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A BILL TO BE ENTITLED
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AN ACT
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relating to coverage for serious mental illness, other disorders, |
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and chemical dependency under certain health benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Subchapter A, Chapter 1355, |
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Insurance Code, is amended to read as follows: |
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SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN |
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SERIOUS MENTAL ILLNESSES AND OTHER DISORDERS |
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SECTION 2. Section 1355.001, Insurance Code, is amended by |
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amending Subdivision (1) and adding Subdivisions (5), (6), and (7) |
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to read as follows: |
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(1) "Serious mental illness" means the following |
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psychiatric illnesses as defined by the American Psychiatric |
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Association in the Diagnostic and Statistical Manual of Mental |
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Disorders (DSM), fifth edition, or a later edition adopted by the |
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commissioner by rule: |
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(A) bipolar disorders (hypomanic, manic, |
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depressive, and mixed); |
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(B) depression in childhood and adolescence; |
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(C) major depressive disorders (single episode |
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or recurrent); |
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(D) obsessive-compulsive disorders; |
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(E) paranoid and other psychotic disorders; |
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(F) posttraumatic stress disorder; |
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(G) schizo-affective disorders (bipolar or |
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depressive); and |
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(H) [(G)] schizophrenia. |
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(5) "Posttraumatic stress disorder" means a disorder |
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that: |
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(A) meets the diagnostic criteria for |
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posttraumatic stress disorder specified by the American |
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Psychiatric Association in the Diagnostic and Statistical Manual of |
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Mental Disorders, fifth edition, or a later edition adopted by the |
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commissioner by rule; and |
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(B) results in an impairment of a person's |
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functioning in the person's community, employment, family, school, |
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or social group. |
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(6) "Eating disorder" means: |
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(A) any eating disorder described by the |
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Diagnostic and Statistical Manual of Mental Disorders, fifth |
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edition, or a later edition adopted by the commissioner by rule, |
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including: |
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(i) anorexia nervosa; |
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(ii) bulimia nervosa; |
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(iii) binge eating disorder; |
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(iv) rumination disorder; |
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(v) avoidant/restrictive food intake |
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disorder; or |
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(vi) any eating disorder not otherwise |
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specified; or |
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(B) any eating disorder contained in a subsequent |
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edition of the Diagnostic and Statistical Manual of Mental |
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Disorders published by the American Psychiatric Association and |
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adopted by the commissioner by rule. |
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(7) "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, by a physician licensed |
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to practice medicine in this state, a psychologist licensed to |
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practice in this state, or a licensed professional counselor |
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licensed to practice in this state, in a person who is at least 3 |
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years of age and younger than 17 years of age; and |
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(B) meets at least one of the following criteria: |
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(i) 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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(ii) the disorder creates a risk that the |
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person will be removed from the person's home and placed in a more |
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restrictive environment, including in a facility or program |
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operated by the Department of Family and Protective Services or an |
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agency that is part of the juvenile justice system; |
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(iii) 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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(iv) the disorder results in the person |
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meeting state special education eligibility requirements for |
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serious emotional disturbance. |
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SECTION 3. Section 1355.002, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsections (c) and (d) to read |
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as follows: |
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(a) This subchapter applies only to a [group] health benefit |
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plan that provides benefits for medical or surgical expenses |
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incurred as a result of a health condition, accident, or sickness, |
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including: |
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(1) an individual, [a] group, blanket, or franchise |
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insurance policy or [, group] insurance agreement, a group hospital |
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service contract, [or] an individual or group evidence of coverage, |
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or a similar coverage document, that is offered by: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a fraternal benefit society operating under |
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Chapter 885; |
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(D) a stipulated premium company operating under |
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Chapter 884; [or] |
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(E) a health maintenance organization operating |
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under Chapter 843; [and] |
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(F) a reciprocal exchange operating under |
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Chapter 942; |
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(G) a Lloyd's plan operating under Chapter 941; |
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(H) an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844; or |
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(I) a multiple employer welfare arrangement that |
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holds a certificate of authority under Chapter 846; and |
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(2) to the extent permitted by the Employee Retirement |
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Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan |
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offered under: |
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(A) a multiple employer welfare arrangement as |
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defined by Section 3 of that Act; or |
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(B) another analogous benefit arrangement. |
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(c) Notwithstanding Section 1501.251 or any other law, this |
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subchapter applies to coverage under a small employer health |
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benefit plan subject to Chapter 1501. |
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(d) This subchapter applies to a standard health benefit |
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plan issued under Chapter 1507. |
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SECTION 4. The heading to Section 1355.003, Insurance Code, |
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is amended to read as follows: |
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Sec. 1355.003. EXCEPTIONS [EXCEPTION]. |
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SECTION 5. Section 1355.003, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsection (c) to read as |
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follows: |
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(a) This subchapter does not apply to coverage under: |
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(1) [a blanket accident and health insurance policy,
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as described by Chapter 1251;
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[(2)] a short-term travel policy; |
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(2) [(3)] an accident-only policy; |
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(3) [(4)] a limited or specified-disease policy that |
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does not provide benefits for mental health care or similar |
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services; |
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(4) [(5)] except as provided by Subsection (b), a plan |
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offered under Chapter 1551 or Chapter 1601; |
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(5) [(6)] a plan offered in accordance with Section |
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1355.151; or |
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(6) [(7)] a Medicare supplement benefit plan, as |
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defined by Section 1652.002. |
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(c) To the extent that this section would otherwise require |
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this state to make a payment under 42 U.S.C. Section |
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18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 |
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C.F.R. Section 155.20, is not required to provide a benefit under |
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this subchapter that exceeds the specified essential health |
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benefits required under 42 U.S.C. Section 18022(b). |
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SECTION 6. Section 1355.004, Insurance Code, is amended to |
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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. (a) A [group] |
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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 1355.001 |
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and coverage, based on medical necessity, for serious mental |
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illness for not less than the following treatments [of serious
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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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(b) A [group] health benefit plan issuer: |
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(1) may not count an outpatient visit for medication |
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management against the number of outpatient visits required to be |
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covered under Subsection (a)(1)(B); and |
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(2) must provide coverage for an outpatient visit |
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described by Subsection (a)(1)(B) under the same terms as the |
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coverage the issuer provides for an outpatient visit for the |
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treatment of physical illness. |
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SECTION 7. Section 1355.005, Insurance Code, is amended to |
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read as follows: |
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Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A [group] |
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health benefit plan issuer may provide or offer coverage required |
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by Section 1355.004 through a managed care plan. |
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SECTION 8. Section 1355.006(b), Insurance Code, is amended |
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to read as follows: |
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(b) This subchapter does not require a [group] health |
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benefit plan to provide coverage for the treatment of: |
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(1) addiction to a controlled substance or marihuana |
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that is used in violation of law; or |
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(2) mental illness that results from the use of a |
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controlled substance or marihuana in violation of law. |
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SECTION 9. Subchapter A, Chapter 1355, Insurance Code, is |
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amended by adding Section 1355.008 to read as follows: |
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Sec. 1355.008. REQUIRED COVERAGE FOR EATING DISORDERS. (a) |
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A health benefit plan must provide coverage, based on medical |
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necessity, for the diagnosis and treatment of an eating disorder. |
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(b) Coverage required under Subsection (a) is limited to a |
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service or medication, to the extent the service or medication is |
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covered by the health benefit plan, ordered by a licensed |
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physician, psychiatrist, psychologist, or therapist within the |
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scope of the practitioner's license and in accordance with a |
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treatment plan. |
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(c) On request from the health benefit plan issuer, an |
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eating disorder treatment plan must include all elements necessary |
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for the issuer to pay a claim under the health benefit plan, which |
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may include a diagnosis, goals, and proposed treatment by type, |
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frequency, and duration. |
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(d) Coverage required under Subsection (a) is not subject to |
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a limit on the number of days of medically necessary treatment |
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except as provided by the treatment plan. |
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(e) A health benefit plan issuer may conduct a utilization |
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review of an eating disorder treatment plan not more than once each |
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six months unless the physician, psychiatrist, psychologist, or |
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therapist treating the enrollee under the treatment plan agrees |
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that a more frequent review is necessary. An agreement to conduct |
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more frequent review under this subsection applies only to the |
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enrollee who is the subject of the agreement. |
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(f) A health benefit plan issuer shall pay any costs of |
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conducting a utilization review of coverage required under |
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Subsection (a) or obtaining a treatment plan. |
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(g) In conducting a utilization review of treatment for an |
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eating disorder, including review of medical necessity or the |
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treatment plan, a utilization review agent shall consider: |
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(1) the overall medical and mental health needs of the |
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individual with the eating disorder; |
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(2) factors in addition to weight; and |
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(3) the most recent Practice Guideline for the |
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Treatment of Patients with Eating Disorders adopted by the American |
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Psychiatric Association. |
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SECTION 10. 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 11. Section 1368.002, Insurance Code, is amended to |
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read as follows: |
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Sec. 1368.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a [group] health benefit plan that provides |
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hospital and medical coverage or services on an expense incurred, |
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service, or prepaid basis, including an individual, [a] group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, an individual or group evidence of |
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coverage, or a similar coverage document, or self-funded or |
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self-insured plan or arrangement, that is offered in this state by: |
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(1) an insurer; |
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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; [or] |
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(4) an employer, trustee, or other self-funded or |
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self-insured plan or arrangement; |
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(5) a fraternal benefit society operating under |
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Chapter 885; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a reciprocal exchange operating under Chapter 942; |
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(8) a Lloyd's plan operating under Chapter 941; |
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(9) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; or |
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(10) a multiple employer welfare arrangement that |
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holds a certificate of authority under Chapter 846. |
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(b) 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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(c) This chapter applies to a standard health benefit plan |
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issued under Chapter 1507. |
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SECTION 12. Section 1368.003, Insurance Code, is amended to |
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read as follows: |
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Sec. 1368.003. EXCEPTIONS [EXCEPTION]. (a) This chapter |
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does not apply to: |
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(1) an employer, trustee, or other self-funded or |
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self-insured plan or arrangement with 250 or fewer employees or |
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members; |
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(2) [an individual insurance policy;
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[(3)
an individual evidence of coverage issued by a
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health maintenance organization;
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[(4)] a health insurance policy that provides only: |
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(A) cash indemnity for hospital or other |
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confinement benefits; |
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(B) supplemental or limited benefit coverage; |
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(C) coverage for specified diseases or |
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accidents; |
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(D) disability income coverage; or |
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(E) any combination of those benefits or |
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coverages; |
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(3) [(5) a blanket insurance policy;
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[(6)] a short-term travel insurance policy; |
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(4) [(7)] an accident-only insurance policy; |
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(5) [(8)] a limited or specified disease insurance |
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policy; |
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(6) [(9)
an individual conversion insurance policy or
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contract;
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[(10)] a policy or contract designed for issuance to a |
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person eligible for Medicare coverage or other similar coverage |
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under a state or federal government plan; or |
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(7) [(11)] an evidence of coverage provided by a |
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health maintenance organization if the plan holder is the subject |
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of a collective bargaining agreement that was in effect on January |
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1, 1982, and that has not expired since that date. |
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(b) To the extent that this section would otherwise require |
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this state to make a payment under 42 U.S.C. Section |
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18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 |
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C.F.R. Section 155.20, is not required to provide a benefit under |
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this chapter that exceeds the specified essential health benefits |
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required under 42 U.S.C. Section 18022(b). |
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SECTION 13. Section 1368.004, Insurance Code, is amended to |
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read as follows: |
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Sec. 1368.004. COVERAGE REQUIRED. (a) A [group] health |
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benefit plan shall provide coverage for the necessary care and |
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treatment of chemical dependency. |
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(b) Coverage required under this section may be provided: |
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(1) directly by the [group] health benefit plan |
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issuer; or |
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(2) by another entity, including a single service |
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health maintenance organization, under contract with the [group] |
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health benefit plan issuer. |
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SECTION 14. Section 1368.005(b), Insurance Code, is amended |
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to read as follows: |
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(b) A [group] health benefit plan may set dollar or |
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durational limits for coverage required under this chapter that are |
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less favorable than for coverage provided for physical illness |
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generally under the plan if those limits are sufficient to provide |
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appropriate care and treatment under the guidelines and standards |
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adopted under Section 1368.007. If guidelines and standards |
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adopted under Section 1368.007 are not in effect, the dollar and |
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durational limits may not be less favorable than for physical |
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illness generally. |
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SECTION 15. Section 1355.007, Insurance Code, is repealed. |
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SECTION 16. The changes in law made by this Act apply only |
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to a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2018. A health benefit plan that is |
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delivered, issued for delivery, or renewed before January 1, 2018, |
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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 17. This Act takes effect September 1, 2017. |