86R4495 PMO-F

By: Zaffirini S.B. No. 314

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 or identified, as applicable, in a person who is at least three years of age and younger than 18 years of age by:

(i) a physician licensed to practice medicine in this state and practicing within the scope of the physician's license; or

(ii) a psychologist or licensed professional counselor licensed to practice in this state and practicing within the scope of the psychologist's or licensed professional counselor's license; and

(B) meets at least one of the following criteria:

(i) 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;

(ii) the disorder creates a risk that the person will be removed from the person's home and placed in a more restrictive environment, including in a facility or program operated by the Department of Family and Protective Services or an agency that is part of the juvenile justice system;

(iii) 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

(iv) the disorder results in the person meeting state special education eligibility requirements for emotional disturbance.

SECTION 2. Subchapter A, Chapter 1355, Insurance Code, is amended by adding Section 1355.0041 to read as follows:

Sec. 1355.0041. REQUIRED COVERAGE FOR SERIOUS EMOTIONAL DISTURBANCE OF A CHILD. (a) Notwithstanding Section 1355.002, this section does not apply to:

(1) a basic plan under Chapter 1575; or

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

(b) A group health benefit plan:

(1) must provide coverage for serious emotional disturbance of a child, based on medical necessity, for not less than the following treatments 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 as the plan includes for physical illness.

(c) 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 (b)(1)(B); and

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

(d) 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.

(e) Not later than August 1, 2020, 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 (d), together with any recommendations for legislation.

(f) This subsection and Subsections (d) and (e) expire September 1, 2021.

SECTION 3. Sections 1355.005 and 1355.007, Insurance Code, are amended to read as follows:

Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A group health benefit plan issuer may provide or offer coverage required by Section 1355.004 or 1355.0041 through a managed care plan.

Sec. 1355.007. SMALL EMPLOYER COVERAGE. An issuer of a group health benefit plan to a small employer must offer the coverage described by Section 1355.004 or 1355.0041 to the employer but is not required to provide the coverage if the employer rejects the coverage.

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 as defined by Section 1355.001 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, 2020. A group health benefit plan that is delivered, issued for delivery, or renewed before January 1, 2020, 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, 2019.