81R10432 PMO-D

By: Vaught H.B. No. 3891

A BILL TO BE ENTITLED

AN ACT

relating to certain health benefit plan coverage for bilateral cochlear implants and related services.

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

SECTION 1. Subtitle E, Title 8, Insurance Code, is amended by adding Chapter 1365A to read as follows:

CHAPTER 1365A. COVERAGE FOR CERTAIN COCHLEAR IMPLANTS FOR MINORS

Sec. 1365A.001. DEFINITIONS. In this chapter:

(1) "Cochlear implant" means a surgically implanted electronic device that provides a sense of sound to a person who is profoundly deaf or severely hearing impaired.

(2) "Enrollee" means an individual entitled to coverage under a health benefit plan.

(3) "Minor" means a person younger than 18 years of age.

Sec. 1365A.002. APPLICABILITY OF CHAPTER. (a) This chapter applies only to a health benefit plan, including a small employer health benefit plan written under Chapter 1501 or coverage provided by a health group cooperative under Subchapter B of that chapter, 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) an 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 chapter applies to health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code.

(c) 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.

(d) Notwithstanding any other law, a standard health benefit plan provided under Chapter 1507 must provide the coverage required by this chapter.

Sec. 1365A.003. REQUIRED COVERAGE FOR COCHLEAR IMPLANTS AND RELATED SERVICES. (a) A health benefit plan must provide coverage to an enrollee who is a minor for bilateral cochlear implants and professional services related to the fitting and use of those implants.

(b) Covered benefits under this chapter are limited to the most appropriate model of bilateral cochlear implants that adequately meets the medical needs of the enrollee as determined by the enrollee's treating physician.

(c) Coverage required under this section:

(1) must be provided in a manner determined to be appropriate in consultation with the treating physician and the enrollee's parent or guardian;

(2) 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; and

(3) may not be subject to annual dollar limits.

Sec. 1365A.004. PREAUTHORIZATION. A health benefit plan may require prior authorization for bilateral cochlear implants in the same manner that the health benefit plan requires prior authorization for any other covered benefit.

Sec. 1365A.005. MANAGED CARE PLAN. A health benefit plan provider may require that, if coverage is provided through a managed care plan, the benefits mandated under this chapter are covered benefits only if the bilateral cochlear implants are provided by a vendor, and related services are rendered by a provider, that contracts with or is designated by the health benefit plan provider. If the health benefit plan provider provides in-network and out-of-network services, the coverage for bilateral cochlear implants provided through out-of-network services must be comparable to that provided through in-network services.

SECTION 2. Chapter 1365A, Insurance Code, as added by this Act, applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2010. A health benefit plan that is delivered, issued for delivery, or renewed before January 1, 2010, is covered by the law in effect at the time the plan was delivered, issued for delivery, or renewed, and that law is continued in effect for that purpose.

SECTION 3. This Act takes effect September 1, 2009.