Texas 2009 - 81st Regular

Texas Senate Bill SB39 Compare Versions

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Old	New	Differences
1	1	81R97 DLF-D
2	2	By: Zaffirini, Van de Putte S.B. No. 39
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan coverage for routine patient care
8	8	costs for enrollees participating in certain clinical trials.
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 1379 to read as follows:
12	12	CHAPTER 1379. COVERAGE FOR ROUTINE PATIENT CARE COSTS FOR
13	13	ENROLLEES PARTICIPATING IN CERTAIN CLINICAL TRIALS
14	14	SUBCHAPTER A. GENERAL PROVISIONS
15	15	Sec. 1379.001. DEFINITIONS. In this chapter:
16	16	(1) "Enrollee" means an individual entitled to
17	17	coverage under a health benefit plan.
18	18	(2) "Life-threatening disease or condition" means a
19	19	disease or condition from which the likelihood of death is probable
20	20	unless the course of the disease or condition is interrupted.
21	21	(3) "Research institution" means the institution or
22	22	other person or entity conducting a phase I, phase II, phase III, or
23	23	phase IV clinical trial.
24	24	Sec. 1379.002. APPLICABILITY OF CHAPTER. (a) This chapter
25	25	applies only to a health benefit plan that provides benefits for
26	26	medical or surgical expenses incurred as a result of a health
27	27	condition, accident, or sickness, including an individual, group,
28	28	blanket, or franchise insurance policy or insurance agreement, a
29	29	group hospital service contract, or an individual or group evidence
30	30	of coverage or similar coverage 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) an exchange operating under Chapter 942;
39	39	(6) a health maintenance organization operating under
40	40	Chapter 843;
41	41	(7) a multiple employer welfare arrangement that holds
42	42	a certificate of authority under Chapter 846; or
43	43	(8) an approved nonprofit health corporation that
44	44	holds a certificate of authority under Chapter 844.
45	45	(b) This chapter applies to group health coverage made
46	46	available by a school district in accordance with Section 22.004,
47	47	Education Code.
48	48	(c) 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	(d) 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	(e) Notwithstanding Section 1501.251 or any other law, this
60	60	chapter applies to coverage under a small employer health benefit
61	61	plan subject to Chapter 1501.
62	62	Sec. 1379.003. APPLICABILITY TO CERTAIN GOVERNMENT
63	63	PROGRAMS. To the extent allowed by federal law, the state Medicaid
64	64	program, and a managed care organization that contracts with the
65	65	Health and Human Services Commission to provide health care
66	66	services to Medicaid recipients through a managed care plan, shall
67	67	provide the benefits required under this chapter to a Medicaid
68	68	recipient.
69	69	Sec. 1379.004. EXCEPTION. This chapter does not apply to:
70	70	(1) a plan that provides coverage:
71	71	(A) for wages or payments in lieu of wages for a
72	72	period during which an employee is absent from work because of
73	73	sickness or injury;
74	74	(B) as a supplement to a liability insurance
75	75	policy;
76	76	(C) for credit insurance;
77	77	(D) only for dental or vision care;
78	78	(E) only for hospital expenses; or
79	79	(F) only for indemnity for hospital confinement;
80	80	(2) a Medicare supplemental policy as defined by
81	81	Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
82	82	(3) a workers' compensation insurance policy;
83	83	(4) medical payment insurance coverage provided under
84	84	a motor vehicle insurance policy; or
85	85	(5) a long-term care policy, including a nursing home
86	86	fixed indemnity policy, unless the commissioner determines that the
87	87	policy provides benefit coverage so comprehensive that the policy
88	88	is a health benefit plan as described by Section 1379.002.
89	89	Sec. 1379.005. RULES. The commissioner, in accordance with
90	90	Subchapter A, Chapter 36, may adopt rules to implement this
91	91	chapter.
92	92	[Sections 1379.006-1379.050 reserved for expansion]
93	93	SUBCHAPTER B. COVERAGE FOR ROUTINE PATIENT CARE COSTS
94	94	Sec. 1379.051. ROUTINE PATIENT CARE COSTS. For purposes of
95	95	this chapter, routine patient care costs means the costs of any
96	96	medically necessary health care service for which benefits are
97	97	provided under a health benefit plan, without regard to whether the
98	98	enrollee is participating in a clinical trial. Routine patient
99	99	care costs do not include:
100	100	(1) the cost of an investigational new drug or device
101	101	that is not approved for any indication by the United States Food
102	102	and Drug Administration, including a drug or device that is the
103	103	subject of the clinical trial;
104	104	(2) the cost of a service that is not a health care
105	105	service, regardless of whether the service is required in
106	106	connection with participation in a clinical trial;
107	107	(3) the cost of a service that is clearly inconsistent
108	108	with widely accepted and established standards of care for a
109	109	particular diagnosis;
110	110	(4) a cost associated with managing a clinical trial;
111	111	or
112	112	(5) the cost of a health care service that is
113	113	specifically excluded from coverage under a health benefit plan.
114	114	Sec. 1379.052. COVERAGE REQUIRED. A health benefit plan
115	115	issuer shall provide benefits for routine patient care costs to an
116	116	enrollee in connection with a phase I, phase II, phase III, or phase
117	117	IV clinical trial if the clinical trial is conducted in relation to
118	118	the prevention, detection, or treatment of a life-threatening
119	119	disease or condition and is approved by:
120	120	(1) the Centers for Disease Control and Prevention of
121	121	the United States Department of Health and Human Services;
122	122	(2) the National Institutes of Health;
123	123	(3) the United States Food and Drug Administration;
124	124	(4) the United States Department of Defense;
125	125	(5) the United States Department of Veterans Affairs;
126	126	or
127	127	(6) an institutional review board of an institution in
128	128	this state that has an agreement with the Office for Human Research
129	129	Protections of the United States Department of Health and Human
130	130	Services.
131	131	Sec. 1379.053. RESEARCH INSTITUTION. (a) A health benefit
132	132	plan issuer is not required to reimburse the research institution
133	133	conducting the clinical trial for the cost of routine patient care
134	134	provided through the research institution unless the research
135	135	institution, and each health care professional providing routine
136	136	patient care through the research institution, agrees to accept
137	137	reimbursement under the health benefit plan, at the rates that are
138	138	established under the plan, as payment in full for the routine
139	139	patient care provided in connection with the clinical trial.
140	140	(b) A health benefit plan issuer is not required to provide
141	141	benefits under this section for services that are a part of the
142	142	subject matter of the clinical trial and that are customarily paid
143	143	for by the research institution conducting the clinical trial.
144	144	Sec. 1379.054. LIMITATIONS ON COVERAGE. (a)
145	145	Notwithstanding Section 1379.053, this chapter does not require a
146	146	health benefit plan issuer to provide benefits for routine patient
147	147	care services provided outside of the plan's health care provider
148	148	network unless out-of-network benefits are otherwise provided
149	149	under the plan.
150	150	(b) This chapter does not require a health benefit plan
151	151	issuer to provide benefits for health care services provided
152	152	outside this state unless the health benefit plan otherwise
153	153	provides benefits for health care services provided outside this
154	154	state.
155	155	Sec. 1379.055. DEDUCTIBLE, COINSURANCE, AND COPAYMENT
156	156	REQUIREMENTS. The benefits required under this chapter may be made
157	157	subject to a deductible, coinsurance, or copayment requirement
158	158	comparable to other deductible, coinsurance, or copayment
159	159	requirements applicable under the health benefit plan.
160	160	Sec. 1379.056. CANCELLATION OR NONRENEWAL PROHIBITED. The
161	161	issuer of a health benefit plan may not cancel or refuse to renew
162	162	coverage under a plan solely because an enrollee in the plan
163	163	participates in a clinical trial described by Section 1379.052.
164	164	SECTION 2. Section 1506.151, Insurance Code, is amended by
165	165	adding Subsection (d) to read as follows:
166	166	(d) Coverage provided by the pool is subject to Chapter
167	167	1379.
168	168	SECTION 3. This Act applies only to a health benefit plan
169	169	that is delivered, issued for delivery, or renewed on or after
170	170	January 1, 2010. A health benefit plan that is delivered, issued
171	171	for delivery, or renewed before January 1, 2010, is governed by the
172	172	law as it existed immediately before the effective date of this Act,
173	173	and that law is continued in effect for that purpose.
174	174	SECTION 4. This Act takes effect September 1, 2009.