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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for home defibrillators. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle E, Title 8, Insurance Code, is amended |
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by adding Chapter 1372 to read as follows: |
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CHAPTER 1372. COVERAGE FOR HOME DEFIBRILLATORS |
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Sec. 1372.001. DEFINITION. In this chapter, "enrollee" |
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means an individual entitled to coverage under a health benefit |
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plan. |
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Sec. 1372.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan, including a small employer |
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health benefit plan written under Chapter 1501 or coverage provided |
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by a health group cooperative under Subchapter B of that chapter, |
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that provides benefits for medical or surgical expenses incurred as |
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a result of a health condition, accident, or sickness, including an |
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individual, group, blanket, or franchise insurance policy or |
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insurance agreement, a group hospital service contract, or an |
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individual or group evidence of coverage or similar coverage |
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document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) a reciprocal exchange operating under Chapter 942; |
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(6) a Lloyd's plan operating under Chapter 941; |
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(7) a health maintenance organization operating under |
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Chapter 843; |
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(8) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(9) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this chapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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(c) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this chapter applies to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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and |
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(4) basic coverage under Chapter 1601. |
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(d) Notwithstanding any other law, a standard health |
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benefit plan provided under Chapter 1507 must provide the coverage |
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required by this chapter. |
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Sec. 1372.003. REQUIRED COVERAGE FOR HOME DEFIBRILLATOR. |
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(a) A health benefit plan must provide coverage for a home |
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defibrillator to an enrollee who: |
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(1) has a medically documented heart illness, |
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including a previous heart attack; and |
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(2) resides 20 miles or more from the nearest |
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hospital, clinic, or other medical facility with the ability to |
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treat a patient in cardiac arrest. |
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(b) Covered benefits under this chapter are limited to the |
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most appropriate model of home defibrillator that adequately meets |
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the medical needs of the enrollee as determined by the enrollee's |
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treating physician. |
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(c) Subject to applicable copayments and deductibles, the |
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repair and replacement of a home defibrillator is a covered benefit |
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under this chapter unless the repair or replacement is necessitated |
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by misuse or loss by the enrollee. |
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(d) Coverage required under this section: |
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(1) may be subject to annual deductibles, copayments, |
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and coinsurance that are consistent with annual deductibles, |
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copayments, and coinsurance required for other coverage under the |
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health benefit plan; and |
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(2) may not be subject to annual dollar limits. |
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Sec. 1372.004. PREAUTHORIZATION. A health benefit plan may |
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require prior authorization for a home defibrillator in the same |
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manner that the health benefit plan requires prior authorization |
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for any other covered benefit. |
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Sec. 1372.005. MANAGED CARE PLAN. A health benefit plan |
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issuer may require that, if coverage is provided through a managed |
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care plan, the benefits mandated under this chapter are covered |
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benefits only if the home defibrillator is provided by a vendor, and |
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related services are rendered by a health care provider, that |
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contracts with or is designated by the health benefit plan issuer. |
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If the health benefit plan issuer provides in-network and |
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out-of-network services, the coverage for a home defibrillator |
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provided through out-of-network services must be comparable to that |
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provided through in-network services. |
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SECTION 2. Chapter 1372, Insurance Code, as added by this |
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Act, applies only to a health benefit plan that is delivered, |
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issued for delivery, or renewed on or after January 1, 2008. A |
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health benefit plan that is delivered, issued for delivery, or |
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renewed before January 1, 2008, is covered by the law in effect at |
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the time the plan was delivered, issued for delivery, or renewed, |
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and that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2007. |