Texas 2009 - 81st Regular

Texas House Bill HB2000 Compare Versions

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1	1	81R5854 PB-F
2	2	By: McCall H.B. No. 2000
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage for certain amino
8	8	acid-based elemental formulas.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
11	11	by adding Chapter 1377 to read as follows:
12	12	CHAPTER 1377. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL
13	13	FORMULAS
14	14	SUBCHAPTER A. GENERAL PROVISIONS
15	15	Sec. 1377.001. DEFINITION. In this chapter, "enrollee"
16	16	means an individual entitled to coverage under a health benefit
17	17	plan.
18	18	Sec. 1377.002. APPLICABILITY OF CHAPTER. (a) This chapter
19	19	applies only to a health benefit plan, including a small employer
20	20	health benefit plan written under Chapter 1501 or coverage provided
21	21	by a health group cooperative under Subchapter B of that chapter,
22	22	that provides benefits for medical or surgical expenses incurred as
23	23	a result of a health condition, accident, or sickness, including an
24	24	individual, group, blanket, or franchise insurance policy or
25	25	insurance agreement, a group hospital service contract, or an
26	26	individual or group evidence of coverage or similar coverage
27	27	document that is offered by:
28	28	(1) an insurance company;
29	29	(2) a group hospital service corporation operating
30	30	under Chapter 842;
31	31	(3) a fraternal benefit society operating under
32	32	Chapter 885;
33	33	(4) a stipulated premium company operating under
34	34	Chapter 884;
35	35	(5) an exchange operating under Chapter 942;
36	36	(6) a Lloyd's plan operating under Chapter 941;
37	37	(7) a health maintenance organization operating under
38	38	Chapter 843;
39	39	(8) a multiple employer welfare arrangement that holds
40	40	a certificate of authority under Chapter 846; or
41	41	(9) an approved nonprofit health corporation that
42	42	holds a certificate of authority under Chapter 844.
43	43	(b) Notwithstanding Section 172.014, Local Government Code,
44	44	or any other law, this chapter applies to health and accident
45	45	coverage provided by a risk pool created under Chapter 172, Local
46	46	Government Code.
47	47	(c) Notwithstanding any provision in Chapter 1551, 1575,
48	48	1579, or 1601 or any other law, this chapter applies to:
49	49	(1) a basic coverage plan under Chapter 1551;
50	50	(2) a basic plan under Chapter 1575;
51	51	(3) a primary care coverage plan under Chapter 1579;
52	52	and
53	53	(4) basic coverage under Chapter 1601.
54	54	(d) Notwithstanding any other law, a standard health
55	55	benefit plan provided under Chapter 1507 must provide the coverage
56	56	required by this chapter.
57	57	Sec. 1377.003. EXCEPTION. This chapter does not apply to:
58	58	(1) a plan that provides coverage:
59	59	(A) only for benefits for a specified disease or
60	60	for another limited benefit, other than a plan that provides
61	61	benefits for a disease or disorder listed in Section 1377.051(a);
62	62	(B) only for accidental death or dismemberment;
63	63	(C) for wages or payments in lieu of wages for a
64	64	period during which an employee is absent from work because of
65	65	sickness or injury;
66	66	(D) as a supplement to a liability insurance
67	67	policy;
68	68	(E) only for dental or vision care; or
69	69	(F) only for indemnity for hospital confinement;
70	70	(2) a Medicare supplemental policy as defined by
71	71	Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
72	72	(3) a workers' compensation insurance policy;
73	73	(4) medical payment insurance coverage provided under
74	74	an automobile insurance policy;
75	75	(5) a credit insurance policy;
76	76	(6) a limited benefit policy that does not provide
77	77	coverage for physical examinations or wellness exams; or
78	78	(7) a long-term care insurance policy, including a
79	79	nursing home fixed indemnity policy, unless the commissioner
80	80	determines that the policy provides benefit coverage so
81	81	comprehensive that the policy is a health benefit plan as described
82	82	by Section 1377.002.
83	83	[Sections 1377.004-1377.050 reserved for expansion]
84	84	SUBCHAPTER B. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL
85	85	FORMULAS
86	86	Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN AMINO
87	87	ACID-BASED ELEMENTAL FORMULAS. (a) A health benefit plan must
88	88	provide coverage as provided by this chapter for amino acid-based
89	89	elemental formulas, regardless of the formula delivery method, that
90	90	are used for the diagnosis and treatment of:
91	91	(1) immunoglobulin E and non-immunoglobulin E
92	92	mediated allergies to multiple food proteins;
93	93	(2) severe food protein-induced enterocolitis
94	94	syndrome;
95	95	(3) eosinophilic disorders, as evidenced by the
96	96	results of a biopsy; and
97	97	(4) impaired absorption of nutrients caused by
98	98	disorders affecting the absorptive surface, functional length, and
99	99	motility of the gastrointestinal tract.
100	100	(b) Subject to Subsection (c), the coverage required under
101	101	Subsection (a) is required if the treating physician has issued a
102	102	written order stating that the amino acid-based elemental formula
103	103	is medically necessary for the treatment of an enrollee who is
104	104	diagnosed with a disease or disorder listed in Subsection (a). The
105	105	coverage must include coverage of any medically necessary services
106	106	associated with the administration of the formula.
107	107	(c) A health benefit plan must provide the coverage
108	108	described by Subsection (a) on a basis no less favorable than the
109	109	basis on which prescription drugs and other medications and related
110	110	services are covered by the plan, and to the same extent that the
111	111	plan provides coverage for drugs that are available only on the
112	112	orders of a physician.
113	113	Sec. 1377.052. UTILIZATION REVIEW. (a) A utilization review
114	114	agent acting on behalf of a health benefit plan issuer may review a
115	115	treating physician's determination of the medical necessity of the
116	116	use of an amino acid-based elemental formula for the treatment of an
117	117	enrollee who is diagnosed with a disease or disorder listed in
118	118	Section 1377.051(a).
119	119	(b) Utilization review under this section is subject to
120	120	Chapter 4201.
121	121	SECTION 2. Chapter 1377, Insurance Code, as added by this
122	122	Act, applies only to a health benefit plan that is delivered, issued
123	123	for delivery, or renewed on or after January 1, 2010. A health
124	124	benefit plan that is delivered, issued for delivery, or renewed
125	125	before January 1, 2010, is covered by the law in effect at the time
126	126	the plan was delivered, issued for delivery, or renewed, and that
127	127	law is continued in effect for that purpose.
128	128	SECTION 3. This Act takes effect September 1, 2009.