83R48 DLF-D
 
  By: Deuell, Van de Putte S.B. No. 996
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit plan coverage for brain injury.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1352.001, Insurance Code, is amended by
  amending Subsection (b) and adding Subsections (c) and (d) to read
  as follows:
         (b)  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) [(2)]  a primary care coverage plan under Chapter
  1579; and
               (4) [(3)]  basic coverage under Chapter 1601.
         (c)  This chapter applies to group health coverage made
  available by a school district in accordance with Section 22.004,
  Education Code.
         (d)  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.
         SECTION 2.  Section 1352.003, Insurance Code, is amended by
  amending Subsections (c) and (d) and adding Subsections (c-1) and
  (c-2) to read as follows:
         (c)  A health benefit plan may not include, in any annual or
  lifetime limitation on the number of days of acute care treatment
  covered under the plan, any post-acute care treatment covered under
  the plan.  Any limitation imposed under the plan on days of the
  post-acute care treatment required by this chapter is subject to
  Subsections (c-1) and (c-2) and must be clearly and separately
  stated in the plan using language that specifically identifies each
  therapy or treatment or rehabilitation, testing, remediation, or
  other service described by Subsections (a) and (b) that is subject
  to the limitation. A provision that purports to limit the number of
  days of treatment under a health benefit plan that does not
  specifically identify a particular therapy or treatment or testing,
  remediation, or other service described by Subsection (a) or (b) is
  void as applied to that therapy, treatment, or service. This
  subsection does not authorize a limitation on the number of days of
  treatment that is otherwise prohibited by state or federal law.
         (c-1)  Notwithstanding Subsection (c), a health benefit plan
  may not limit the number of days of covered post-acute care,
  including any therapy or treatment or rehabilitation, testing,
  remediation, or other service described by Subsections (a) and (b),
  or the number of days of covered inpatient care to the extent that
  the treatment or care is determined to be medically necessary as a
  result of and related to an acquired brain injury. The insured's or
  enrollee's treating physician shall determine whether treatment or
  care is medically necessary for purposes of this subsection in
  consultation with the treatment or care provider, the insured or
  enrollee, and, if appropriate, members of the insured's or
  enrollee's family. The determination is subject to review under
  Section 1352.006.
         (c-2)  A health benefit plan must provide coverage for
  custodial care for an insured or enrollee if custodial care is
  determined to be the appropriate level of care for the insured or
  enrollee as a result of and related to an acquired brain injury.
  Notwithstanding Subsection (c), a health benefit plan may not limit
  the number of days of covered custodial care under this subsection.
  The insured's or enrollee's treating physician shall determine
  whether custodial care is the appropriate level of care for
  purposes of this subsection in consultation with the care provider,
  the insured or enrollee, and, if appropriate, members of the
  insured's or enrollee's family. The determination is subject to
  review under Section 1352.006 as if it were a determination of
  medical necessity.
         (d)  Except as provided by Subsection (c), (c-1), or (c-2), a
  health benefit plan must include the same payment limitations,
  deductibles, copayments, and coinsurance factors for coverage
  required under this chapter as applicable to other similar coverage
  provided under the health benefit plan.
         SECTION 3.  Section 1352.007, Insurance Code, is amended by
  adding Subsections (c), (d), (e), and (f) to read as follows:
         (c)  The issuer of a health benefit plan, including a
  preferred provider benefit plan or health maintenance organization
  plan, that contracts with a hospital to provide services under this
  chapter to insureds and enrollees may not, solely because a
  facility is an assisted living facility, refuse to contract with
  that facility to provide services that are:
               (1)  required under this chapter; and
               (2)  within the scope of the license of the assisted
  living facility.
         (d)  The issuer of a health benefit plan that requires or
  encourages insureds or enrollees to use health care providers
  designated by the plan shall ensure that the services required by
  this chapter that are within the scope of the license of an assisted
  living facility are made available and accessible to the insureds
  or enrollees at an adequate number of assisted living facilities.
         (e)  A health benefit plan may not treat care provided in
  accordance with this subchapter as custodial care solely because it
  is provided by an assisted living facility.
         (f)  To ensure the health and safety of insureds and
  enrollees, the commissioner by rule may require that an assisted
  living facility that provides covered post-acute care other than
  custodial care under this chapter to an insured or enrollee with
  acquired brain injury meet specific criteria in addition to
  licensure or obtain a nationally recognized accreditation
  specified by the commissioner.
         SECTION 4.  Chapter 1352, Insurance Code, as amended 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 in effect immediately before the
  effective date of this Act, and that law is continued in effect for
  that purpose.
         SECTION 5.  This Act takes effect September 1, 2013.