82R5786 PMO-F
By: Castro H.B. No. 1192
A BILL TO BE ENTITLED
AN ACT
relating to the requirement and study of insurance coverage for
serious emotional disturbance of a child.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1355.001, Insurance Code, is amended by
adding Subdivision (5) to read as follows:
(5) "Serious emotional disturbance of a child" means
an emotional or behavioral disorder or a neuropsychiatric condition
that causes a person's functioning to be impaired in thought,
perception, affect, or behavior and that:
(A) has been diagnosed in a person who is at least
three years of age and younger than 17 years of age;
(B) results in behavior inappropriate to the
person's age according to expected developmental norms; and
(C) meets at least one of the following criteria:
(i) the disorder is likely to continue
without treatment;
(ii) the disorder substantially impairs the
person's ability in at least two of the following activities or
tasks:
(a) self-care;
(b) engaging in family relationships;
(c) functioning in school; or
(d) functioning in the community;
(iii) the disorder creates a risk that the
person will be removed from the person's home;
(iv) the disorder causes the person to be
removed from the person's home;
(v) the disorder causes the person to:
(a) display psychotic features or
violent behavior; or
(b) pose a danger to the person's self
or others; or
(vi) the disorder results in the person
meeting state special education eligibility requirements.
SECTION 2. The heading to Section 1355.004, Insurance Code,
is amended to read as follows:
Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS EMOTIONAL
DISTURBANCE OF A CHILD AND SERIOUS MENTAL ILLNESS.
SECTION 3. Section 1355.004, Insurance Code, is amended by
amending Subsection (a) and adding Subsections (c), (d), and (e) to
read as follows:
(a) A group health benefit plan:
(1) must provide coverage for serious emotional
disturbance of a child diagnosed as described by Section
1355.001(5) and coverage, based on medical necessity, for serious
mental illness for not less than the following treatments [of
serious mental illness] in each calendar year:
(A) 45 days of inpatient treatment; and
(B) 60 visits for outpatient treatment,
including group and individual outpatient treatment;
(2) may not include a lifetime limitation on the
number of days of inpatient treatment or the number of visits for
outpatient treatment covered under the plan; and
(3) must include the same amount limitations,
deductibles, copayments, and coinsurance factors for serious
emotional disturbance of a child and serious mental illness as the
plan includes for physical illness.
(c) The department shall conduct a study to determine and
evaluate the extent to which enrollees are making claims under
coverage for serious emotional disturbance of a child and the
impact, if any, the coverage for serious emotional disturbance of a
child and the claims have on the cost of the coverage for group
health benefit plans.
(d) Not later than August 1, 2012, the department shall
submit to the governor, the lieutenant governor, the speaker of the
house of representatives, and the appropriate standing committees
of the legislature a report regarding the results of the study
required by Subsection (c), together with any recommendations for
legislation.
(e) This subsection and Subsections (c) and (d) expire
September 1, 2013.
SECTION 4. Section 1355.054(a), Insurance Code, is amended
to read as follows:
(a) Benefits of coverage provided under this subchapter may
be used only in a situation in which:
(1) the covered individual has a serious mental
illness or serious emotional disturbance of a child that requires
confinement of the individual in a hospital unless treatment is
available through a residential treatment center for children and
adolescents or a crisis stabilization unit; and
(2) the covered individual's mental illness or
emotional disturbance:
(A) substantially impairs the individual's
thought, perception of reality, emotional process, or judgment; or
(B) as manifested by the individual's recent
disturbed behavior, grossly impairs the individual's behavior.
SECTION 5. The change in law made by this Act applies only
to a group health benefit plan that is delivered, issued for
delivery, or renewed on or after January 1, 2012. A group health
benefit plan that is delivered, issued for delivery, or renewed
before January 1, 2012, 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 6. This Act takes effect September 1, 2011.