83R24902 DLF-F
By: Sheets H.B. No. 2929
Substitute the following for H.B. No. 2929:
By: Sheets C.S.H.B. No. 2929
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for brain injury.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1352.001, Insurance Code, is amended by
amending Subsection (b) and adding Subsection (c) to read as
follows:
(b) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) [(2)] a primary care coverage plan under Chapter
1579; and
(4) [(3)] basic coverage under Chapter 1601.
(c) This chapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
SECTION 2. Section 1352.002, Insurance Code, is amended to
read as follows:
Sec. 1352.002. EXCEPTION; APPLICATION TO QUALIFIED HEALTH
PLAN. (a) This chapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or for another
limited benefit other than an accident policy;
(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 dental or vision care;
(G) only for hospital expenses; or
(H) 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),
as amended;
(3) a workers' compensation insurance policy;
(4) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(5) 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 1352.001.
(b) This chapter does not apply to a standard health benefit
plan issued under Chapter 1507.
(c) To the extent that a change in law made to this chapter
after January 1, 2013, would otherwise require this state to make a
payment under 42 U.S.C. Section 18031(d)(3)(B)(ii), a qualified
health plan, as defined by 45 C.F.R. Section 155.20, is not required
to provide a benefit under this section that exceeds the specified
essential health benefits required under 42 U.S.C. Section
18022(b).
SECTION 3. Section 1352.003, Insurance Code, is amended by
amending Subsections (c) and (d) and adding Subsection (c-1) to
read as follows:
(c) A health benefit plan may not include, in any annual or
lifetime limitation on the number of days of acute care treatment
covered under the plan, any post-acute care treatment covered under
the plan. [Any limitation imposed under the plan on days of
post-acute care treatment must be separately stated in the plan.]
(c-1) A health benefit plan may not limit the number of days
of covered post-acute care, including any therapy or treatment or
rehabilitation, testing, remediation, or other service described
by Subsections (a) and (b), or the number of days of covered
inpatient care to the extent that the treatment or care is
determined to be medically necessary as a result of and related to
an acquired brain injury. The insured's or enrollee's treating
physician shall determine whether treatment or care is medically
necessary for purposes of this subsection in consultation with the
treatment or care provider, the insured or enrollee, and, if
appropriate, members of the insured's or enrollee's family. The
determination is subject to review under Section 1352.006.
(d) Except as provided by Subsection (c) or (c-1), a health
benefit plan must include the same amount [payment] limitations,
deductibles, copayments, and coinsurance factors for coverage
required under this chapter as applicable to other medical
conditions for which [similar] coverage is provided under the
health benefit plan.
SECTION 4. Section 1352.0035(b), Insurance Code, is amended
to read as follows:
(b) Coverage required under this section may be subject to
deductibles, copayments, coinsurance, or annual or maximum amount
[payment] limits that are consistent with the deductibles,
copayments, coinsurance, or annual or maximum amount [payment]
limits applicable to other medical conditions for which [similar]
coverage is provided under the small employer health benefit plan.
SECTION 5. Section 1352.007, Insurance Code, is amended by
adding Subsections (c), (d), (e), and (f) to read as follows:
(c) The issuer of a health benefit plan, including a
preferred provider benefit plan or health maintenance organization
plan, that contracts with or approves admission to a service
provider under this chapter may not, solely because a facility is
licensed by this state as an assisted living facility, refuse to
contract with or approve admission to that facility to provide
services that are:
(1) required under this chapter;
(2) within the scope of the license of an assisted
living facility; and
(3) within the scope of the services provided under a
CARF-accredited rehabilitation program for brain injury or another
nationally recognized accredited rehabilitation program for brain
injury.
(d) The issuer of a health benefit plan that requires or
encourages insureds or enrollees to use health care providers
designated by the plan shall ensure that the services required by
this chapter that are within the scope of the license of an assisted
living facility and that may be provided under a program described
by Subsection (c)(3) are made available and accessible to the
insureds or enrollees at an adequate number of assisted living
facilities.
(e) A health benefit plan may not treat care provided in
accordance with this chapter as custodial care solely because it is
provided by an assisted living facility if the facility holds a CARF
accreditation or other nationally recognized accreditation for a
rehabilitation program for brain injury.
(f) To ensure the health and safety of insureds and
enrollees, the commissioner may require that a licensed assisted
living facility that provides covered post-acute care other than
custodial care under this chapter to an insured or enrollee with
acquired brain injury hold a CARF accreditation or other nationally
recognized accreditation for a rehabilitation program for brain
injury.
SECTION 6. Chapter 1352, Insurance Code, as amended by this
Act, applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2014. A health benefit
plan delivered, issued for delivery, or renewed before January 1,
2014, is governed by the law in effect immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.
SECTION 7. This Act takes effect September 1, 2013.