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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 enrollees with autism |
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spectrum disorder. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1355, Insurance Code, is amended by |
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adding Subchapter F to read as follows: |
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SUBCHAPTER F. HEALTH BENEFIT PLAN COVERAGE FOR ENROLLEE WITH |
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AUTISM SPECTRUM DISORDER |
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Sec. 1355.251. DEFINITIONS. In this subchapter: |
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(1) "Autism spectrum disorder" means a |
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neurobiological disorder that includes autism, Asperger's |
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syndrome, or Pervasive Developmental Disorder--Not Otherwise |
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Specified. |
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(2) "Enrollee" means an individual who is enrolled in |
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a health benefit plan, including a covered dependent. |
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(3) "Neurobiological disorder" means an illness of the |
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nervous system caused by genetic, metabolic, or other biological |
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factors. |
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Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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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 insurance company operating |
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under 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 subchapter 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) This subchapter applies to basic coverage provided |
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under Chapter 1551, a basic plan provided under Chapter 1575, a |
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primary care coverage plan provided under Chapter 1579, or basic |
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coverage provided under Chapter 1601. |
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Sec. 1355.253. EXCEPTION. This subchapter does not apply |
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to: |
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(1) a plan that provides coverage: |
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(A) only for benefits for a specified disease or |
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for another limited benefit, other than a plan that provides |
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benefits for mental health or similar services; |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) only for dental or vision care; or |
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(F) only for indemnity for hospital confinement; |
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(2) a small employer health benefit plan written under |
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Chapter 1501; |
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(3) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(4) a workers' compensation insurance policy; |
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(5) medical payment insurance coverage provided under |
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an automobile insurance policy; or |
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(6) a long-term care insurance policy, including a |
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nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1355.252. |
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Sec. 1355.254. EXCLUSION OF COVERAGE AND DENIAL OF BENEFITS |
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PROHIBITED. A health benefit plan may not exclude coverage or deny |
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benefits otherwise available to an enrollee for treatment, |
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equipment, or therapy based on the enrollee's having autism |
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spectrum disorder. |
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Sec. 1355.255. REQUIRED COVERAGE FOR CERTAIN CHILDREN. |
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(a) At a minimum, a health benefit plan must provide coverage as |
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provided by this section to an enrollee older than two years of age |
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and younger than six years of age who is diagnosed with autism |
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spectrum disorder. If an enrollee who is being treated for autism |
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spectrum disorder becomes six years of age or older and continues to |
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need treatment, this subsection does not preclude coverage of |
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treatment and services described by Subsection (b). |
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(b) The health benefit plan must provide coverage under this |
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subchapter to the enrollee for all generally recognized services |
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prescribed in relation to autism spectrum disorder by the |
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enrollee's primary care physician in the treatment plan recommended |
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by that physician. An individual providing treatment prescribed |
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under this subsection must be a health care practitioner: |
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(1) who is licensed, certified, or registered by an |
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appropriate agency of this state; |
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(2) whose professional credential is recognized and |
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accepted by an appropriate agency of the United States; or |
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(3) who is certified as a provider under the TRICARE |
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military health system. |
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(c) For purposes of Subsection (b), "generally recognized |
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services" may include services such as: |
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(1) evaluation and assessment services; |
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(2) applied behavior analysis; |
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(3) behavior training and behavior management; |
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(4) speech therapy; |
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(5) occupational therapy; |
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(6) physical therapy; or |
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(7) medications or nutritional supplements used to |
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address symptoms of autism spectrum disorder. |
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(d) Coverage under Subsection (b) may be subject to annual |
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deductibles, copayments, and coinsurance that are consistent with |
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annual deductibles, copayments, and coinsurance required for other |
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coverage under the health benefit plan. |
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Sec. 1355.256. RULES. The commissioner shall adopt rules |
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as necessary to administer this subchapter. |
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SECTION 2. Subdivision (1), Section 1355.001, Insurance |
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Code, is amended to read as follows: |
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(1) "Serious mental illness" means the following |
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psychiatric illnesses as defined by the American Psychiatric |
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Association in the Diagnostic and Statistical Manual (DSM): |
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(A) bipolar disorders (hypomanic, manic, |
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depressive, and mixed); |
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(B) depression in childhood and adolescence; |
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(C) major depressive disorders (single episode |
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or recurrent); |
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(D) obsessive-compulsive disorders; |
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(E) paranoid and other psychotic disorders; |
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(F) [pervasive developmental disorders;
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[(G)] schizo-affective disorders (bipolar or |
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depressive); and |
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(G) [(H)] schizophrenia. |
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SECTION 3. This Act applies only to a health benefit plan |
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delivered, issued for delivery, or renewed on or after January 1, |
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2008. A health benefit plan delivered, issued for delivery, or |
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renewed before January 1, 2008, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2007. |
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* * * * * |