|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to health benefit plan coverage for treatment for certain |
|
brain injuries and serious mental illnesses. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Section 1352.001, Insurance Code, is amended to |
|
read as follows: |
|
Sec. 1352.001. APPLICABILITY OF CHAPTER. (a) This |
|
chapter applies only to a health benefit plan, including, subject |
|
to this chapter, a small employer health benefit plan written under |
|
Chapter 1501, 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 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 any provision in Chapter 1551, 1575, |
|
1579, or 1601 or any other law, this chapter applies to: |
|
(1) a basic coverage plan under Chapter 1551; |
|
(2) a basic plan under Chapter 1575; |
|
(3) a primary care coverage plan under Chapter 1579; |
|
and |
|
(4) basic coverage under Chapter 1601. |
|
SECTION 2. Section 1352.003, Insurance Code, is amended to |
|
read as follows: |
|
Sec. 1352.003. REQUIRED COVERAGES--HEALTH BENEFIT PLANS |
|
OTHER THAN SMALL EMPLOYER HEALTH BENEFIT PLANS [EXCLUSION OF
|
|
COVERAGE PROHIBITED]. (a) A health benefit plan must include [may
|
|
not exclude] coverage for cognitive rehabilitation therapy, |
|
cognitive communication therapy, neurocognitive therapy and |
|
rehabilitation, neurobehavioral, neurophysiological, |
|
neuropsychological, and [or] psychophysiological testing and [or] |
|
treatment, neurofeedback therapy, and remediation required for and |
|
related to treatment of an acquired brain injury. |
|
(b) A health benefit plan must include coverage for [,] |
|
post-acute transition services, [or] community reintegration |
|
services, including outpatient day treatment services, or other |
|
post-acute care treatment services necessary as a result of and |
|
related to an acquired brain injury. |
|
(c) A health benefit plan may not include, in any lifetime |
|
limitation on the number of days of acute care treatment covered |
|
under the plan, any post-acute care treatment covered under the |
|
plan. Any limitation imposed under the plan on days of post-acute |
|
care treatment must be separately stated in the plan. |
|
(d) Except as provided by Subsection (c), a health benefit |
|
plan must include the same payment limitations, deductibles, |
|
copayments, and coinsurance factors for coverage [(b) Coverage] |
|
required under this chapter as [may be subject to deductibles,
|
|
copayments, coinsurance, or annual or maximum payment limits that
|
|
are consistent with the deductibles, copayments, coinsurance, or
|
|
annual or maximum payment limits] applicable to other similar |
|
coverage provided under the health benefit plan. |
|
(e) To ensure that appropriate post-acute care treatment is |
|
provided, a health benefit plan must include coverage for |
|
reasonable expenses related to periodic reevaluation of the care of |
|
an individual covered under the plan who: |
|
(1) has incurred an acquired brain injury; |
|
(2) has been unresponsive to treatment; and |
|
(3) becomes responsive to treatment at a later date. |
|
(f) A determination of whether expenses, as described by |
|
Subsection (e), are reasonable may include consideration of factors |
|
including: |
|
(1) cost; |
|
(2) the time that has expired since the previous |
|
evaluation; |
|
(3) any difference in the expertise of the physician |
|
or practitioner performing the evaluation; |
|
(4) changes in technology; and |
|
(5) advances in medicine. |
|
(g) [(c)] The commissioner shall adopt rules as necessary |
|
to implement this chapter [section]. |
|
(h) This section does not apply to a small employer health |
|
benefit plan. |
|
SECTION 3. Chapter 1352, Insurance Code, is amended by |
|
adding Section 1352.0035 to read as follows: |
|
Sec. 1352.0035. REQUIRED COVERAGES--SMALL EMPLOYER HEALTH |
|
BENEFIT PLANS. (a) A small employer health benefit plan may not |
|
exclude coverage for cognitive rehabilitation therapy, cognitive |
|
communication therapy, neurocognitive therapy and rehabilitation, |
|
neurobehavioral, neurophysiological, neuropsychological, or |
|
psychophysiological testing or treatment, neurofeedback therapy, |
|
remediation, post-acute transition services, or community |
|
reintegration services necessary as a result of and related to an |
|
acquired brain injury. |
|
(b) Coverage required under this section may be subject to |
|
deductibles, copayments, coinsurance, or annual or maximum payment |
|
limits that are consistent with the deductibles, copayments, |
|
coinsurance, or annual or maximum payment limits applicable to |
|
other similar coverage provided under the small employer health |
|
benefit plan. |
|
(c) The commissioner shall adopt rules as necessary to |
|
implement this section. |
|
SECTION 4. Section 1352.004(b), Insurance Code, is amended |
|
to read as follows: |
|
(b) The commissioner by rule shall require a health benefit |
|
plan issuer to provide adequate training to personnel responsible |
|
for preauthorization of coverage or utilization review under the |
|
plan. The purpose of the training is to prevent denial of coverage |
|
in violation of Section 1352.003 and to avoid confusion of medical |
|
benefits with mental health benefits. The commissioner, in |
|
consultation with the Texas Traumatic Brain Injury Advisory |
|
Council, shall prescribe by rule the basic requirements for the |
|
training described by this subsection. |
|
SECTION 5. Chapter 1352, Insurance Code, is amended by |
|
adding Sections 1352.005, 1352.006, 1352.007, and 1352.008 to read |
|
as follows: |
|
Sec. 1352.005. NOTICE TO INSUREDS AND ENROLLEES. (a) A |
|
health benefit plan issuer subject to this chapter, other than a |
|
small employer health benefit plan issuer, must notify each insured |
|
or enrollee under the plan in writing about the coverages described |
|
by Section 1352.003. |
|
(b) The commissioner, in consultation with the Texas |
|
Traumatic Brain Injury Advisory Council, shall prescribe by rule |
|
the specific contents and wording of the notice required under this |
|
section. |
|
(c) The notice required under this section must include: |
|
(1) a description of the benefits listed under Section |
|
1352.003; |
|
(2) a statement that the fact that an acquired brain |
|
injury does not result in hospitalization or receipt of a specific |
|
treatment or service described by Section 1352.003 for acute care |
|
treatment does not affect the right of the insured or enrollee to |
|
receive benefits described by Section 1352.003 commensurate with |
|
the condition of the insured or enrollee; and |
|
(3) a statement of the fact that benefits described by |
|
Section 1352.003 may be provided in a facility listed in Section |
|
1352.007. |
|
(d) The notice described by this section must be provided |
|
not later than the 10th day after the date on which the health |
|
benefit plan issuer receives a claim for coverage for treatment |
|
that would reasonably indicate that the insured or enrollee has |
|
incurred an acquired brain injury. |
|
Sec. 1352.006. DETERMINATION OF MEDICAL NECESSITY; |
|
EXTENSION OF COVERAGE. (a) In this section, "utilization review" |
|
has the meaning assigned by Section 4201.002. |
|
(b) Notwithstanding Chapter 4201 or any other law relating |
|
to the determination of medical necessity under this code, a health |
|
benefit plan shall respond to a person requesting utilization |
|
review or appealing for an extension of coverage based on an |
|
allegation of medical necessity not later than three business days |
|
after the date on which the person makes the request or submits the |
|
appeal. The person must make the request or submit the appeal in |
|
the manner prescribed by the terms of the plan's health insurance |
|
policy or agreement, contract, evidence of coverage, or similar |
|
coverage document. To comply with the requirements of this |
|
section, the health benefit plan issuer must respond through a |
|
direct telephone contact made by a representative of the issuer. |
|
This subsection does not apply to a small employer health benefit |
|
plan. |
|
(c) Notwithstanding Section 4201.152 or any other law of |
|
this state, a physician or other health care practitioner who |
|
determines the medical necessity of a health care service provided |
|
under this chapter to a resident of this state must be licensed to |
|
practice in this state. |
|
Sec. 1352.007. TREATMENT FACILITIES. (a) A health benefit |
|
plan may not deny coverage under this chapter based solely on the |
|
fact that the treatment or services are provided at a facility other |
|
than a hospital. Treatment for an acquired brain injury may be |
|
provided under the coverage required by this chapter, as |
|
appropriate, at a facility at which appropriate services may be |
|
provided, including: |
|
(1) a hospital regulated under Chapter 241, Health and |
|
Safety Code, including an acute rehabilitation hospital; |
|
(2) an assisted living facility regulated under |
|
Chapter 247, Health and Safety Code; |
|
(3) a nursing home regulated under Chapter 242, Health |
|
and Safety Code; |
|
(4) a community home; |
|
(5) an acute or post-acute rehabilitation facility, |
|
including a residential or outpatient facility; or |
|
(6) a medical office. |
|
(b) This section does not apply to a small employer health |
|
benefit plan. |
|
Sec. 1352.008. CONSUMER INFORMATION. The commissioner |
|
shall prepare information for use by consumers, purchasers of |
|
health benefit plan coverage, and self-insurers regarding |
|
coverages recommended for acquired brain injuries. The department |
|
shall publish information prepared under this section on the |
|
department's Internet website. |
|
SECTION 6. 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] |
|
(H) schizophrenia; and |
|
(I) anorexia nervosa and bulimia nervosa. |
|
SECTION 7. Section 1355.007, Insurance Code, is amended to |
|
read as follows: |
|
Sec. 1355.007. SMALL EMPLOYER COVERAGE. (a) An issuer of a |
|
group health benefit plan to a small employer must offer the |
|
coverage described by Section 1355.004 to the employer but is not |
|
required to provide the coverage if the employer rejects the |
|
coverage. |
|
(b) Regardless of whether a small employer accepts the |
|
coverage required by Subsection (a), an issuer of a group health |
|
benefit plan to a small employer must provide the coverage required |
|
by Section 1355.004 for persons under the age of 19 years for the |
|
following psychiatric illnesses as defined by the American |
|
Psychiatric Association in the Diagnostic and Statistical Manual |
|
(DSM): |
|
(1) depression in childhood and adolescence; and |
|
(2) anorexia nervosa and bulimia nervosa. |
|
SECTION 8. (a) On or before September 1, 2012, the Sunset |
|
Advisory Commission shall conduct a study to determine: |
|
(1) to what extent the health benefit plan coverage |
|
required 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, 2013. |
|
(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 9. 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 10. This Act takes effect September 1, 2007. |