85R8017 MEW-F
By: Price H.B. No. 2094
A BILL TO BE ENTITLED
AN ACT
relating to coverage for serious mental illness, other disorders,
and chemical dependency under certain health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to 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
SECTION 2. Section 1355.001, Insurance Code, is amended by
amending Subdivision (1) and adding Subdivisions (5), (6), and (7)
to read as follows:
(1) "Serious mental illness" means the following
psychiatric illnesses as defined by the American Psychiatric
Association in the Diagnostic and Statistical Manual of Mental
Disorders (DSM), fifth edition, or a later edition adopted by the
commissioner by rule:
(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) posttraumatic stress disorder;
(G) schizo-affective disorders (bipolar or
depressive); and
(H) [(G)] schizophrenia.
(5) "Posttraumatic stress disorder" means a disorder
that:
(A) meets the diagnostic criteria for
posttraumatic stress disorder specified by the American
Psychiatric Association in the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition, or a later edition adopted by the
commissioner by rule; and
(B) results in an impairment of a person's
functioning in the person's community, employment, family, school,
or social group.
(6) "Eating disorder" means:
(A) any eating disorder described by the
Diagnostic and Statistical Manual of Mental Disorders, fifth
edition, or a later edition adopted by the commissioner by rule,
including:
(i) anorexia nervosa;
(ii) bulimia nervosa;
(iii) binge eating disorder;
(iv) rumination disorder;
(v) avoidant/restrictive food intake
disorder; or
(vi) any eating disorder not otherwise
specified; or
(B) any eating disorder contained in a subsequent
edition of the Diagnostic and Statistical Manual of Mental
Disorders published by the American Psychiatric Association and
adopted by the commissioner by rule.
(7) "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, by a physician licensed
to practice medicine in this state, a psychologist licensed to
practice in this state, or a licensed professional counselor
licensed to practice in this state, in a person who is at least 3
years of age and younger than 17 years of age; and
(B) meets at least one of the following criteria:
(i) 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;
(ii) the disorder creates a risk that the
person will be removed from the person's home and placed in a more
restrictive environment, including in a facility or program
operated by the Department of Family and Protective Services or an
agency that is part of the juvenile justice system;
(iii) 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
(iv) the disorder results in the person
meeting state special education eligibility requirements for
serious emotional disturbance.
SECTION 3. Section 1355.002, Insurance Code, is amended by
amending Subsection (a) and adding Subsections (c) and (d) to read
as follows:
(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:
(1) an individual, [a] group, blanket, or franchise
insurance policy or [, group] insurance agreement, a group hospital
service contract, [or] an individual or group evidence of coverage,
or a similar coverage document, that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884; [or]
(E) a health maintenance organization operating
under Chapter 843; [and]
(F) a reciprocal exchange operating under
Chapter 942;
(G) a Lloyd's plan operating under Chapter 941;
(H) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; or
(I) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846; and
(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 as
defined by Section 3 of that Act; or
(B) another analogous benefit arrangement.
(c) Notwithstanding Section 1501.251 or any other law, this
subchapter applies to coverage under a small employer health
benefit plan subject to Chapter 1501.
(d) This subchapter applies to a standard health benefit
plan issued under Chapter 1507.
SECTION 4. The heading to Section 1355.003, Insurance Code,
is amended to read as follows:
Sec. 1355.003. EXCEPTIONS [EXCEPTION].
SECTION 5. Section 1355.003, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (c) to read as
follows:
(a) This subchapter does not apply to coverage under:
(1) [a blanket accident and health insurance policy,
as described by Chapter 1251;
[(2)] a short-term travel policy;
(2) [(3)] an accident-only policy;
(3) [(4)] a limited or specified-disease policy that
does not provide benefits for mental health care or similar
services;
(4) [(5)] except as provided by Subsection (b), a plan
offered under Chapter 1551 or Chapter 1601;
(5) [(6)] a plan offered in accordance with Section
1355.151; or
(6) [(7)] a Medicare supplement benefit plan, as
defined by Section 1652.002.
(c) To the extent that this section 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 subchapter that exceeds the specified essential health
benefits required under 42 U.S.C. Section 18022(b).
SECTION 6. 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. (a) A [group]
health benefit plan:
(1) must provide coverage for serious emotional
disturbance of a child diagnosed as described by Section 1355.001
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.
(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.
SECTION 7. Section 1355.005, Insurance Code, is amended to
read as follows:
Sec. 1355.005. 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.
SECTION 8. Section 1355.006(b), Insurance Code, is amended
to read as follows:
(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.
SECTION 9. Subchapter A, Chapter 1355, Insurance Code, is
amended by adding Section 1355.008 to read as follows:
Sec. 1355.008. REQUIRED COVERAGE FOR EATING DISORDERS. (a)
A health benefit plan must provide coverage, based on medical
necessity, for the diagnosis and treatment of an eating disorder.
(b) Coverage required under Subsection (a) is limited to a
service or medication, to the extent the service or medication is
covered by the health benefit plan, ordered by a licensed
physician, psychiatrist, psychologist, or therapist within the
scope of the practitioner's license and in accordance with a
treatment plan.
(c) On request from the health benefit plan issuer, an
eating disorder treatment plan must include all elements necessary
for the issuer to pay a claim under the health benefit plan, which
may include a diagnosis, goals, and proposed treatment by type,
frequency, and duration.
(d) Coverage required under Subsection (a) is not subject to
a limit on the number of days of medically necessary treatment
except as provided by the treatment plan.
(e) A health benefit plan issuer may conduct a utilization
review of an eating disorder treatment plan not more than once each
six months unless the physician, psychiatrist, psychologist, or
therapist treating the enrollee under the treatment plan agrees
that a more frequent review is necessary. An agreement to conduct
more frequent review under this subsection applies only to the
enrollee who is the subject of the agreement.
(f) A health benefit plan issuer shall pay any costs of
conducting a utilization review of coverage required under
Subsection (a) or obtaining a treatment plan.
(g) In conducting a utilization review of treatment for an
eating disorder, including review of medical necessity or the
treatment plan, a utilization review agent shall consider:
(1) the overall medical and mental health needs of the
individual with the eating disorder;
(2) factors in addition to weight; and
(3) the most recent Practice Guideline for the
Treatment of Patients with Eating Disorders adopted by the American
Psychiatric Association.
SECTION 10. 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 11. Section 1368.002, Insurance Code, is amended to
read as follows:
Sec. 1368.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a [group] health benefit plan that provides
hospital and medical coverage or services on an expense incurred,
service, or prepaid basis, including an individual, [a] group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, an individual or group evidence of
coverage, or a similar coverage document, or self-funded or
self-insured plan or arrangement, that is offered in this state by:
(1) an insurer;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843; [or]
(4) an employer, trustee, or other self-funded or
self-insured plan or arrangement;
(5) a fraternal benefit society operating under
Chapter 885;
(6) a stipulated premium company operating under
Chapter 884;
(7) a reciprocal exchange operating under Chapter 942;
(8) a Lloyd's plan operating under Chapter 941;
(9) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844; or
(10) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846.
(b) Notwithstanding Section 1501.251 or any other law, this
chapter applies to coverage under a small employer health benefit
plan subject to Chapter 1501.
(c) This chapter applies to a standard health benefit plan
issued under Chapter 1507.
SECTION 12. Section 1368.003, Insurance Code, is amended to
read as follows:
Sec. 1368.003. EXCEPTIONS [EXCEPTION]. (a) This chapter
does not apply to:
(1) an employer, trustee, or other self-funded or
self-insured plan or arrangement with 250 or fewer employees or
members;
(2) [an individual insurance policy;
[(3) an individual evidence of coverage issued by a
health maintenance organization;
[(4)] a health insurance policy that provides only:
(A) cash indemnity for hospital or other
confinement benefits;
(B) supplemental or limited benefit coverage;
(C) coverage for specified diseases or
accidents;
(D) disability income coverage; or
(E) any combination of those benefits or
coverages;
(3) [(5) a blanket insurance policy;
[(6)] a short-term travel insurance policy;
(4) [(7)] an accident-only insurance policy;
(5) [(8)] a limited or specified disease insurance
policy;
(6) [(9) an individual conversion insurance policy or
contract;
[(10)] a policy or contract designed for issuance to a
person eligible for Medicare coverage or other similar coverage
under a state or federal government plan; or
(7) [(11)] an evidence of coverage provided by a
health maintenance organization if the plan holder is the subject
of a collective bargaining agreement that was in effect on January
1, 1982, and that has not expired since that date.
(b) To the extent that this section 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 chapter that exceeds the specified essential health benefits
required under 42 U.S.C. Section 18022(b).
SECTION 13. Section 1368.004, Insurance Code, is amended to
read as follows:
Sec. 1368.004. COVERAGE REQUIRED. (a) A [group] health
benefit plan shall provide coverage for the necessary care and
treatment of chemical dependency.
(b) Coverage required under this section may be provided:
(1) directly by the [group] health benefit plan
issuer; or
(2) by another entity, including a single service
health maintenance organization, under contract with the [group]
health benefit plan issuer.
SECTION 14. Section 1368.005(b), Insurance Code, is amended
to read as follows:
(b) A [group] health benefit plan may set dollar or
durational limits for coverage required under this chapter that are
less favorable than for coverage provided for physical illness
generally under the plan if those limits are sufficient to provide
appropriate care and treatment under the guidelines and standards
adopted under Section 1368.007. If guidelines and standards
adopted under Section 1368.007 are not in effect, the dollar and
durational limits may not be less favorable than for physical
illness generally.
SECTION 15. Section 1355.007, Insurance Code, is repealed.
SECTION 16. The changes in law made by this Act apply only
to a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2018. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2018,
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 17. This Act takes effect September 1, 2017.