83R5979 PMO-D

By: Coleman H.B. No. 3326

A BILL TO BE ENTITLED

AN ACT

relating to health benefit plan coverage for an enrollee with certain mental disorders.

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

ARTICLE 1. AMENDMENTS TO SUBCHAPTER A, CHAPTER 1355,

INSURANCE CODE

SECTION 1.01. The heading to Subchapter A, Chapter 1355, Insurance Code, is amended to read as follows:

SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR

CERTAIN [SERIOUS] MENTAL [ILLNESSES AND OTHER] DISORDERS

SECTION 1.02. Sections 1355.001 through 1355.007, Insurance Code, are amended to read as follows:

Sec. 1355.001. DEFINITIONS. In this subchapter:

(1) "Mental disorder" ["Serious mental illness"] means a disorder [the following psychiatric illnesses] as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or in a subsequent edition of that manual that the commissioner adopts to take the place of the fourth edition or any subsequent edition for the purposes of this subdivision, that results in an impairment of a person's functioning in the person's community, employment, family, school, or social group [(DSM):

[(A) bipolar disorders (hypomanic, manic, depressive, and mixed);

[(B) depression in childhood and adolescence;

[(C) major depressive disorders (single episode or recurrent);

[(D) obsessive-compulsive disorders;

[(E) paranoid and other psychotic disorders;

[(F) schizo-affective disorders (bipolar or depressive); and

[(G) schizophrenia].

(2) ["Small employer" has the meaning assigned by Section 1501.002.

[(3)] "Autism spectrum disorder" means a neurobiological disorder that includes autism, Asperger's syndrome, or Pervasive Developmental Disorder--Not Otherwise Specified.

[(4) "Neurobiological disorder" means an illness of the nervous system caused by genetic, metabolic, or other biological factors.]

Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a [group] health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual,[:

[(1) a] group, blanket, or franchise insurance policy or[, group] insurance agreement, a group hospital service contract, an individual or group evidence of coverage, or a similar coverage document, that is offered by:

(1) [(A)] an insurance company;

(2) [(B)] a group hospital service corporation operating under Chapter 842;

(3) [(C)] a fraternal benefit society operating under Chapter 885;

(4) [(D)] a stipulated premium company operating under Chapter 884; [or]

(5) [(E)] a health maintenance organization operating under Chapter 843;

(6) a reciprocal exchange operating under Chapter 942;

(7) a Lloyd's plan operating under Chapter 941;

(8) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; or [and]

(9) [(2) to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan offered under:

[(A)] a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846 [as defined by Section 3 of that Act; or

[(B) another analogous benefit arrangement].

(b) Notwithstanding any provision in Chapter 1575 or 1579 or any other law, Section 1355.015 applies to:

(1) a basic plan under Chapter 1575; and

(2) a primary care coverage plan under Chapter 1579.

(c) This subchapter applies to a small employer health benefit plan written under Chapter 1501.

Sec. 1355.003. EXCEPTION. [(a)] This subchapter does not apply to [coverage under]:

(1) a plan that provides coverage:

(A) only for benefits for a specified disease or for another limited benefit, other than a plan that provides benefits for mental health or similar services;

(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) only for dental or vision care;

(F) only for hospital expenses; 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) medical payment insurance coverage provided under an automobile insurance policy;

(5) a credit 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 1355.002 [a blanket accident and health insurance policy, as described by Chapter 1251;

[(2) a short-term travel policy;

[(3) an accident-only policy;

[(4) a limited or specified-disease policy that does not provide benefits for mental health care or similar services;

[(5) except as provided by Subsection (b), a plan offered under Chapter 1551 or Chapter 1601;

[(6) a plan offered in accordance with Section 1355.151; or

[(7) a Medicare supplement benefit plan, as defined by Section 1652.002].

[(b) For the purposes of a plan described by Subsection (a)(5), "serious mental illness" has the meaning assigned by Section 1355.001.]

Sec. 1355.004. REQUIRED COVERAGE [FOR SERIOUS MENTAL ILLNESS]. [(a)] A group health benefit plan[:

[(1)] must provide coverage for the diagnosis and treatment of a mental disorder under the same terms and conditions as coverage provided for the diagnosis and treatment of physical illness[, based on medical necessity, 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 mental illness as the plan includes for physical illness].

[(b) A group health benefit plan issuer:

[(1) may not count an outpatient visit for medication management against the number of outpatient visits required to be covered under Subsection (a)(1)(B); and

[(2) must provide coverage for an outpatient visit described by Subsection (a)(1)(B) under the same terms as the coverage the issuer provides for an outpatient visit for the treatment of physical illness.]

Sec. 1355.005. COVERAGE OF INPATIENT STAYS AND OUTPATIENT VISITS. A health benefit plan must cover inpatient stays and outpatient visits under this subchapter under the same terms and conditions as the plan covers inpatient stays and outpatient visits for treatment of a physical illness. [MANAGED CARE PLAN AUTHORIZED. A group health benefit plan issuer may provide or offer coverage required by Section 1355.004 through a managed care plan.]

Sec. 1355.006. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS; COINSURANCE. Coverage provided under this subchapter must be subject to the same amount limits, deductibles, copayments, and coinsurance factors as coverage for physical illness. [COVERAGE FOR CERTAIN CONDITIONS RELATED TO CONTROLLED SUBSTANCE OR MARIHUANA NOT REQUIRED. (a) In this section, "controlled substance" and "marihuana" have the meanings assigned by Section 481.002, Health and Safety Code.

[(b) This subchapter does not require a group health benefit plan to provide coverage for the treatment of:

[(1) addiction to a controlled substance or marihuana that is used in violation of law; or

[(2) mental illness that results from the use of a controlled substance or marihuana in violation of law.]

Sec. 1355.007. RULES. The commissioner shall adopt rules as necessary to implement this subchapter. [SMALL EMPLOYER COVERAGE. An issuer of a group health benefit plan to a small employer must offer the coverage described by Section 1355.004 to the employer but is not required to provide the coverage if the employer rejects the coverage.]

ARTICLE 2. CONFORMING AMENDMENTS

SECTION 2.01. Section 1355.151, Insurance Code, is amended to read as follows:

Sec. 1355.151. PROHIBITION ON EXCLUSION OR LIMITATION OF CERTAIN COVERAGES. (a) In this section, "mental disorder" ["serious mental illness"] has the meaning assigned by Section 1355.001.

(b) A political subdivision that provides group health insurance coverage, health maintenance organization coverage, or self-insured health care coverage to the political subdivision's officers or employees may not contract for or provide coverage that is less extensive for a mental disorder [serious mental illness] than the coverage provided for any other physical illness.

SECTION 2.02. Section 1507.003(b), Insurance Code, is amended to read as follows:

(b) For purposes of this subchapter, "state-mandated health benefits" does not include benefits that are mandated by federal law or standard provisions or rights required under this code or other laws of this state to be provided in an individual, blanket, or group policy for accident and health insurance that are unrelated to a specific health illness, injury, or condition of an insured, including provisions related to:

(1) continuation of coverage under:

(A) Subchapters F and G, Chapter 1251;

(B) Section 1201.059; and

(C) Subchapter B, Chapter 1253;

(2) termination of coverage under Sections 1202.051 and 1501.108;

(3) preexisting conditions under Subchapter D, Chapter 1201, and Sections 1501.102-1501.105;

(4) coverage of children, including newborn or adopted children, under:

(A) Subchapter D, Chapter 1251;

(B) Sections 1201.053, 1201.061, 1201.063-1201.065, and Subchapter A, Chapter 1367;

(C) Chapter 1504;

(D) Chapter 1503;

(E) Section 1501.157;

(F) Section 1501.158; and

(G) Sections 1501.607-1501.609;

(5) services of practitioners under:

(A) Subchapters A, B, and C, Chapter 1451; or

(B) Section 1301.052;

(6) supplies and services associated with the treatment of diabetes under Subchapter B, Chapter 1358;

(7) coverage for a mental disorder [serious mental illness] under Subchapter A, Chapter 1355;

(8) coverage for childhood immunizations and hearing screening as required by Subchapters B and C, Chapter 1367, other than Section 1367.053(c) and Chapter 1353;

(9) coverage for reconstructive surgery for certain craniofacial abnormalities of children as required by Subchapter D, Chapter 1367;

(10) coverage for the dietary treatment of phenylketonuria as required by Chapter 1359;

(11) coverage for referral to a non-network physician or provider when medically necessary covered services are not available through network physicians or providers, as required by Section 1271.055; and

(12) coverage for cancer screenings under:

(A) Chapter 1356;

(B) Chapter 1362;

(C) Chapter 1363; and

(D) Chapter 1370.

SECTION 2.03. Section 1507.053(b), Insurance Code, is amended to read as follows:

(b) For purposes of this subchapter, "state-mandated health benefits" does not include coverage that is mandated by federal law or standard provisions or rights required under this code or other laws of this state to be provided in an evidence of coverage that are unrelated to a specific health illness, injury, or condition of an enrollee, including provisions related to:

(1) continuation of coverage under Subchapter G, Chapter 1251;

(2) termination of coverage under Sections 1202.051 and 1501.108;

(3) preexisting conditions under Subchapter D, Chapter 1201, and Sections 1501.102-1501.105;

(4) coverage of children, including newborn or adopted children, under:

(A) Chapter 1504;

(B) Chapter 1503;

(C) Section 1501.157;

(D) Section 1501.158; and

(E) Sections 1501.607-1501.609;

(5) services of providers under Section 843.304;

(6) coverage for a mental disorder [serious mental health illness] under Subchapter A, Chapter 1355; and

(7) coverage for cancer screenings under:

(A) Chapter 1356;

(B) Chapter 1362;

(C) Chapter 1363; and

(D) Chapter 1370.

SECTION 2.04. Section 1551.003, Insurance Code, is amended by amending Subdivision (10-a) and adding Subdivision (10-b) to read as follows:

(10-a) "Mental disorder" has the meaning assigned by Section 1355.001.

(10-b) "Participant" means an eligible individual who participates in the group benefits program.

SECTION 2.05. Section 1551.205, Insurance Code, is amended to read as follows:

Sec. 1551.205. LIMITATIONS. The board of trustees may not contract for or provide a coverage plan that:

(1) excludes or limits coverage or services for acquired immune deficiency syndrome, as defined by the Centers for Disease Control and Prevention of the United States Public Health Service, or human immunodeficiency virus infection;

(2) provides coverage for a mental disorder [serious mental illness] that is less extensive than the coverage provided for any physical illness; or

(3) may provide coverage for prescription drugs to assist in stopping smoking at a lower benefit level than is provided for other prescription drugs.

SECTION 2.06. Section 1601.109, Insurance Code, is amended to read as follows:

Sec. 1601.109. COVERAGE FOR AIDS, HIV, OR [SERIOUS] MENTAL DISORDER [ILLNESS]. (a) In this section, "mental disorder" ["serious mental illness"] has the meaning assigned by Section 1355.001.

(b) A system may not contract for or provide for group insurance or HMO coverage or provide self-insured coverage, that:

(1) excludes or limits coverage or services for acquired immune deficiency syndrome, as defined by the Centers for Disease Control and Prevention of the United States Public Health Service, or human immunodeficiency virus infection; or

(2) provides coverage for a mental disorder [serious mental illness] that is less extensive than the coverage provided for any other physical illness.

SECTION 2.07. Section 1551.003(12), Insurance Code, is repealed.

ARTICLE 3. TRANSITION; EFFECTIVE DATE

SECTION 3.01. The change in law made by this Act applies only to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2014. A health benefit plan delivered, issued for delivery, or renewed before January 1, 2014, 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 3.02. This Act takes effect September 1, 2013.