By: McCall (Senate Sponsor - Van de Putte) H.B. No. 2000
(In the Senate - Received from the House May 15, 2009;
May 18, 2009, read first time and referred to Committee on State
Affairs; May 23, 2009, reported favorably by the following vote:
Yeas 8, Nays 0; May 23, 2009, sent to printer.)
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for certain amino
acid-based elemental formulas.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
by adding Chapter 1377 to read as follows:
CHAPTER 1377. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL
FORMULAS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1377.001. DEFINITION. In this chapter, "enrollee"
means an individual entitled to coverage under a health benefit
plan.
Sec. 1377.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including a small employer
health benefit plan written under Chapter 1501 or coverage provided
by a health group cooperative under Subchapter B of that chapter,
that provides benefits for medical or surgical expenses incurred as
a result of a health condition, accident, or sickness, including an
individual, group, blanket, or franchise insurance policy or
insurance agreement, a group hospital service contract, or an
individual or group 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;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) an exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under
Chapter 843;
(8) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
Sec. 1377.003. EXCEPTION. This chapter 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 a disease or disorder listed in Section 1377.051(a);
(B) only for accidental death or dismemberment;
(C) 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 Medicare supplemental policy as defined by
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
an automobile insurance policy;
(5) a credit insurance policy;
(6) a limited benefit policy that does not provide
coverage for physical examinations or wellness exams; or
(7) 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 Section 1377.002.
[Sections 1377.004-1377.050 reserved for expansion]
SUBCHAPTER B. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL
FORMULAS
Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN AMINO
ACID-BASED ELEMENTAL FORMULAS. (a) A health benefit plan must
provide coverage as provided by this chapter for amino acid-based
elemental formulas, regardless of the formula delivery method, that
are used for the diagnosis and treatment of:
(1) immunoglobulin E and non-immunoglobulin E
mediated allergies to multiple food proteins;
(2) severe food protein-induced enterocolitis
syndrome;
(3) eosinophilic disorders, as evidenced by the
results of a biopsy; and
(4) impaired absorption of nutrients caused by
disorders affecting the absorptive surface, functional length, and
motility of the gastrointestinal tract.
(b) Subject to Subsection (c), the coverage required under
Subsection (a) is required if the treating physician has issued a
written order stating that the amino acid-based elemental formula
is medically necessary for the treatment of an enrollee who is
diagnosed with a disease or disorder listed in Subsection (a). The
coverage must include coverage of any medically necessary services
associated with the administration of the formula.
(c) A health benefit plan must provide the coverage
described by Subsection (a) on a basis no less favorable than the
basis on which prescription drugs and other medications and related
services are covered by the plan, and to the same extent that the
plan provides coverage for drugs that are available only on the
orders of a physician.
Sec. 1377.052. UTILIZATION REVIEW. (a) A utilization review
agent acting on behalf of a health benefit plan issuer may review a
treating physician's determination of the medical necessity of the
use of an amino acid-based elemental formula for the treatment of an
enrollee who is diagnosed with a disease or disorder listed in
Section 1377.051(a).
(b) Utilization review under this section is subject to
Chapter 4201.
SECTION 2. Chapter 1377, 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, 2010. A health
benefit plan that is delivered, issued for delivery, or renewed
before January 1, 2010, is covered by the law in effect at the time
the plan was delivered, issued for delivery, or renewed, and that
law is continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2009.
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