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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 certain prosthetic |
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devices, orthotic devices, and related services. |
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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 1371 to read as follows: |
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CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC |
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DEVICES, AND RELATED SERVICES |
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Sec. 1371.001. DEFINITIONS. In this chapter: |
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(1) "Enrollee" means an individual entitled to |
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coverage under a health benefit plan. |
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(2) "Orthotic device" means a custom-fitted or |
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custom-fabricated medical device that is applied to a part of the |
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human body to correct a deformity, improve function, or relieve |
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symptoms of a disease. |
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(3) "Prosthetic device" means an artificial device |
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designed to replace, wholly or partly, an arm or leg. |
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Sec. 1371.002. 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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Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES, |
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ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit plan |
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must provide coverage for prosthetic devices, orthotic devices, and |
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professional services related to the fitting and use of those |
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devices that equals the coverage provided under federal laws for |
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health insurance for the aged and disabled under Sections 1832, |
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1833, and 1834, Social Security Act (42 U.S.C. Sections 1395k, |
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1395l, and 1395m), and 42 C.F.R. Sections 410.100, 414.202, |
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414.210, and 414.228, as applicable. |
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(b) Covered benefits under this chapter are limited to the |
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most appropriate model of prosthetic device or orthotic device that |
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adequately meets the medical needs of the enrollee as determined by |
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the enrollee's treating physician or podiatrist and prosthetist or |
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orthotist, as applicable. |
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(c) Subject to applicable copayments and deductibles, the |
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repair and replacement of a prosthetic device or orthotic device is |
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a covered benefit under this chapter unless the repair or |
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replacement is necessitated by misuse or loss by the enrollee. |
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(d) Coverage required under this section: |
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(1) must be provided in a manner determined to be |
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appropriate in consultation with the treating physician or |
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podiatrist and prosthetist or orthotist, as applicable, and the |
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enrollee; |
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(2) 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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(3) may not be subject to annual dollar limits. |
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(e) Covered benefits under this chapter may be provided by a |
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pharmacy that has employees who are qualified under the Medicare |
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system and applicable Medicaid regulations to service and bill for |
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orthotic services. This chapter does not preclude a pharmacy from |
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being reimbursed by a health benefit plan for the provision of |
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orthotic services. |
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Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may |
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require prior authorization for a prosthetic device or an orthotic |
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device in the same manner that the health benefit plan requires |
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prior authorization for any other covered benefit. |
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Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan |
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provider may require that, if coverage is provided through a |
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managed care plan, the benefits mandated under this chapter are |
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covered benefits only if the prosthetic devices or orthotic devices |
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are provided by a vendor or a provider, and related services are |
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rendered by a provider, that contracts with or is designated by the |
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health benefit plan provider. If the health benefit plan provider |
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provides in-network and out-of-network services, the coverage for |
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prosthetic devices or orthotic devices provided through |
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out-of-network services must be comparable to that provided through |
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in-network services. |
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SECTION 2. Chapter 1371, 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, 2010. A |
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health benefit plan that is delivered, issued for delivery, or |
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renewed before January 1, 2010, 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, 2009. |