Texas 2017 - 85th Regular

Texas House Bill HB2094 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	85R8017 MEW-F
2	2	By: Price H.B. No. 2094
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to coverage for serious mental illness, other disorders,
8	8	and chemical dependency under certain health benefit plans.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. The heading to Subchapter A, Chapter 1355,
11	11	Insurance Code, is amended to read as follows:
12	12	SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN
13	13	SERIOUS MENTAL ILLNESSES AND OTHER DISORDERS
14	14	SECTION 2. Section 1355.001, Insurance Code, is amended by
15	15	amending Subdivision (1) and adding Subdivisions (5), (6), and (7)
16	16	to read as follows:
17	17	(1) "Serious mental illness" means the following
18	18	psychiatric illnesses as defined by the American Psychiatric
19	19	Association in the Diagnostic and Statistical Manual of Mental
20	20	Disorders (DSM), fifth edition, or a later edition adopted by the
21	21	commissioner by rule:
22	22	(A) bipolar disorders (hypomanic, manic,
23	23	depressive, and mixed);
24	24	(B) depression in childhood and adolescence;
25	25	(C) major depressive disorders (single episode
26	26	or recurrent);
27	27	(D) obsessive-compulsive disorders;
28	28	(E) paranoid and other psychotic disorders;
29	29	(F) posttraumatic stress disorder;
30	30	(G) schizo-affective disorders (bipolar or
31	31	depressive); and
32	32	(H) [(G)] schizophrenia.
33	33	(5) "Posttraumatic stress disorder" means a disorder
34	34	that:
35	35	(A) meets the diagnostic criteria for
36	36	posttraumatic stress disorder specified by the American
37	37	Psychiatric Association in the Diagnostic and Statistical Manual of
38	38	Mental Disorders, fifth edition, or a later edition adopted by the
39	39	commissioner by rule; and
40	40	(B) results in an impairment of a person's
41	41	functioning in the person's community, employment, family, school,
42	42	or social group.
43	43	(6) "Eating disorder" means:
44	44	(A) any eating disorder described by the
45	45	Diagnostic and Statistical Manual of Mental Disorders, fifth
46	46	edition, or a later edition adopted by the commissioner by rule,
47	47	including:
48	48	(i) anorexia nervosa;
49	49	(ii) bulimia nervosa;
50	50	(iii) binge eating disorder;
51	51	(iv) rumination disorder;
52	52	(v) avoidant/restrictive food intake
53	53	disorder; or
54	54	(vi) any eating disorder not otherwise
55	55	specified; or
56	56	(B) any eating disorder contained in a subsequent
57	57	edition of the Diagnostic and Statistical Manual of Mental
58	58	Disorders published by the American Psychiatric Association and
59	59	adopted by the commissioner by rule.
60	60	(7) "Serious emotional disturbance of a child" means
61	61	an emotional or behavioral disorder or a neuropsychiatric condition
62	62	that causes a person's functioning to be impaired in thought,
63	63	perception, affect, or behavior and that:
64	64	(A) has been diagnosed, by a physician licensed
65	65	to practice medicine in this state, a psychologist licensed to
66	66	practice in this state, or a licensed professional counselor
67	67	licensed to practice in this state, in a person who is at least 3
68	68	years of age and younger than 17 years of age; and
69	69	(B) meets at least one of the following criteria:
70	70	(i) the disorder substantially impairs the
71	71	person's ability in at least two of the following activities or
72	72	tasks:
73	73	(a) self-care;
74	74	(b) engaging in family relationships;
75	75	(c) functioning in school; or
76	76	(d) functioning in the community;
77	77	(ii) the disorder creates a risk that the
78	78	person will be removed from the person's home and placed in a more
79	79	restrictive environment, including in a facility or program
80	80	operated by the Department of Family and Protective Services or an
81	81	agency that is part of the juvenile justice system;
82	82	(iii) the disorder causes the person to:
83	83	(a) display psychotic features or
84	84	violent behavior; or
85	85	(b) pose a danger to the person's self
86	86	or others; or
87	87	(iv) the disorder results in the person
88	88	meeting state special education eligibility requirements for
89	89	serious emotional disturbance.
90	90	SECTION 3. Section 1355.002, Insurance Code, is amended by
91	91	amending Subsection (a) and adding Subsections (c) and (d) to read
92	92	as follows:
93	93	(a) This subchapter applies only to a [group] health benefit
94	94	plan that provides benefits for medical or surgical expenses
95	95	incurred as a result of a health condition, accident, or sickness,
96	96	including:
97	97	(1) an individual, [a] group, blanket, or franchise
98	98	insurance policy or [, group] insurance agreement, a group hospital
99	99	service contract, [or] an individual or group evidence of coverage,
100	100	or a similar coverage document, that is offered by:
101	101	(A) an insurance company;
102	102	(B) a group hospital service corporation
103	103	operating under Chapter 842;
104	104	(C) a fraternal benefit society operating under
105	105	Chapter 885;
106	106	(D) a stipulated premium company operating under
107	107	Chapter 884; [or]
108	108	(E) a health maintenance organization operating
109	109	under Chapter 843; [and]
110	110	(F) a reciprocal exchange operating under
111	111	Chapter 942;
112	112	(G) a Lloyd's plan operating under Chapter 941;
113	113	(H) an approved nonprofit health corporation
114	114	that holds a certificate of authority under Chapter 844; or
115	115	(I) a multiple employer welfare arrangement that
116	116	holds a certificate of authority under Chapter 846; and
117	117	(2) to the extent permitted by the Employee Retirement
118	118	Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan
119	119	offered under:
120	120	(A) a multiple employer welfare arrangement as
121	121	defined by Section 3 of that Act; or
122	122	(B) another analogous benefit arrangement.
123	123	(c) Notwithstanding Section 1501.251 or any other law, this
124	124	subchapter applies to coverage under a small employer health
125	125	benefit plan subject to Chapter 1501.
126	126	(d) This subchapter applies to a standard health benefit
127	127	plan issued under Chapter 1507.
128	128	SECTION 4. The heading to Section 1355.003, Insurance Code,
129	129	is amended to read as follows:
130	130	Sec. 1355.003. EXCEPTIONS [EXCEPTION].
131	131	SECTION 5. Section 1355.003, Insurance Code, is amended by
132	132	amending Subsection (a) and adding Subsection (c) to read as
133	133	follows:
134	134	(a) This subchapter does not apply to coverage under:
135	135	(1) [a blanket accident and health insurance policy,
136	136	as described by Chapter 1251;
137	137	[(2)] a short-term travel policy;
138	138	(2) [(3)] an accident-only policy;
139	139	(3) [(4)] a limited or specified-disease policy that
140	140	does not provide benefits for mental health care or similar
141	141	services;
142	142	(4) [(5)] except as provided by Subsection (b), a plan
143	143	offered under Chapter 1551 or Chapter 1601;
144	144	(5) [(6)] a plan offered in accordance with Section
145	145	1355.151; or
146	146	(6) [(7)] a Medicare supplement benefit plan, as
147	147	defined by Section 1652.002.
148	148	(c) To the extent that this section would otherwise require
149	149	this state to make a payment under 42 U.S.C. Section
150	150	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
151	151	C.F.R. Section 155.20, is not required to provide a benefit under
152	152	this subchapter that exceeds the specified essential health
153	153	benefits required under 42 U.S.C. Section 18022(b).
154	154	SECTION 6. Section 1355.004, Insurance Code, is amended to
155	155	read as follows:
156	156	Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS EMOTIONAL
157	157	DISTURBANCE OF A CHILD AND SERIOUS MENTAL ILLNESS. (a) A [group]
158	158	health benefit plan:
159	159	(1) must provide coverage for serious emotional
160	160	disturbance of a child diagnosed as described by Section 1355.001
161	161	and coverage, based on medical necessity, for serious mental
162	162	illness for not less than the following treatments [of serious
163	163	mental illness] in each calendar year:
164	164	(A) 45 days of inpatient treatment; and
165	165	(B) 60 visits for outpatient treatment,
166	166	including group and individual outpatient treatment;
167	167	(2) may not include a lifetime limitation on the
168	168	number of days of inpatient treatment or the number of visits for
169	169	outpatient treatment covered under the plan; and
170	170	(3) must include the same amount limitations,
171	171	deductibles, copayments, and coinsurance factors for serious
172	172	emotional disturbance of a child and serious mental illness as the
173	173	plan includes for physical illness.
174	174	(b) A [group] health benefit plan issuer:
175	175	(1) may not count an outpatient visit for medication
176	176	management against the number of outpatient visits required to be
177	177	covered under Subsection (a)(1)(B); and
178	178	(2) must provide coverage for an outpatient visit
179	179	described by Subsection (a)(1)(B) under the same terms as the
180	180	coverage the issuer provides for an outpatient visit for the
181	181	treatment of physical illness.
182	182	SECTION 7. Section 1355.005, Insurance Code, is amended to
183	183	read as follows:
184	184	Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A [group]
185	185	health benefit plan issuer may provide or offer coverage required
186	186	by Section 1355.004 through a managed care plan.
187	187	SECTION 8. Section 1355.006(b), Insurance Code, is amended
188	188	to read as follows:
189	189	(b) This subchapter does not require a [group] health
190	190	benefit plan to provide coverage for the treatment of:
191	191	(1) addiction to a controlled substance or marihuana
192	192	that is used in violation of law; or
193	193	(2) mental illness that results from the use of a
194	194	controlled substance or marihuana in violation of law.
195	195	SECTION 9. Subchapter A, Chapter 1355, Insurance Code, is
196	196	amended by adding Section 1355.008 to read as follows:
197	197	Sec. 1355.008. REQUIRED COVERAGE FOR EATING DISORDERS. (a)
198	198	A health benefit plan must provide coverage, based on medical
199	199	necessity, for the diagnosis and treatment of an eating disorder.
200	200	(b) Coverage required under Subsection (a) is limited to a
201	201	service or medication, to the extent the service or medication is
202	202	covered by the health benefit plan, ordered by a licensed
203	203	physician, psychiatrist, psychologist, or therapist within the
204	204	scope of the practitioner's license and in accordance with a
205	205	treatment plan.
206	206	(c) On request from the health benefit plan issuer, an
207	207	eating disorder treatment plan must include all elements necessary
208	208	for the issuer to pay a claim under the health benefit plan, which
209	209	may include a diagnosis, goals, and proposed treatment by type,
210	210	frequency, and duration.
211	211	(d) Coverage required under Subsection (a) is not subject to
212	212	a limit on the number of days of medically necessary treatment
213	213	except as provided by the treatment plan.
214	214	(e) A health benefit plan issuer may conduct a utilization
215	215	review of an eating disorder treatment plan not more than once each
216	216	six months unless the physician, psychiatrist, psychologist, or
217	217	therapist treating the enrollee under the treatment plan agrees
218	218	that a more frequent review is necessary. An agreement to conduct
219	219	more frequent review under this subsection applies only to the
220	220	enrollee who is the subject of the agreement.
221	221	(f) A health benefit plan issuer shall pay any costs of
222	222	conducting a utilization review of coverage required under
223	223	Subsection (a) or obtaining a treatment plan.
224	224	(g) In conducting a utilization review of treatment for an
225	225	eating disorder, including review of medical necessity or the
226	226	treatment plan, a utilization review agent shall consider:
227	227	(1) the overall medical and mental health needs of the
228	228	individual with the eating disorder;
229	229	(2) factors in addition to weight; and
230	230	(3) the most recent Practice Guideline for the
231	231	Treatment of Patients with Eating Disorders adopted by the American
232	232	Psychiatric Association.
233	233	SECTION 10. Section 1355.054(a), Insurance Code, is amended
234	234	to read as follows:
235	235	(a) Benefits of coverage provided under this subchapter may
236	236	be used only in a situation in which:
237	237	(1) the covered individual has a serious mental
238	238	illness or serious emotional disturbance of a child that requires
239	239	confinement of the individual in a hospital unless treatment is
240	240	available through a residential treatment center for children and
241	241	adolescents or a crisis stabilization unit; and
242	242	(2) the covered individual's mental illness or
243	243	emotional disturbance:
244	244	(A) substantially impairs the individual's
245	245	thought, perception of reality, emotional process, or judgment; or
246	246	(B) as manifested by the individual's recent
247	247	disturbed behavior, grossly impairs the individual's behavior.
248	248	SECTION 11. Section 1368.002, Insurance Code, is amended to
249	249	read as follows:
250	250	Sec. 1368.002. APPLICABILITY OF CHAPTER. (a) This chapter
251	251	applies only to a [group] health benefit plan that provides
252	252	hospital and medical coverage or services on an expense incurred,
253	253	service, or prepaid basis, including an individual, [a] group,
254	254	blanket, or franchise insurance policy or insurance agreement, a
255	255	group hospital service contract, an individual or group evidence of
256	256	coverage, or a similar coverage document, or self-funded or
257	257	self-insured plan or arrangement, that is offered in this state by:
258	258	(1) an insurer;
259	259	(2) a group hospital service corporation operating
260	260	under Chapter 842;
261	261	(3) a health maintenance organization operating under
262	262	Chapter 843; [or]
263	263	(4) an employer, trustee, or other self-funded or
264	264	self-insured plan or arrangement;
265	265	(5) a fraternal benefit society operating under
266	266	Chapter 885;
267	267	(6) a stipulated premium company operating under
268	268	Chapter 884;
269	269	(7) a reciprocal exchange operating under Chapter 942;
270	270	(8) a Lloyd's plan operating under Chapter 941;
271	271	(9) an approved nonprofit health corporation that
272	272	holds a certificate of authority under Chapter 844; or
273	273	(10) a multiple employer welfare arrangement that
274	274	holds a certificate of authority under Chapter 846.
275	275	(b) Notwithstanding Section 1501.251 or any other law, this
276	276	chapter applies to coverage under a small employer health benefit
277	277	plan subject to Chapter 1501.
278	278	(c) This chapter applies to a standard health benefit plan
279	279	issued under Chapter 1507.
280	280	SECTION 12. Section 1368.003, Insurance Code, is amended to
281	281	read as follows:
282	282	Sec. 1368.003. EXCEPTIONS [EXCEPTION]. (a) This chapter
283	283	does not apply to:
284	284	(1) an employer, trustee, or other self-funded or
285	285	self-insured plan or arrangement with 250 or fewer employees or
286	286	members;
287	287	(2) [an individual insurance policy;
288	288	[(3) an individual evidence of coverage issued by a
289	289	health maintenance organization;
290	290	[(4)] a health insurance policy that provides only:
291	291	(A) cash indemnity for hospital or other
292	292	confinement benefits;
293	293	(B) supplemental or limited benefit coverage;
294	294	(C) coverage for specified diseases or
295	295	accidents;
296	296	(D) disability income coverage; or
297	297	(E) any combination of those benefits or
298	298	coverages;
299	299	(3) [(5) a blanket insurance policy;
300	300	[(6)] a short-term travel insurance policy;
301	301	(4) [(7)] an accident-only insurance policy;
302	302	(5) [(8)] a limited or specified disease insurance
303	303	policy;
304	304	(6) [(9) an individual conversion insurance policy or
305	305	contract;
306	306	[(10)] a policy or contract designed for issuance to a
307	307	person eligible for Medicare coverage or other similar coverage
308	308	under a state or federal government plan; or
309	309	(7) [(11)] an evidence of coverage provided by a
310	310	health maintenance organization if the plan holder is the subject
311	311	of a collective bargaining agreement that was in effect on January
312	312	1, 1982, and that has not expired since that date.
313	313	(b) To the extent that this section would otherwise require
314	314	this state to make a payment under 42 U.S.C. Section
315	315	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
316	316	C.F.R. Section 155.20, is not required to provide a benefit under
317	317	this chapter that exceeds the specified essential health benefits
318	318	required under 42 U.S.C. Section 18022(b).
319	319	SECTION 13. Section 1368.004, Insurance Code, is amended to
320	320	read as follows:
321	321	Sec. 1368.004. COVERAGE REQUIRED. (a) A [group] health
322	322	benefit plan shall provide coverage for the necessary care and
323	323	treatment of chemical dependency.
324	324	(b) Coverage required under this section may be provided:
325	325	(1) directly by the [group] health benefit plan
326	326	issuer; or
327	327	(2) by another entity, including a single service
328	328	health maintenance organization, under contract with the [group]
329	329	health benefit plan issuer.
330	330	SECTION 14. Section 1368.005(b), Insurance Code, is amended
331	331	to read as follows:
332	332	(b) A [group] health benefit plan may set dollar or
333	333	durational limits for coverage required under this chapter that are
334	334	less favorable than for coverage provided for physical illness
335	335	generally under the plan if those limits are sufficient to provide
336	336	appropriate care and treatment under the guidelines and standards
337	337	adopted under Section 1368.007. If guidelines and standards
338	338	adopted under Section 1368.007 are not in effect, the dollar and
339	339	durational limits may not be less favorable than for physical
340	340	illness generally.
341	341	SECTION 15. Section 1355.007, Insurance Code, is repealed.
342	342	SECTION 16. The changes in law made by this Act apply only
343	343	to a health benefit plan that is delivered, issued for delivery, or
344	344	renewed on or after January 1, 2018. A health benefit plan that is
345	345	delivered, issued for delivery, or renewed before January 1, 2018,
346	346	is governed by the law as it existed immediately before the
347	347	effective date of this Act, and that law is continued in effect for
348	348	that purpose.
349	349	SECTION 17. This Act takes effect September 1, 2017.