84R20872 PMO-F
By: Zerwas H.B. No. 2541
Substitute the following for H.B. No. 2541:
By: Paul C.S.H.B. No. 2541
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage of certain treatments for
enrollees diagnosed with a terminal illness; authorizing
administrative and civil penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
by adding Chapter 1372 to read as follows:
CHAPTER 1372. ACCESS TO TREATMENT FOR INDIVIDUALS WITH A TERMINAL
ILLNESS
Sec. 1372.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual entitled to
coverage under a health benefit plan.
(2) "Physician" means an individual licensed to
practice medicine in this state.
(3) "Terminal illness" means an illness or physical
condition, including a physical injury, that can reasonably be
expected to result in death within not more than two years.
Sec. 1372.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a 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, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885; or
(8) an exchange operating under Chapter 942.
(b) This chapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to health
benefit plan coverage provided under:
(1) Chapter 1551;
(2) Chapter 1575;
(3) Chapter 1579; and
(4) Chapter 1601.
(d) Notwithstanding Section 1501.251 or any other law, this
chapter applies to coverage under a small employer health benefit
plan subject to Chapter 1501.
(e) This chapter applies to a consumer choice of benefits
plan issued under Chapter 1507.
(f) To the extent allowed by federal law, the child health
plan program operated under Chapter 62, Health and Safety Code, the
health benefits plan for children operated under Chapter 63, Health
and Safety Code, the state Medicaid program, and a managed care
organization that contracts with the Health and Human Services
Commission to provide health care services to recipients through a
managed care plan shall provide coverage to a recipient in
accordance with this chapter.
Sec. 1372.003. EXCEPTION TO APPLICABILITY OF CHAPTER. This
chapter does not apply to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for 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 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);
(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 1372.002.
Sec. 1372.004. APPLICABILITY TO CERTAIN TREATMENT. This
chapter applies to treatment for an enrollee diagnosed by a
physician with a terminal illness:
(1) that is:
(A) medically accepted as treatment for the
terminal illness or another illness or condition with which the
enrollee has been diagnosed by a physician; and
(B) prescribed by a physician to treat the
terminal illness or other illness or condition; and
(2) to which the enrollee or the enrollee's legal
guardian or other legal representative consents.
Sec. 1372.005. CERTAIN DENIALS OF COVERAGE PROHIBITED.
Notwithstanding any other law, a health benefit plan may not deny
coverage for a treatment to which this chapter applies based solely
on the enrollee's diagnosis with a terminal illness.
Sec. 1372.006. PROHIBITED CONDUCT. A health benefit plan
issuer or third-party administrator may not with respect to a
treatment to which this chapter applies:
(1) refuse to accept a physician's recommendation of
the treatment based solely on the enrollee's diagnosis with a
terminal illness; or
(2) reduce, prohibit, or deny payment or other forms
of reimbursement for the treatment based solely on the enrollee's
diagnosis with a terminal illness.
Sec. 1372.007. UNFAIR OR DECEPTIVE ACT OR PRACTICE; UNFAIR
CLAIM SETTLEMENT PRACTICE. A violation of this chapter is an unfair
or deceptive act or practice in the business of insurance for
purposes of Chapter 541 and an unfair claim settlement practice for
purposes of Chapter 542.
Sec. 1372.008. ADMINISTRATIVE PENALTIES. A health benefit
plan issuer or third-party administrator that commits a violation
of this chapter is subject to administrative penalties under
Chapters 82 and 84.
SECTION 2. Chapter 1372, Insurance Code, as added by this
Act, applies only to a health benefit plan that is delivered, issued
for delivery, or renewed on or after September 1, 2015. A plan
delivered, issued for delivery, or renewed before September 1,
2015, 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, 2015.