Texas 2009 - 81st Regular

Texas House Bill HB806 Compare Versions

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1	1	H.B. No. 806
2	2
3	3
4	4	AN ACT
5	5	relating to health benefit plan coverage for certain prosthetic
6	6	devices, orthotic devices, and related services.
7	7	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8	8	SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
9	9	by adding Chapter 1371 to read as follows:
10	10	CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC
11	11	DEVICES, AND RELATED SERVICES
12	12	Sec. 1371.001. DEFINITIONS. In this chapter:
13	13	(1) "Enrollee" means an individual entitled to
14	14	coverage under a health benefit plan.
15	15	(2) "Orthotic device" means a custom-fitted or
16	16	custom-fabricated medical device that is applied to a part of the
17	17	human body to correct a deformity, improve function, or relieve
18	18	symptoms of a disease.
19	19	(3) "Prosthetic device" means an artificial device
20	20	designed to replace, wholly or partly, an arm or leg.
21	21	Sec. 1371.002. APPLICABILITY OF CHAPTER. (a) This chapter
22	22	applies only to a health benefit plan, including a small employer
23	23	health benefit plan written under Chapter 1501 or coverage provided
24	24	by a health group cooperative under Subchapter B of that chapter,
25	25	that provides benefits for medical or surgical expenses incurred as
26	26	a result of a health condition, accident, or sickness, including an
27	27	individual, group, blanket, or franchise insurance policy or
28	28	insurance agreement, a group hospital service contract, or an
29	29	individual or group evidence of coverage or similar coverage
30	30	document that is offered by:
31	31	(1) an insurance company;
32	32	(2) a group hospital service corporation operating
33	33	under Chapter 842;
34	34	(3) a fraternal benefit society operating under
35	35	Chapter 885;
36	36	(4) a stipulated premium company operating under
37	37	Chapter 884;
38	38	(5) a reciprocal exchange operating under Chapter 942;
39	39	(6) a Lloyd's plan operating under Chapter 941;
40	40	(7) a health maintenance organization operating under
41	41	Chapter 843;
42	42	(8) a multiple employer welfare arrangement that holds
43	43	a certificate of authority under Chapter 846; or
44	44	(9) an approved nonprofit health corporation that
45	45	holds a certificate of authority under Chapter 844.
46	46	(b) Notwithstanding any provision in Chapter 1551, 1575,
47	47	1579, or 1601 or any other law, this chapter applies to:
48	48	(1) a basic coverage plan under Chapter 1551;
49	49	(2) a basic plan under Chapter 1575;
50	50	(3) a primary care coverage plan under Chapter 1579;
51	51	and
52	52	(4) basic coverage under Chapter 1601.
53	53	Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES,
54	54	ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit plan
55	55	must provide coverage for prosthetic devices, orthotic devices, and
56	56	professional services related to the fitting and use of those
57	57	devices that equals the coverage provided under federal laws for
58	58	health insurance for the aged and disabled under Sections 1832,
59	59	1833, and 1834, Social Security Act (42 U.S.C. Sections 1395k,
60	60	1395l, and 1395m), and 42 C.F.R. Sections 410.100, 414.202,
61	61	414.210, and 414.228, as applicable.
62	62	(b) Covered benefits under this chapter are limited to the
63	63	most appropriate model of prosthetic device or orthotic device that
64	64	adequately meets the medical needs of the enrollee as determined by
65	65	the enrollee's treating physician or podiatrist and prosthetist or
66	66	orthotist, as applicable.
67	67	(c) Subject to applicable copayments and deductibles, the
68	68	repair and replacement of a prosthetic device or orthotic device is
69	69	a covered benefit under this chapter unless the repair or
70	70	replacement is necessitated by misuse or loss by the enrollee.
71	71	(d) Coverage required under this section:
72	72	(1) must be provided in a manner determined to be
73	73	appropriate in consultation with the treating physician or
74	74	podiatrist and prosthetist or orthotist, as applicable, and the
75	75	enrollee;
76	76	(2) may be subject to annual deductibles, copayments,
77	77	and coinsurance that are consistent with annual deductibles,
78	78	copayments, and coinsurance required for other coverage under the
79	79	health benefit plan; and
80	80	(3) may not be subject to annual dollar limits.
81	81	(e) Covered benefits under this chapter may be provided by a
82	82	pharmacy that has employees who are qualified under the Medicare
83	83	system and applicable Medicaid regulations to service and bill for
84	84	orthotic services. This chapter does not preclude a pharmacy from
85	85	being reimbursed by a health benefit plan for the provision of
86	86	orthotic services.
87	87	Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may
88	88	require prior authorization for a prosthetic device or an orthotic
89	89	device in the same manner that the health benefit plan requires
90	90	prior authorization for any other covered benefit.
91	91	Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan
92	92	provider may require that, if coverage is provided through a
93	93	managed care plan, the benefits mandated under this chapter are
94	94	covered benefits only if the prosthetic devices or orthotic devices
95	95	are provided by a vendor or a provider, and related services are
96	96	rendered by a provider, that contracts with or is designated by the
97	97	health benefit plan provider. If the health benefit plan provider
98	98	provides in-network and out-of-network services, the coverage for
99	99	prosthetic devices or orthotic devices provided through
100	100	out-of-network services must be comparable to that provided through
101	101	in-network services.
102	102	SECTION 2. Chapter 1371, Insurance Code, as added by this
103	103	Act, applies only to a health benefit plan that is delivered,
104	104	issued for delivery, or renewed on or after January 1, 2010. A
105	105	health benefit plan that is delivered, issued for delivery, or
106	106	renewed before January 1, 2010, is covered by the law in effect at
107	107	the time the plan was delivered, issued for delivery, or renewed,
108	108	and that law is continued in effect for that purpose.
109	109	SECTION 3. This Act takes effect September 1, 2009.
110	110	______________________________ ______________________________
111	111	President of the Senate Speaker of the House
112	112	I certify that H.B. No. 806 was passed by the House on April
113	113	2, 2009, by the following vote: Yeas 105, Nays 35, 1 present, not
114	114	voting; and that the House concurred in Senate amendments to H.B.
115	115	No. 806 on May 4, 2009, by the following vote: Yeas 140, Nays 0, 1
116	116	present, not voting.
117	117	______________________________
118	118	Chief Clerk of the House
119	119	I certify that H.B. No. 806 was passed by the Senate, with
120	120	amendments, on April 30, 2009, by the following vote: Yeas 31,
121	121	Nays 0.
122	122	______________________________
123	123	Secretary of the Senate
124	124	APPROVED: __________________
125	125	Date
126	126	__________________
127	127	Governor