|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to health insurance coverage for diagnosis and treatment |
|
of conditions affecting the temporomandibular joint. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Sections 1360.002, 1360.003, 1360.004, and |
|
1360.005, Insurance Code, are amended to read as follows: |
|
Sec. 1360.002. APPLICABILITY OF CHAPTER. (a) Except as |
|
provided by Subsection (b), this [This] chapter applies [only] to a |
|
group health benefit plan delivered or issued for delivery in this |
|
state that: |
|
(1) provides benefits for dental, medical, or surgical |
|
expenses incurred as a result of a health condition, accident, or |
|
sickness, including: |
|
(A) a group, blanket, or franchise insurance |
|
policy or insurance agreement, a group hospital service contract, |
|
or a group evidence of coverage that is offered by: |
|
(i) an insurance company; |
|
(ii) a group hospital service corporation |
|
operating under Chapter 842; |
|
(iii) a fraternal benefit society operating |
|
under Chapter 885; |
|
(iv) a stipulated premium company operating |
|
under Chapter 884; or |
|
(v) a health maintenance organization |
|
operating under Chapter 843; and |
|
(B) to the extent permitted by the Employee |
|
Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et |
|
seq.), a health benefit plan that is offered by: |
|
(i) a multiple employer welfare arrangement |
|
as defined by Section 3 of that Act; |
|
(ii) an entity not authorized under this |
|
code or another insurance law of this state that contracts directly |
|
for health care services on a risk-sharing basis, including a |
|
capitation basis; or |
|
(iii) another analogous benefit |
|
arrangement; or |
|
(2) is offered by an approved nonprofit health |
|
corporation that holds a certificate of authority under Chapter |
|
844. |
|
(b) This chapter applies to an individual insurance policy |
|
delivered or issued for delivery in this state that provides |
|
benefits for dental, medical, or surgical expenses incurred as a |
|
result of a health condition, accident, or sickness. |
|
Sec. 1360.003. EXCEPTION. This chapter does not apply to: |
|
(1) a plan or policy that provides coverage: |
|
(A) only for a specified disease or another |
|
limited benefit; |
|
(B) only for accidental death or dismemberment; |
|
(C) for wages or payments in lieu of wages for a |
|
period during which an employee is absent from work because of |
|
sickness or injury; |
|
(D) as a supplement to a liability insurance |
|
policy; |
|
(E) for credit insurance; |
|
(F) only for vision care; or |
|
(G) only for indemnity for hospital confinement; |
|
(2) a Medicare supplemental policy as defined by |
|
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
|
(3) a workers' compensation insurance policy; |
|
(4) a small employer health benefit plan written under |
|
Chapter 1501; |
|
(5) medical payment insurance coverage provided under |
|
a motor vehicle insurance policy; or |
|
(6) a long-term care insurance policy, including a |
|
nursing home fixed indemnity policy, unless the commissioner |
|
determines that the policy provides benefit coverage so |
|
comprehensive that the policy is a health benefit plan as described |
|
by Section 1360.002. |
|
Sec. 1360.004. COVERAGE REQUIRED. (a) A health benefit |
|
plan or individual insurance policy that provides coverage for |
|
medically necessary diagnostic or surgical treatment of conditions |
|
affecting skeletal joints must provide comparable coverage for |
|
diagnostic or surgical treatment of conditions affecting the |
|
temporomandibular joint if the treatment is medically necessary as |
|
a result of: |
|
(1) an accident; |
|
(2) a trauma; |
|
(3) a congenital defect; |
|
(4) a developmental defect; or |
|
(5) a pathology. |
|
(b) Coverage required under this section may be subject to |
|
any provision in the health benefit plan or individual insurance |
|
policy that is generally applicable to surgical treatment, |
|
including a requirement for precertification of coverage. |
|
Sec. 1360.005. DENTAL SERVICES COVERAGE NOT REQUIRED. |
|
(a) This chapter does not require a health benefit plan or |
|
individual insurance policy to provide coverage for dental services |
|
if dental services are not otherwise scheduled or provided as part |
|
of the coverage provided under the plan. |
|
(b) A health benefit plan or individual insurance policy may |
|
not exclude from coverage under the plan or policy an individual who |
|
is unable to undergo dental treatment in an office setting or under |
|
local anesthesia due to a documented physical, mental, or medical |
|
reason as determined by the individual's physician or by the |
|
dentist providing the dental care. |
|
SECTION 2. This Act applies only to an insurance policy that |
|
is delivered, issued for delivery, or renewed on or after January 1, |
|
2010. A policy delivered, issued for delivery, or renewed before |
|
January 1, 2010, 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 3. This Act takes effect September 1, 2009. |