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A BILL TO BE ENTITLED
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AN ACT
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relating to the requirement and study of insurance coverage for |
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serious emotional disturbance of a child. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1355.001, Insurance Code, is amended by |
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adding Subdivision (5) to read as follows: |
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(5) "Serious emotional disturbance of a child" means |
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an emotional or behavioral disorder or a neuropsychiatric condition |
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that causes a person's functioning to be impaired in thought, |
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perception, affect, or behavior and that: |
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(A) has been diagnosed in a person who is at least |
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three years of age and younger than 17 years of age; |
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(B) results in behavior inappropriate to the |
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person's age according to expected developmental norms; and |
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(C) meets at least one of the following criteria: |
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(i) the disorder is likely to continue |
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without treatment; |
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(ii) the disorder substantially impairs the |
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person's ability in at least two of the following activities or |
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tasks: |
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(a) self-care; |
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(b) engaging in family relationships; |
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(c) functioning in school; or |
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(d) functioning in the community; |
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(iii) the disorder creates a risk that the |
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person will be removed from the person's home; |
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(iv) the disorder causes the person to be |
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removed from the person's home; |
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(v) the disorder causes the person to: |
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(a) display psychotic features or |
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violent behavior; or |
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(b) pose a danger to the person's self |
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or others; or |
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(vi) the disorder results in the person |
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meeting state special education eligibility requirements. |
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SECTION 2. The heading to Section 1355.004, Insurance Code, |
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is amended to read as follows: |
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Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS EMOTIONAL |
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DISTURBANCE OF A CHILD AND SERIOUS MENTAL ILLNESS. |
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SECTION 3. Section 1355.004, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsections (c), (d), and (e) to |
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read as follows: |
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(a) A group health benefit plan: |
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(1) must provide coverage for serious emotional |
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disturbance of a child diagnosed as described by Section |
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1355.001(5) and coverage, based on medical necessity, for serious |
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mental illness for not less than the following treatments [of
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serious mental illness] in each calendar year: |
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(A) 45 days of inpatient treatment; and |
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(B) 60 visits for outpatient treatment, |
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including group and individual outpatient treatment; |
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(2) may not include a lifetime limitation on the |
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number of days of inpatient treatment or the number of visits for |
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outpatient treatment covered under the plan; and |
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(3) must include the same amount limitations, |
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deductibles, copayments, and coinsurance factors for serious |
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emotional disturbance of a child and serious mental illness as the |
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plan includes for physical illness. |
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(c) The department shall conduct a study to determine and |
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evaluate the extent to which enrollees are making claims under |
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coverage for serious emotional disturbance of a child and the |
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impact, if any, the coverage for serious emotional disturbance of a |
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child and the claims have on the cost of the coverage for group |
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health benefit plans. |
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(d) Not later than August 1, 2012, the department shall |
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submit to the governor, the lieutenant governor, the speaker of the |
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house of representatives, and the appropriate standing committees |
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of the legislature a report regarding the results of the study |
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required by Subsection (c), together with any recommendations for |
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legislation. |
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(e) This subsection and Subsections (c) and (d) expire |
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September 1, 2013. |
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SECTION 4. Section 1355.054(a), Insurance Code, is amended |
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to read as follows: |
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(a) Benefits of coverage provided under this subchapter may |
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be used only in a situation in which: |
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(1) the covered individual has a serious mental |
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illness or serious emotional disturbance of a child that requires |
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confinement of the individual in a hospital unless treatment is |
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available through a residential treatment center for children and |
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adolescents or a crisis stabilization unit; and |
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(2) the covered individual's mental illness or |
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emotional disturbance: |
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(A) substantially impairs the individual's |
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thought, perception of reality, emotional process, or judgment; or |
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(B) as manifested by the individual's recent |
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disturbed behavior, grossly impairs the individual's behavior. |
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SECTION 5. The change in law made by this Act applies only |
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to a group health benefit plan that is delivered, issued for |
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delivery, or renewed on or after January 1, 2012. A group health |
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benefit plan that is delivered, issued for delivery, or renewed |
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before January 1, 2012, 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 6. This Act takes effect September 1, 2011. |