SB 35 Comments?

[Guest guest]

This senate bill was filed on Monday (7/7/03), just wanted to pick

y'alls brains about it:

By: Lucio

S.B. No. 35

A BILL TO BE ENTITLED

AN ACT

relating to health benefit plan coverage for an enrollee with

autism or a pervasive developmental disorder.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF

TEXAS:

SECTION 1. Subchapter E, Chapter 21, Insurance Code, is

amended by adding Article 21.53X to read as follows:

Art. 21.53X. INDIVIDUAL HEALTH BENEFIT PLAN COVERAGE FOR

ENROLLEE WITH AUTISM OR PERVASIVE DEVELOPMENTAL DISORDER

Sec. 1. DEFINITION. In this article, " enrollee " means an

individual who is enrolled in a health benefit plan, including a

covered dependent.

Sec. 2. APPLICABILITY OF ARTICLE. (a) This article

applies only 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

insurance policy or insurance agreement, an individual evidence of

coverage, or similar coverage document that is offered by:

(1) an insurance

company;

(2) a group hospital service corporation operating

under Chapter 842 of this code;

(3) a fraternal benefit society operating under

Chapter 885 of this code;

(4) a stipulated premium insurance company

operating

under Chapter 884 of this code;

(5) a reciprocal exchange operating under Chapter

942

of this code;

(6) a Lloyd's plan operating under Chapter 941 of

this

code;

(7) a health maintenance organization operating

under

Chapter 843 of this code;

(8) a multiple employer welfare arrangement that

holds

a certificate of authority under Chapter 846 of this code; or

(9) an approved nonprofit health corporation that

holds a certificate of authority under Chapter 844 of this code.

( Notwithstanding Section 172.014, Local Government Code,

or any other law, this article applies to health and accident

coverage provided by a risk pool created under Chapter 172, Local

Government Code.

© This article does not apply

to:

(1) a plan that provides

coverage:

(A) only for benefits for a specified

disease or

for another limited benefit, other than a plan that provides

benefits for mental health or similar services;

( only for accidental death or

dismemberment;

© for wages or payments in lieu of wages

for a

period during which an employee is absent from work because of

sickness or injury;

(D) as a supplement to a liability

insurance

policy;

(E) only for dental or vision care;

or

(F) only for indemnity for hospital

confinement;

(2) a small employer health benefit plan written

under

Chapter 26 of this code;

(3) a Medicare supplemental policy as defined by

Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),

as amended;

(4) a workers' compensation insurance

policy;

(5) medical payment insurance coverage provided

under

a motor vehicle insurance policy; or

(6) a long-term care insurance policy, including a

nursing home fixed indemnity policy, unless the commissioner

determines that the policy provides benefit coverage so

comprehensive that the policy is a health benefit plan as described

by Subsection (a) of this section.

Sec. 3. EXCLUSION OF COVERAGE AND DENIAL OF BENEFITS

PROHIBITED. A health benefit plan may not exclude coverage or deny

benefits otherwise available to an enrollee for treatment,

equipment, or therapy based on the enrollee's having autism or a

pervasive developmental disorder.

Sec. 4. RULES. The commissioner shall adopt rules as

necessary to administer this article.

SECTION 2. Subdivision (1), Section 1, Article 3.51-14,

Insurance Code, is amended to read as follows:

(1) " Serious mental illness " means the following

psychiatric illnesses as defined by the American Psychiatric

Association in the Diagnostic and Statistical Manual (DSM):

(A)

schizophrenia;

( paranoid and other psychotic

disorders;

© bipolar disorders (hypomanic, manic,

depressive, and mixed);

(D) major depressive disorders (single

episode

or recurrent);

(E) schizo-affective disorders (bipolar or

depressive);

(F) pervasive developmental disorders,

including

autism;

(G) obsessive-compulsive disorders;

and

(H) depression in childhood and

adolescence.

SECTION 3. Section 2, Article 3.51-14, Insurance Code, is

amended to read as follows:

Sec. 2. SCOPE OF ARTICLE. (a) This article applies only

to

a group health benefit plan that provides benefits for medical or

surgical expenses incurred as a result of a health condition,

accident, or sickness, including:

(1) a group, blanket, or franchise insurance policy

or

insurance agreement, a group hospital service contract, or a group

evidence of coverage that is offered by:

(A) an insurance

company;

( a group hospital service corporation

operating under Chapter 20 of this code;

© a health maintenance organization

operating

under the Texas Health Maintenance Organization Act (Chapter 20A,

Vernon's Texas Insurance Code);

(D) a fraternal benefit society operating

under

Chapter 10 of this code; [or]

(E) a stipulated premium insurance company

operating under Chapter 22 of this code;

(F) a reciprocal exchange operating under

Chapter 942 of this code;

(G) a Lloyd's plan operating under Chapter

941 of

this code; or

(H) an approved nonprofit health

corporation

that holds a certificate of authority under Chapter 844 of this

code; and

(2) to the extent permitted by the Employee

Retirement

Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a

group health benefit plan that is offered under:

(A) a multiple employer welfare arrangement

as

defined by Section 3, Employee Retirement Income Security Act of

1974 (29 U.S.C. Section 1002); or

( another analogous benefit

arrangement.

( This article does not apply to coverage

under:

(1) [a blanket accident and health insurance policy

as

that term is defined under Section 2, Article 3.51-6, of this code;

[(2)] a short-term travel

policy;

(2) [(3)] an accident-only

policy;

(3) [(4)] a limited or specified-disease policy,

other than a plan that provides benefits for mental health care or

similar services;

(4) [(5)] with the exception of Section 1 of this

article which shall apply, a plan offered under the Texas Employees

Uniform Group Insurance Benefits Act (Article 3.50-2, Vernon's

Texas Insurance Code) or the Texas State College and University

Employees Uniform Insurance Benefits Act (Article 3.50-3, Vernon's

Texas Insurance Code);

(5) [(6)] a plan offered under or in accordance

with

Article 3.51-5A of this code; or

(6) [(7)] a medicare supplement policy, as that

term

is defined under Section 1((3), Article 3.74, of this code.

SECTION 4. Subsection (a), Section 3, Article 3.51-14,

Insurance Code, is amended to read as follows:

(a) Except as provided by Section 4 of this article, a

group

health benefit plan:

(1) must provide coverage, based on medical

necessity,

for the following treatment of serious mental illness in each

calendar year:

(A) 45 days of inpatient treatment;

and

( 60 visits for outpatient treatment,

including group and individual outpatient treatment;

(2) may not include a lifetime limit on the number

of

days of inpatient treatment or the number of outpatient visits

covered under the plan; [and]

(3) must include equipment and therapy in the

coverage

of treatment of pervasive developmental disorder; and

(4) must include the same amount limits,

deductibles,

copayments, and coinsurance factors for serious mental illness as

for physical illness.

SECTION 5. Article 3.51-14, Insurance Code, is amended by

adding Section 6 to read as follows:

Sec. 6. RULES. The commissioner shall adopt rules as

necessary to administer this article.

SECTION 6. This Act takes effect September 1, 2003, and

applies only to a health benefit plan delivered, issued for

delivery, or renewed on or after January 1, 2004. A health benefit

plan delivered, issued for delivery, or renewed before January 1,

2004, 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.