88R22336 RDS-F

By: Gervin-Hawkins, Lalani, Campos, Garcia, H.B. No. 1164

et al.

A BILL TO BE ENTITLED

AN ACT

relating to health benefit plan coverage for hair prostheses for breast 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 BREAST 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 subchapter 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) group health coverage made available by a school district in accordance with Section 22.004, Education Code;

(5) the state Medicaid program, including the Medicaid managed care program operated under Chapter 533, Government Code;

(6) the child health plan program under Chapter 62, Health and Safety Code;

(7) a regional or local health care program operated under Section 75.104, Health and Safety Code; and

(8) a self-funded health benefit plan sponsored by a professional employer organization under Chapter 91, Labor Code.

(c) This subchapter 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 breast 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 not less than $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.