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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage of certain treatments for |
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enrollees diagnosed with a terminal illness; authorizing |
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administrative and civil penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle E, Title 8, Insurance Code, is amended |
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by adding Chapter 1372 to read as follows: |
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CHAPTER 1372. ACCESS TO TREATMENT FOR INDIVIDUALS WITH A TERMINAL |
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ILLNESS |
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Sec. 1372.001. DEFINITIONS. In this chapter: |
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(1) "Enrollee" means an individual entitled to |
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coverage under a health benefit plan. |
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(2) "Physician" means an individual licensed to |
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practice medicine in this state. |
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(3) "Terminal illness" means an illness or physical |
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condition, including a physical injury, that can reasonably be |
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expected to result in death within not more than two years. |
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Sec. 1372.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; or |
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(8) an exchange operating under Chapter 942. |
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(b) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this chapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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(c) This chapter applies to group health coverage made |
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available by a school district in accordance with Section 22.004, |
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Education Code. |
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(d) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this chapter applies to health |
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benefit plan coverage provided under: |
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(1) Chapter 1551; |
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(2) Chapter 1575; |
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(3) Chapter 1579; and |
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(4) Chapter 1601. |
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(e) Notwithstanding Section 1501.251 or any other law, this |
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chapter applies to coverage under a small employer health benefit |
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plan subject to Chapter 1501. |
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(f) This chapter applies to a consumer choice of benefits |
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plan issued under Chapter 1507. |
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(g) To the extent allowed by federal law, the child health |
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plan program operated under Chapter 62, Health and Safety Code, the |
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health benefits plan for children operated under Chapter 63, Health |
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and Safety Code, the state Medicaid program, and a managed care |
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organization that contracts with the Health and Human Services |
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Commission to provide health care services to recipients through a |
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managed care plan shall provide coverage to a recipient in |
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accordance with this chapter. |
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Sec. 1372.003. EXCEPTION TO APPLICABILITY OF CHAPTER. This |
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chapter does not apply to: |
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(1) a health benefit plan that provides coverage: |
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(A) only for a specified disease or for another |
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limited benefit; |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) for credit insurance; |
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(F) only for dental or vision care; |
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(G) only for hospital expenses; or |
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(H) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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a motor vehicle insurance policy; or |
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(5) a long-term care insurance policy, including a |
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nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1372.002. |
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Sec. 1372.004. APPLICABILITY TO CERTAIN TREATMENT. This |
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chapter applies to treatment for an enrollee diagnosed by a |
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physician with a terminal illness: |
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(1) that is: |
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(A) medically accepted as treatment for the |
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terminal illness or another illness or condition with which the |
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enrollee has been diagnosed by a physician; and |
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(B) prescribed by a physician to treat the |
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terminal illness or other illness or condition; and |
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(2) to which the enrollee or the enrollee's legal |
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guardian or other legal representative consents. |
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Sec. 1372.005. CERTAIN DENIALS OF COVERAGE PROHIBITED. |
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Notwithstanding any other law, a health benefit plan may not deny |
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coverage for a treatment to which this chapter applies based solely |
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on the enrollee's diagnosis with a terminal illness. |
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Sec. 1372.006. PROHIBITED CONDUCT. A health benefit plan |
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issuer or third-party administrator may not with respect to a |
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treatment to which this chapter applies: |
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(1) refuse to accept a physician's recommendation of |
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the treatment based solely on the enrollee's diagnosis with a |
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terminal illness; or |
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(2) reduce, prohibit, or deny payment or other forms |
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of reimbursement for the treatment based solely on the enrollee's |
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diagnosis with a terminal illness. |
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Sec. 1372.007. UNFAIR OR DECEPTIVE ACT OR PRACTICE; UNFAIR |
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CLAIM SETTLEMENT PRACTICE. A violation of this chapter is an unfair |
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or deceptive act or practice in the business of insurance for |
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purposes of Chapter 541 and an unfair claim settlement practice for |
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purposes of Chapter 542. |
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Sec. 1372.008. ADMINISTRATIVE PENALTIES. A health benefit |
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plan issuer or third-party administrator that commits a violation |
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of this chapter is subject to administrative penalties under |
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Chapters 82 and 84. |
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SECTION 2. Chapter 1372, Insurance Code, as added by this |
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Act, applies only to a health benefit plan that is delivered, issued |
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for delivery, or renewed on or after September 1, 2015. A plan |
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delivered, issued for delivery, or renewed before September 1, |
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2015, is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 3. This Act takes effect September 1, 2015. |