| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to health benefit plan coverage for hair prostheses for |
|
|
cancer patients. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. The heading to Chapter 1371, Insurance Code, is |
|
|
amended to read as follows: |
|
|
CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES AND OTHER |
|
|
PROSTHESES, ORTHOTIC DEVICES, AND RELATED SERVICES |
|
|
SECTION 2. Chapter 1371, Insurance Code, is amended by |
|
|
designating Sections 1371.001 and 1371.002 as Subchapter A and |
|
|
adding a subchapter heading to read as follows: |
|
|
SUBCHAPTER A. GENERAL PROVISIONS |
|
|
SECTION 3. Chapter 1371, Insurance Code, is amended by |
|
|
designating Sections 1371.003 through 1371.005 as Subchapter B and |
|
|
adding a subchapter heading to read as follows: |
|
|
SUBCHAPTER B. PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED |
|
|
SERVICES |
|
|
SECTION 4. Sections 1371.003(b), (c), and (e), Insurance |
|
|
Code, are amended to read as follows: |
|
|
(b) Covered benefits under this subchapter [chapter] are |
|
|
limited to the most appropriate model of prosthetic device or |
|
|
orthotic device that adequately meets the medical needs of the |
|
|
enrollee as determined by the enrollee's treating physician or |
|
|
podiatrist and prosthetist or orthotist, as applicable. |
|
|
(c) Subject to applicable copayments and deductibles, the |
|
|
repair and replacement of a prosthetic device or orthotic device is |
|
|
a covered benefit under this subchapter [chapter] unless the repair |
|
|
or replacement is necessitated by misuse or loss by the enrollee. |
|
|
(e) Covered benefits under this subchapter [chapter] may be |
|
|
provided by a pharmacy that has employees who are qualified under |
|
|
the Medicare system and applicable Medicaid regulations to service |
|
|
and bill for orthotic services. This subchapter [chapter] does not |
|
|
preclude a pharmacy from being reimbursed by a health benefit plan |
|
|
for the provision of orthotic services. |
|
|
SECTION 5. Section 1371.005, Insurance Code, is amended to |
|
|
read as follows: |
|
|
Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan |
|
|
provider may require that, if coverage is provided through a |
|
|
managed care plan, the benefits mandated under this subchapter |
|
|
[chapter] are covered benefits only if the prosthetic devices or |
|
|
orthotic devices are provided by a vendor or a provider, and related |
|
|
services are rendered by a provider, that contracts with or is |
|
|
designated by the health benefit plan provider. If the health |
|
|
benefit plan provider provides in-network and out-of-network |
|
|
services, the coverage for prosthetic devices or orthotic devices |
|
|
provided through out-of-network services must be comparable to that |
|
|
provided through in-network services. |
|
|
SECTION 6. Chapter 1371, Insurance Code, is amended by |
|
|
adding Subchapter C to read as follows: |
|
|
SUBCHAPTER C. HAIR PROSTHESES FOR CANCER PATIENTS |
|
|
Sec. 1371.051. APPLICABILITY OF SUBCHAPTER. (a) In |
|
|
addition to a health benefit plan subject to this chapter under |
|
|
Section 1371.002, this subchapter applies to a 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 or group evidence of coverage or similar coverage |
|
|
document that is issued by an approved nonprofit health corporation |
|
|
that holds a certificate of authority under Chapter 844. |
|
|
(b) Notwithstanding any other law, this chapter applies to: |
|
|
(1) a standard health benefit plan issued under |
|
|
Chapter 1507; |
|
|
(2) nonprofit agricultural organization health |
|
|
benefits offered by a nonprofit agricultural organization under |
|
|
Chapter 1682; |
|
|
(3) alternative health benefit coverage offered by a |
|
|
subsidiary of the Texas Mutual Insurance Company under Subchapter |
|
|
M, Chapter 2054; |
|
|
(4) health benefits provided by or through a church |
|
|
benefits board under Subchapter I, Chapter 22, Business |
|
|
Organizations Code; |
|
|
(5) group health coverage made available by a school |
|
|
district in accordance with Section 22.004, Education Code; |
|
|
(6) the state Medicaid program, including the Medicaid |
|
|
managed care program operated under Chapter 533, Government Code; |
|
|
(7) the child health plan program under Chapter 62, |
|
|
Health and Safety Code; |
|
|
(8) a regional or local health care program operated |
|
|
under Section 75.104, Health and Safety Code; and |
|
|
(9) a self-funded health benefit plan sponsored by a |
|
|
professional employer organization under Chapter 91, Labor Code. |
|
|
(c) This chapter applies to coverage under a group health |
|
|
benefit plan provided to a resident of this state regardless of |
|
|
whether the group policy, agreement, or contract is delivered, |
|
|
issued for delivery, or renewed in this state. |
|
|
Sec. 1371.052. REQUIRED COVERAGE FOR HAIR PROSTHESES FOR |
|
|
CERTAIN CANCER PATIENTS. (a) A health benefit plan must provide |
|
|
coverage for: |
|
|
(1) a hair prosthesis: |
|
|
(A) for an enrollee who is undergoing or has |
|
|
undergone medical treatment for cancer; and |
|
|
(B) determined by the enrollee's treating |
|
|
physician to be appropriate for the enrollee in connection with the |
|
|
side effects of the treatment described by Paragraph (A); and |
|
|
(2) repair or replacement of a hair prosthesis |
|
|
described by Subdivision (1) unless the repair or replacement is |
|
|
necessitated by misuse or loss by the enrollee. |
|
|
(b) The benefit amount for the coverage required under |
|
|
Subsection (a) must be $100 for a hair prosthesis or the repair or |
|
|
replacement of a hair prosthesis. |
|
|
(c) An additional premium may not be charged for the |
|
|
coverage required by Subsection (a). |
|
|
(d) Coverage required under Subsection (a) may be subject to |
|
|
the annual deductibles, copayments, and coinsurance that are |
|
|
consistent with annual deductibles, copayments, and coinsurance |
|
|
for other coverage under the health benefit plan. |
|
|
SECTION 7. If before implementing any provision of this Act |
|
|
a state agency determines that a waiver or authorization from a |
|
|
federal agency is necessary for implementation of that provision, |
|
|
the agency affected by the provision shall request the waiver or |
|
|
authorization and may delay implementing that provision until the |
|
|
waiver or authorization is granted. |
|
|
SECTION 8. Subchapter C, Chapter 1371, Insurance Code, as |
|
|
added by this Act, applies only to a health benefit plan that is |
|
|
delivered, issued for delivery, or renewed on or after January 1, |
|
|
2024. A health benefit plan delivered, issued for delivery, or |
|
|
renewed before January 1, 2024, 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 9. This Act takes effect September 1, 2023. |