81R3102 PB-D
By: Gallego, et al. H.B. No. 806
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for certain prosthetic
devices, orthotic devices, and related services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
by adding Chapter 1371 to read as follows:
CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC
DEVICES, AND RELATED SERVICES
Sec. 1371.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual entitled to
coverage under a health benefit plan.
(2) "Orthotic device" means a custom-fitted or
custom-fabricated medical device that is applied to a part of the
human body to correct a deformity, improve function, or relieve
symptoms of a disease.
(3) "Prosthetic device" means an artificial device
designed to replace, wholly or partly, an arm or leg.
Sec. 1371.002. 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) a reciprocal 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 Section 172.014, Local Government Code,
or any other law, this chapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(c) 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. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES,
ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit plan
must provide coverage for prosthetic devices, orthotic devices, and
professional services related to the fitting and use of those
devices that equals the coverage provided under federal laws for
health insurance for the aged and disabled under Sections 1832,
1833, and 1834, Social Security Act (42 U.S.C. Sections 1395k,
1395l, and 1395m), and 42 C.F.R. Sections 410.100, 414.202,
414.210, and 414.228, as applicable.
(b) Covered benefits under this 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 chapter unless the repair or
replacement is necessitated by misuse or loss by the enrollee.
(d) Coverage required under this section:
(1) must be provided in a manner determined to be
appropriate in consultation with the treating physician or
podiatrist and prosthetist or orthotist, as applicable, and the
enrollee;
(2) may be subject to annual deductibles, copayments,
and coinsurance that are consistent with annual deductibles,
copayments, and coinsurance required for other coverage under the
health benefit plan; and
(3) may not be subject to annual dollar limits.
(e) Covered benefits under this 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 chapter does not preclude a pharmacy from
being reimbursed by a health benefit plan for the provision of
orthotic services.
Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may
require prior authorization for a prosthetic device or an orthotic
device in the same manner that the health benefit plan requires
prior authorization for any other covered benefit.
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 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 2. 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, 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.