82R8107 PMO-D
By: Coleman H.B. No. 2300
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for an enrollee with
certain mental disorders.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. AMENDMENTS TO SUBCHAPTER A, CHAPTER 1355,
INSURANCE CODE
SECTION 1.01. Subchapter A, Chapter 1355, Insurance Code,
is amended to read as follows:
SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR
CERTAIN [SERIOUS] MENTAL [ILLNESSES AND OTHER] DISORDERS
Sec. 1355.001. DEFINITIONS. In this subchapter:
(1) "Mental disorder" ["Serious mental illness"]
means a disorder [the following psychiatric illnesses] as defined
by the American Psychiatric Association in the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition, or in a
subsequent edition of that manual that the commissioner adopts to
take the place of the fourth edition or any subsequent edition for
the purposes of this subdivision, that results in an impairment of a
person's functioning in the person's community, employment, family,
school, or social group [(DSM):
[(A) bipolar disorders (hypomanic, manic,
depressive, and mixed);
[(B) depression in childhood and adolescence;
[(C) major depressive disorders (single episode
or recurrent);
[(D) obsessive-compulsive disorders;
[(E) paranoid and other psychotic disorders;
[(F) schizo-affective disorders (bipolar or
depressive); and
[(G) schizophrenia].
(2) ["Small employer" has the meaning assigned by
Section 1501.002.
[(3)] "Autism spectrum disorder" means a
neurobiological disorder that includes autism, Asperger's
syndrome, or Pervasive Developmental Disorder--Not Otherwise
Specified.
[(4) "Neurobiological disorder" means an illness of
the nervous system caused by genetic, metabolic, or other
biological factors.]
Sec. 1355.002. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to a [group] health benefit plan that
provides benefits for medical or surgical expenses incurred as a
result of a health condition, accident, or sickness, including an
individual,[:
[(1) a] group, blanket, or franchise insurance policy
or[, group] insurance agreement, a group hospital service contract,
an individual or group evidence of coverage, or a similar coverage
document, that is offered by:
(1) [(A)] an insurance company;
(2) [(B)] a group hospital service corporation
operating under Chapter 842;
(3) [(C)] a fraternal benefit society operating under
Chapter 885;
(4) [(D)] a stipulated premium company operating
under Chapter 884; [or]
(5) [(E)] a health maintenance organization operating
under Chapter 843;
(6) a reciprocal exchange operating under Chapter 942;
(7) a Lloyd's plan operating under Chapter 941;
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844; or [and]
(9) [(2) to the extent permitted by the Employee
Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
seq.), a plan offered under:
[(A)] a multiple employer welfare arrangement
that holds a certificate of authority under Chapter 846 [as defined
by Section 3 of that Act; or
[(B) another analogous benefit arrangement].
(b) Notwithstanding any provision in Chapter 1575 or 1579 or
any other law, Section 1355.015 applies to:
(1) a basic plan under Chapter 1575; and
(2) a primary care coverage plan under Chapter 1579.
(c) This subchapter applies to a small employer health
benefit plan written under Chapter 1501.
Sec. 1355.003. EXCEPTION. [(a)] This subchapter does not
apply to [coverage under]:
(1) a plan that provides coverage:
(A) only for benefits for a specified disease or
for another limited benefit, other than a plan that provides
benefits for mental health or similar services;
(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) only for dental or vision care;
(F) only for hospital expenses; 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) medical payment insurance coverage provided under
an automobile insurance policy;
(5) a credit 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 1355.002 [a blanket accident and health insurance
policy, as described by Chapter 1251;
[(2) a short-term travel policy;
[(3) an accident-only policy;
[(4) a limited or specified-disease policy that does
not provide benefits for mental health care or similar services;
[(5) except as provided by Subsection (b), a plan
offered under Chapter 1551 or Chapter 1601;
[(6) a plan offered in accordance with Section
1355.151; or
[(7) a Medicare supplement benefit plan, as defined by
Section 1652.002].
[(b) For the purposes of a plan described by Subsection
(a)(5), "serious mental illness" has the meaning assigned by
Section 1355.001.]
Sec. 1355.004. REQUIRED COVERAGE [FOR SERIOUS MENTAL
ILLNESS]. [(a)] A group health benefit plan[:
[(1)] must provide coverage for the diagnosis and
treatment of a mental disorder under the same terms and conditions
as coverage provided for the diagnosis and treatment of physical
illness[, based on medical necessity, 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
mental illness as the plan includes for physical illness].
[(b) A group health benefit plan issuer:
[(1) may not count an outpatient visit for medication
management against the number of outpatient visits required to be
covered under Subsection (a)(1)(B); and
[(2) must provide coverage for an outpatient visit
described by Subsection (a)(1)(B) under the same terms as the
coverage the issuer provides for an outpatient visit for the
treatment of physical illness.]
Sec. 1355.005. COVERAGE OF INPATIENT STAYS AND OUTPATIENT
VISITS. A health benefit plan must cover inpatient stays and
outpatient visits under this subchapter under the same terms and
conditions as the plan covers inpatient stays and outpatient visits
for treatment of a physical illness. [MANAGED CARE PLAN
AUTHORIZED. A group health benefit plan issuer may provide or
offer coverage required by Section 1355.004 through a managed care
plan.]
Sec. 1355.006. AMOUNT LIMITS; DEDUCTIBLES; COPAYMENTS;
COINSURANCE. Coverage provided under this subchapter must be
subject to the same amount limits, deductibles, copayments, and
coinsurance factors as coverage for physical illness. [COVERAGE FOR
CERTAIN CONDITIONS RELATED TO CONTROLLED SUBSTANCE OR MARIHUANA NOT
REQUIRED. (a) In this section, "controlled substance" and
"marihuana" have the meanings assigned by Section 481.002, Health
and Safety Code.
[(b) This subchapter does not require a group health benefit
plan to provide coverage for the treatment of:
[(1) addiction to a controlled substance or marihuana
that is used in violation of law; or
[(2) mental illness that results from the use of a
controlled substance or marihuana in violation of law.]
Sec. 1355.007. RULES. The commissioner shall adopt rules
as necessary to implement this subchapter. [SMALL EMPLOYER
COVERAGE. An issuer of a group health benefit plan to a small
employer must offer the coverage described by Section 1355.004 to
the employer but is not required to provide the coverage if the
employer rejects the coverage.]
ARTICLE 2. CONFORMING AMENDMENTS
SECTION 2.01. Section 1355.151, Insurance Code, is amended
to read as follows:
Sec. 1355.151. PROHIBITION ON EXCLUSION OR LIMITATION OF
CERTAIN COVERAGES. (a) In this section, "mental disorder"
["serious mental illness"] has the meaning assigned by Section
1355.001.
(b) A political subdivision that provides group health
insurance coverage, health maintenance organization coverage, or
self-insured health care coverage to the political subdivision's
officers or employees may not contract for or provide coverage that
is less extensive for a mental disorder [serious mental illness]
than the coverage provided for any other physical illness.
SECTION 2.02. Section 1507.003(b), Insurance Code, is
amended to read as follows:
(b) For purposes of this subchapter, "state-mandated health
benefits" does not include benefits that are mandated by federal
law or standard provisions or rights required under this code or
other laws of this state to be provided in an individual, blanket,
or group policy for accident and health insurance that are
unrelated to a specific health illness, injury, or condition of an
insured, including provisions related to:
(1) continuation of coverage under:
(A) Subchapters F and G, Chapter 1251;
(B) Section 1201.059; and
(C) Subchapter B, Chapter 1253;
(2) termination of coverage under Sections 1202.051
and 1501.108;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105;
(4) coverage of children, including newborn or adopted
children, under:
(A) Subchapter D, Chapter 1251;
(B) Sections 1201.053, 1201.061,
1201.063-1201.065, and Subchapter A, Chapter 1367;
(C) Chapter 1504;
(D) Chapter 1503;
(E) Section 1501.157;
(F) Section 1501.158; and
(G) Sections 1501.607-1501.609;
(5) services of practitioners under:
(A) Subchapters A, B, and C, Chapter 1451; or
(B) Section 1301.052;
(6) supplies and services associated with the
treatment of diabetes under Subchapter B, Chapter 1358;
(7) coverage for a mental disorder [serious mental
illness] under Subchapter A, Chapter 1355;
(8) coverage for childhood immunizations and hearing
screening as required by Subchapters B and C, Chapter 1367, other
than Section 1367.053(c) and Chapter 1353;
(9) coverage for reconstructive surgery for certain
craniofacial abnormalities of children as required by Subchapter D,
Chapter 1367;
(10) coverage for the dietary treatment of
phenylketonuria as required by Chapter 1359;
(11) coverage for referral to a non-network physician
or provider when medically necessary covered services are not
available through network physicians or providers, as required by
Section 1271.055; and
(12) coverage for cancer screenings under:
(A) Chapter 1356;
(B) Chapter 1362;
(C) Chapter 1363; and
(D) Chapter 1370.
SECTION 2.03. Section 1507.053(b), Insurance Code, is
amended to read as follows:
(b) For purposes of this subchapter, "state-mandated health
benefits" does not include coverage that is mandated by federal law
or standard provisions or rights required under this code or other
laws of this state to be provided in an evidence of coverage that
are unrelated to a specific health illness, injury, or condition of
an enrollee, including provisions related to:
(1) continuation of coverage under Subchapter G,
Chapter 1251;
(2) termination of coverage under Sections 1202.051
and 1501.108;
(3) preexisting conditions under Subchapter D,
Chapter 1201, and Sections 1501.102-1501.105;
(4) coverage of children, including newborn or adopted
children, under:
(A) Chapter 1504;
(B) Chapter 1503;
(C) Section 1501.157;
(D) Section 1501.158; and
(E) Sections 1501.607-1501.609;
(5) services of providers under Section 843.304;
(6) coverage for a mental disorder [serious mental
health illness] under Subchapter A, Chapter 1355; and
(7) coverage for cancer screenings under:
(A) Chapter 1356;
(B) Chapter 1362;
(C) Chapter 1363; and
(D) Chapter 1370.
SECTION 2.04. Section 1551.003, Insurance Code, is amended
by amending Subdivision (10-a) and adding Subdivision (10-b) to
read as follows:
(10-a) "Mental disorder" has the meaning assigned by
Section 1355.001.
(10-b) "Participant" means an eligible individual who
participates in the group benefits program.
SECTION 2.05. Section 1551.205, Insurance Code, is amended
to read as follows:
Sec. 1551.205. LIMITATIONS. The board of trustees may not
contract for or provide a coverage plan that:
(1) excludes or limits coverage or services for
acquired immune deficiency syndrome, as defined by the Centers for
Disease Control and Prevention of the United States Public Health
Service, or human immunodeficiency virus infection;
(2) provides coverage for a mental disorder [serious
mental illness] that is less extensive than the coverage provided
for any physical illness; or
(3) may provide coverage for prescription drugs to
assist in stopping smoking at a lower benefit level than is provided
for other prescription drugs.
SECTION 2.06. Section 1601.109, Insurance Code, is amended
to read as follows:
Sec. 1601.109. COVERAGE FOR AIDS, HIV, OR [SERIOUS] MENTAL
DISORDER [ILLNESS]. (a) In this section, "mental disorder"
["serious mental illness"] has the meaning assigned by Section
1355.001.
(b) A system may not contract for or provide for group
insurance or HMO coverage or provide self-insured coverage, that:
(1) excludes or limits coverage or services for
acquired immune deficiency syndrome, as defined by the Centers for
Disease Control and Prevention of the United States Public Health
Service, or human immunodeficiency virus infection; or
(2) provides coverage for a mental disorder [serious
mental illness] that is less extensive than the coverage provided
for any other physical illness.
SECTION 2.07. Section 1551.003(12), Insurance Code, is
repealed.
ARTICLE 3. TRANSITION; EFFECTIVE DATE
SECTION 3.01. The change in law made by this Act applies
only to a health benefit plan delivered, issued for delivery, or
renewed on or after January 1, 2012. A health benefit plan
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 3.02. This Act takes effect September 1, 2011.