575, a primary care coverage plan provided under Chapter 1579, or basic coverage provided under Chapter 1601.

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 spectrum disorder.

Sec. 1355.255. REQUIRED COVERAGE FOR CERTAIN CHILDREN. (a) At a minimum, a health benefit plan must provide coverage as provided by this section to an enrollee older than two years of age and younger than six years of age who is diagnosed with autism spectrum disorder. If an enrollee who is being treated for autism spectrum disorder becomes six years of age or older and continues to need treatment, this subsection does not preclude coverage of treatment and services described by Subsection (b).

(b) The health benefit plan must provide coverage under this subchapter to the enrollee for all generally recognized services prescribed in relation to autism spectrum disorder by the enrollee's primary care physician in the treatment plan recommended by that physician. An individual providing treatment prescribed under this subsection must be a health care practitioner who is licensed, certified, or registered by an appropriate agency of this state or the United States. For purposes of this subsection, "generally recognized services" may include services such as:

(1) applied behavioral analysis;

(2) behavior training and behavior management;

(3) speech therapy;

(4) occupational therapy;

(5) physical therapy; or

(6) medications or nutritional supplements used to address symptoms of autism spectrum disorder.

(c) Coverage under Subsection (b) may be subject to annual deductibles, copayments, and coinsurance that are consistent with annual deductibles, copayments, and coinsurance required for other coverage under the health benefit plan.

Sec. 1355.256. RULES. The commissioner shall adopt rules as necessary to administer this subchapter.

SECTION 2. Section 1355.001(1), Insurance Code, 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;

[(G)] schizo-affective disorders (bipolar or depressive); and

(G) [(H)] schizophrenia.

SECTION 3. Section 1507.004, Insurance Code, is amended by adding Subsection (c) to read as follows:

(c) A standard health benefit plan must include coverage as required by Subchapter F, Chapter 1355, for treatment for an enrollee with autism spectrum disorder.

SECTION 4. Section 1507.054, Insurance Code, is amended to read as follows:

Sec. 1507.054. STANDARD HEALTH BENEFIT PLANS AUTHORIZED; COVERAGE REQUIREMENT. (a) A health maintenance organization authorized to issue an evidence of coverage in this state may offer one or more standard health benefit plans.

(b) A standard health benefit plan offered by a health maintenance organization must include coverage as required by Subchapter F, Chapter 1355, for treatment for an enrollee with autism spectrum disorder.

SECTION 5. This Act applies only to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2008. A 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 6. This Act takes effect September 1, 2007.