Texas 2009 - 81st Regular

Texas House Bill HB844 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	81R151 PB-F
2	2	By: Martinez H.B. No. 844
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 prosthetic
8	8	devices, orthotic devices, and related services.
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 1371 to read as follows:
12	12	CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC
13	13	DEVICES, AND RELATED SERVICES
14	14	Sec. 1371.001. DEFINITIONS. In this chapter:
15	15	(1) "Enrollee" means an individual entitled to
16	16	coverage under a health benefit plan.
17	17	(2) "Orthotic device" means a custom-fitted or
18	18	custom-fabricated medical device that is applied to a part of the
19	19	human body to correct a deformity, improve function, or relieve
20	20	symptoms of a disease.
21	21	(3) "Prosthetic device" means an artificial device
22	22	designed to replace, wholly or partly, an arm or leg.
23	23	Sec. 1371.002. APPLICABILITY OF CHAPTER. (a) This chapter
24	24	applies only to a health benefit plan, including a small employer
25	25	health benefit plan written under Chapter 1501 or coverage provided
26	26	by a health group cooperative under Subchapter B of that chapter,
27	27	that provides benefits for medical or surgical expenses incurred as
28	28	a result of a health condition, accident, or sickness, including an
29	29	individual, group, blanket, or franchise insurance policy or
30	30	insurance agreement, a group hospital service contract, or an
31	31	individual or group evidence of coverage or similar coverage
32	32	document that is offered by:
33	33	(1) an insurance company;
34	34	(2) a group hospital service corporation operating
35	35	under Chapter 842;
36	36	(3) a fraternal benefit society operating under
37	37	Chapter 885;
38	38	(4) a stipulated premium company operating under
39	39	Chapter 884;
40	40	(5) an exchange operating under Chapter 942;
41	41	(6) a Lloyd's plan operating under Chapter 941;
42	42	(7) a health maintenance organization operating under
43	43	Chapter 843;
44	44	(8) a multiple employer welfare arrangement that holds
45	45	a certificate of authority under Chapter 846; or
46	46	(9) an approved nonprofit health corporation that
47	47	holds a certificate of authority under Chapter 844.
48	48	(b) Notwithstanding Section 172.014, Local Government Code,
49	49	or any other law, this chapter applies to health and accident
50	50	coverage provided by a risk pool created under Chapter 172, Local
51	51	Government Code.
52	52	(c) Notwithstanding any provision in Chapter 1551, 1575,
53	53	1579, or 1601 or any other law, this chapter applies to:
54	54	(1) a basic coverage plan under Chapter 1551;
55	55	(2) a basic plan under Chapter 1575;
56	56	(3) a primary care coverage plan under Chapter 1579;
57	57	and
58	58	(4) basic coverage under Chapter 1601.
59	59	(d) Notwithstanding any other law, a standard health
60	60	benefit plan provided under Chapter 1507 must provide the coverage
61	61	required by this chapter.
62	62	Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES,
63	63	ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit plan
64	64	must provide coverage for prosthetic devices, orthotic devices, and
65	65	professional services related to the fitting and use of those
66	66	devices that equals the coverage provided under federal laws for
67	67	health insurance for the aged and disabled under Sections 1832,
68	68	1833, and 1834, Social Security Act (42 U.S.C. Sections 1395k,
69	69	1395l, and 1395m), and 42 C.F.R. Sections 410.100, 414.202,
70	70	414.210, and 414.228, as applicable.
71	71	(b) Covered benefits under this chapter are limited to the
72	72	most appropriate model of prosthetic device or orthotic device that
73	73	adequately meets the medical needs of the enrollee as determined by
74	74	the enrollee's treating physician and prosthetist or orthotist, as
75	75	applicable.
76	76	(c) Coverage required under this section:
77	77	(1) must be provided in a manner determined to be
78	78	appropriate in consultation with the treating physician and
79	79	prosthetist or orthotist, as applicable, and the enrollee;
80	80	(2) may be subject to annual deductibles, copayments,
81	81	and coinsurance that are consistent with annual deductibles,
82	82	copayments, and coinsurance required for other coverage under the
83	83	health benefit plan; and
84	84	(3) may not be subject to annual dollar limits.
85	85	Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may
86	86	require prior authorization for a prosthetic device or an orthotic
87	87	device in the same manner that the health benefit plan requires
88	88	prior authorization for any other covered benefit.
89	89	Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan
90	90	provider may require that, if coverage is provided through a
91	91	managed care plan, the benefits mandated under this chapter are
92	92	covered benefits only if the prosthetic devices or orthotic devices
93	93	are provided by a vendor, and related services are rendered by a
94	94	provider, that contracts with or is designated by the health
95	95	benefit plan provider. If the health benefit plan provider
96	96	provides in-network and out-of-network services, the coverage for
97	97	prosthetic devices or orthotic devices provided through
98	98	out-of-network services must be comparable to that provided through
99	99	in-network services.
100	100	SECTION 2. Chapter 1371, Insurance Code, as added by this
101	101	Act, applies only to a health benefit plan that is delivered,
102	102	issued for delivery, or renewed on or after January 1, 2010. A
103	103	health benefit plan that is delivered, issued for delivery, or
104	104	renewed before January 1, 2010, is covered by the law in effect at
105	105	the time the plan was delivered, issued for delivery, or renewed,
106	106	and that law is continued in effect for that purpose.
107	107	SECTION 3. This Act takes effect September 1, 2009.