82R5786 PMO-F
 
  By: Van de Putte S.B. No. 574
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the requirement and study of insurance coverage for
  serious emotional disturbance of a child.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1355.001, Insurance Code, is amended by
  adding Subdivision (5) to read as follows:
               (5)  "Serious emotional disturbance of a child" means
  an emotional or behavioral disorder or a neuropsychiatric condition
  that causes a person's functioning to be impaired in thought,
  perception, affect, or behavior and that:
                     (A)  has been diagnosed in a person who is at least
  three years of age and younger than 17 years of age;
                     (B)  results in behavior inappropriate to the
  person's age according to expected developmental norms; and
                     (C)  meets at least one of the following criteria:
                           (i)  the disorder is likely to continue
  without treatment;
                           (ii)  the disorder substantially impairs the
  person's ability in at least two of the following activities or
  tasks:
                                 (a)  self-care;
                                 (b)  engaging in family relationships;
                                 (c)  functioning in school; or
                                 (d)  functioning in the community;
                           (iii)  the disorder creates a risk that the
  person will be removed from the person's home;
                           (iv)  the disorder causes the person to be
  removed from the person's home;
                           (v)  the disorder causes the person to:
                                 (a)  display psychotic features or
  violent behavior; or
                                 (b)  pose a danger to the person's self
  or others; or
                           (vi)  the disorder results in the person
  meeting state special education eligibility requirements.
         SECTION 2.  The heading to Section 1355.004, Insurance Code,
  is amended to read as follows:
         Sec. 1355.004.  REQUIRED COVERAGE FOR SERIOUS EMOTIONAL
  DISTURBANCE OF A CHILD AND SERIOUS MENTAL ILLNESS.
         SECTION 3.  Section 1355.004, Insurance Code, is amended by
  amending Subsection (a) and adding Subsections (c), (d), and (e) to
  read as follows:
         (a)  A group health benefit plan:
               (1)  must provide coverage for serious emotional
  disturbance of a child diagnosed as described by Section
  1355.001(5) and coverage, based on medical necessity, for serious
  mental illness for not less than the following treatments [of
  serious mental illness] in each calendar year:
                     (A)  45 days of inpatient treatment; and
                     (B)  60 visits for outpatient treatment,
  including group and individual outpatient treatment;
               (2)  may not include a lifetime limitation on the
  number of days of inpatient treatment or the number of visits for
  outpatient treatment covered under the plan; and
               (3)  must include the same amount limitations,
  deductibles, copayments, and coinsurance factors for serious
  emotional disturbance of a child and serious mental illness as the
  plan includes for physical illness.
         (c)  The department shall conduct a study to determine and
  evaluate the extent to which enrollees are making claims under
  coverage for serious emotional disturbance of a child and the
  impact, if any, the coverage for serious emotional disturbance of a
  child and the claims have on the cost of the coverage for group
  health benefit plans.
         (d)  Not later than August 1, 2012, the department shall
  submit to the governor, the lieutenant governor, the speaker of the
  house of representatives, and the appropriate standing committees
  of the legislature a report regarding the results of the study
  required by Subsection (c), together with any recommendations for
  legislation.
         (e)  This subsection and Subsections (c) and (d) expire
  September 1, 2013.
         SECTION 4.  Section 1355.054(a), Insurance Code, is amended
  to read as follows:
         (a)  Benefits of coverage provided under this subchapter may
  be used only in a situation in which:
               (1)  the covered individual has a serious mental
  illness or serious emotional disturbance of a child that requires
  confinement of the individual in a hospital unless treatment is
  available through a residential treatment center for children and
  adolescents or a crisis stabilization unit; and
               (2)  the covered individual's mental illness or
  emotional disturbance:
                     (A)  substantially impairs the individual's
  thought, perception of reality, emotional process, or judgment; or
                     (B)  as manifested by the individual's recent
  disturbed behavior, grossly impairs the individual's behavior.
         SECTION 5.  The change in law made by this Act applies only
  to a group health benefit plan that is delivered, issued for
  delivery, or renewed on or after January 1, 2012. A group health
  benefit plan that is delivered, issued for delivery, or renewed
  before January 1, 2012, 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 6.  This Act takes effect September 1, 2011.