2009S0680-1 03/11/09
By: Uresti S.B. No. 2076
A BILL TO BE ENTITLED
AN ACT
relating to health insurance coverage for diagnosis and treatment
of conditions affecting the temporomandibular joint.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Sections 1360.002, 1360.003, 1360.004, and
1360.005, Insurance Code, are amended to read as follows:
Sec. 1360.002. APPLICABILITY OF CHAPTER. (a) Except as
provided by Subsection (b), this [This] chapter applies [only] to a
group health benefit plan delivered or issued for delivery in this
state that:
(1) provides benefits for dental, medical, or surgical
expenses incurred as a result of a health condition, accident, or
sickness, including:
(A) a group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or a group evidence of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation
operating under Chapter 842;
(iii) a fraternal benefit society operating
under Chapter 885;
(iv) a stipulated premium company operating
under Chapter 884; or
(v) a health maintenance organization
operating under Chapter 843; and
(B) to the extent permitted by the Employee
Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
seq.), a health benefit plan that is offered by:
(i) a multiple employer welfare arrangement
as defined by Section 3 of that Act;
(ii) an entity not authorized under this
code or another insurance law of this state that contracts directly
for health care services on a risk-sharing basis, including a
capitation basis; or
(iii) another analogous benefit
arrangement; or
(2) is offered by an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844.
(b) This chapter applies to an individual insurance policy
delivered or issued for delivery in this state that provides
benefits for dental, medical, or surgical expenses incurred as a
result of a health condition, accident, or sickness.
Sec. 1360.003. EXCEPTION. This chapter does not apply to:
(1) a plan or policy that provides coverage:
(A) only for a specified disease or another
limited benefit;
(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) for credit insurance;
(F) only for vision care; or
(G) 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) a small employer health benefit plan written under
Chapter 1501;
(5) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(6) 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 1360.002.
Sec. 1360.004. COVERAGE REQUIRED. (a) A health benefit
plan or individual insurance policy that provides coverage for
medically necessary diagnostic or surgical treatment of conditions
affecting skeletal joints must provide comparable coverage for
diagnostic or surgical treatment of conditions affecting the
temporomandibular joint if the treatment is medically necessary as
a result of:
(1) an accident;
(2) a trauma;
(3) a congenital defect;
(4) a developmental defect; or
(5) a pathology.
(b) Coverage required under this section may be subject to
any provision in the health benefit plan or individual insurance
policy that is generally applicable to surgical treatment,
including a requirement for precertification of coverage.
Sec. 1360.005. DENTAL SERVICES COVERAGE NOT REQUIRED.
(a) This chapter does not require a health benefit plan or
individual insurance policy to provide coverage for dental services
if dental services are not otherwise scheduled or provided as part
of the coverage provided under the plan.
(b) A health benefit plan or individual insurance policy may
not exclude from coverage under the plan or policy an individual who
is unable to undergo dental treatment in an office setting or under
local anesthesia due to a documented physical, mental, or medical
reason as determined by the individual's physician or by the
dentist providing the dental care.
SECTION 2. This Act applies only to an insurance policy that
is delivered, issued for delivery, or renewed on or after January 1,
2010. A policy delivered, issued for delivery, or renewed before
January 1, 2010, is governed by the law as it existed immediately
before the effective date of this Act, and that law is continued in
effect for that purpose.
SECTION 3. This Act takes effect September 1, 2009.