Texas 2017 - 85th Regular

Texas House Bill HB2096 Compare Versions

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

Old	New	Differences
1	1	85R3974 MEW-D
2	2	By: Price H.B. No. 2096
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to access to and benefits for mental health conditions and
8	8	substance use disorders.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter B, Chapter 531, Government Code, is
11	11	amended by adding Sections 531.02251 and 531.02252 to read as
12	12	follows:
13	13	Sec. 531.02251. OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO
14	14	CARE. (a) In this section, "ombudsman" means the individual
15	15	designated as the ombudsman for behavioral health access to care.
16	16	(b) The executive commissioner shall designate an ombudsman
17	17	for behavioral health access to care.
18	18	(c) The ombudsman is administratively attached to the
19	19	office of the ombudsman for the commission.
20	20	(d) The ombudsman serves as a neutral party to help
21	21	consumers, including consumers who are uninsured or have public or
22	22	private health benefit coverage, and behavioral health care
23	23	providers navigate and resolve issues related to consumer access to
24	24	behavioral health care, including care for mental health conditions
25	25	and substance use disorders.
26	26	(e) The ombudsman shall:
27	27	(1) interact with consumers and behavioral health care
28	28	providers with concerns or complaints to help the consumers and
29	29	providers resolve behavioral health care access issues;
30	30	(2) identify, track, and help report potential
31	31	violations of state or federal rules, regulations, or statutes
32	32	concerning the availability of, and terms and conditions of,
33	33	benefits for mental health conditions or substance use disorders,
34	34	including potential violations related to nonquantitative
35	35	treatment limitations;
36	36	(3) report concerns, complaints, and potential
37	37	violations described by Subdivision (2) to the appropriate
38	38	regulatory or oversight agency;
39	39	(3) provide appropriate referrals to help consumers
40	40	obtain behavioral health care;
41	41	(4) develop appropriate points of contact for
42	42	referrals to other state and federal agencies; and
43	43	(5) provide appropriate referrals and information to
44	44	help consumers or providers file appeals or complaints with the
45	45	appropriate entities, including insurers and other state and
46	46	federal agencies.
47	47	(f) The ombudsman shall participate on the mental health
48	48	condition and substance use disorder parity work group established
49	49	under Section 531.02252, and provide summary reports of concerns,
50	50	complaints, and potential violations described by Subsection
51	51	(e)(2) to the work group. This subsection expires September 1,
52	52	2021.
53	53	(g) The Texas Department of Insurance shall appoint a
54	54	liaison to the ombudsman to receive reports of concerns,
55	55	complaints, and potential violations described by Subsection
56	56	(e)(2) from the ombudsman, consumers, or behavioral health care
57	57	providers.
58	58	Sec. 531.02252. MENTAL HEALTH CONDITION AND SUBSTANCE USE
59	59	DISORDER PARITY WORK GROUP. (a) The commission shall establish and
60	60	facilitate a mental health condition and substance use disorder
61	61	parity work group at the office of mental health coordination to
62	62	increase understanding of and compliance with state and federal
63	63	rules, regulations, and statutes concerning the availability of,
64	64	and terms and conditions of, benefits for mental health conditions
65	65	and substance use disorders.
66	66	(b) The work group may be a part of or a subcommittee of the
67	67	behavioral health advisory committee.
68	68	(c) The work group is composed of:
69	69	(1) a representative of:
70	70	(A) Medicaid and the child health plan program;
71	71	(B) the office of mental health coordination;
72	72	(C) the Texas Department of Insurance;
73	73	(D) Medicaid managed care organizations;
74	74	(E) commercial health benefit plans;
75	75	(F) mental health provider organizations;
76	76	(G) substance use disorder providers;
77	77	(H) mental health consumer advocates;
78	78	(I) substance use disorder treatment consumers;
79	79	(J) family members of mental health or substance
80	80	use disorder treatment consumers;
81	81	(K) physicians;
82	82	(L) hospitals;
83	83	(M) children's mental health providers;
84	84	(N) utilization review agents; and
85	85	(O) independent review organizations; and
86	86	(2) the ombudsman for behavioral health access to
87	87	care.
88	88	(d) The work group shall meet at least quarterly.
89	89	(e) The work group shall study and make recommendations on:
90	90	(1) increasing compliance with the rules,
91	91	regulations, and statutes described by Subsection (a);
92	92	(2) strengthening enforcement and oversight of these
93	93	laws at state and federal agencies;
94	94	(3) improving the complaint processes relating to
95	95	potential violations of these laws for consumers and providers;
96	96	(4) ensuring the commission and the Texas Department
97	97	of Insurance can accept information concerns relating to these laws
98	98	and investigate potential violations based on de-identified
99	99	information and data submitted to providers in addition to
100	100	individual complaints; and
101	101	(5) increasing public and provider education on these
102	102	laws.
103	103	(f) The work group shall develop a strategic plan with
104	104	metrics to serve as a road map to increase compliance with the
105	105	rules, regulations, and statutes described by Subsection (a) in
106	106	this state and to increase education and outreach relating to these
107	107	laws.
108	108	(g) Not later than September 1 of each even-numbered year,
109	109	the work group shall submit a report to the appropriate committees
110	110	of the legislature and the appropriate state agencies on the
111	111	findings, recommendations, and strategic plan required by
112	112	Subsections (e) and (f).
113	113	(h) The work group is abolished and this section expires
114	114	September 1, 2021.
115	115	SECTION 2. The heading to Subchapter A, Chapter 1355,
116	116	Insurance Code, is amended to read as follows:
117	117	SUBCHAPTER A. [GROUP] HEALTH BENEFIT PLAN COVERAGE FOR CERTAIN
118	118	SERIOUS MENTAL ILLNESSES AND OTHER DISORDERS
119	119	SECTION 3. Section 1355.001, Insurance Code, is amended by
120	120	amending Subdivision (1) and adding Subdivisions (5), (6), and (7)
121	121	to read as follows:
122	122	(1) "Serious mental illness" means the following
123	123	psychiatric illnesses as defined by the American Psychiatric
124	124	Association in the Diagnostic and Statistical Manual of Mental
125	125	Disorders (DSM), fifth edition, or a later edition adopted by the
126	126	commissioner by rule:
127	127	(A) bipolar disorders (hypomanic, manic,
128	128	depressive, and mixed);
129	129	(B) depression in childhood and adolescence;
130	130	(C) major depressive disorders (single episode
131	131	or recurrent);
132	132	(D) obsessive-compulsive disorders;
133	133	(E) paranoid and other psychotic disorders;
134	134	(F) posttraumatic stress disorder;
135	135	(G) schizo-affective disorders (bipolar or
136	136	depressive); and
137	137	(H) [(G)] schizophrenia.
138	138	(5) "Posttraumatic stress disorder" means a disorder
139	139	that:
140	140	(A) meets the diagnostic criteria for
141	141	posttraumatic stress disorder specified by the American
142	142	Psychiatric Association in the Diagnostic and Statistical Manual of
143	143	Mental Disorders, fifth edition, or a later edition adopted by the
144	144	commissioner by rule; and
145	145	(B) results in an impairment of a person's
146	146	functioning in the person's community, employment, family, school,
147	147	or social group.
148	148	(6) "Eating disorder" means:
149	149	(A) any eating disorder described by the
150	150	Diagnostic and Statistical Manual of Mental Disorders, fifth
151	151	edition, or a later edition adopted by the commissioner by rule,
152	152	including:
153	153	(i) anorexia nervosa;
154	154	(ii) bulimia nervosa;
155	155	(iii) binge eating disorder;
156	156	(iv) rumination disorder;
157	157	(v) avoidant/restrictive food intake
158	158	disorder; or
159	159	(vi) any eating disorder not otherwise
160	160	specified; or
161	161	(B) any eating disorder contained in a subsequent
162	162	edition of the Diagnostic and Statistical Manual of Mental
163	163	Disorders published by the American Psychiatric Association and
164	164	adopted by the commissioner by rule.
165	165	(7) "Serious emotional disturbance of a child" means
166	166	an emotional or behavioral disorder or a neuropsychiatric condition
167	167	that causes a person's functioning to be impaired in thought,
168	168	perception, affect, or behavior and that:
169	169	(A) has been diagnosed, by a physician licensed
170	170	to practice medicine in this state, a psychologist licensed to
171	171	practice in this state, or a licensed professional counselor
172	172	licensed to practice in this state, in a person who is at least 3
173	173	years of age and younger than 17 years of age; and
174	174	(B) meets at least one of the following criteria:
175	175	(i) the disorder substantially impairs the
176	176	person's ability in at least two of the following activities or
177	177	tasks:
178	178	(a) self-care;
179	179	(b) engaging in family relationships;
180	180	(c) functioning in school; or
181	181	(d) functioning in the community;
182	182	(ii) the disorder creates a risk that the
183	183	person will be removed from the person's home and placed in a more
184	184	restrictive environment, including in a facility or program
185	185	operated by the Department of Family and Protective Services or an
186	186	agency that is part of the juvenile justice system;
187	187	(iii) the disorder causes the person to:
188	188	(a) display psychotic features or
189	189	violent behavior; or
190	190	(b) pose a danger to the person's self
191	191	or others; or
192	192	(iv) the disorder results in the person
193	193	meeting state special education eligibility requirements for
194	194	serious emotional disturbance.
195	195	SECTION 4. Section 1355.002, Insurance Code, is amended by
196	196	amending Subsection (a) and adding Subsections (c) and (d) to read
197	197	as follows:
198	198	(a) This subchapter applies only to a [group] health benefit
199	199	plan that provides benefits for medical or surgical expenses
200	200	incurred as a result of a health condition, accident, or sickness,
201	201	including:
202	202	(1) an individual, [a] group, blanket, or franchise
203	203	insurance policy or [, group] insurance agreement, a group hospital
204	204	service contract, [or] an individual or group evidence of coverage,
205	205	or a similar coverage document, that is offered by:
206	206	(A) an insurance company;
207	207	(B) a group hospital service corporation
208	208	operating under Chapter 842;
209	209	(C) a fraternal benefit society operating under
210	210	Chapter 885;
211	211	(D) a stipulated premium company operating under
212	212	Chapter 884; [or]
213	213	(E) a health maintenance organization operating
214	214	under Chapter 843; [and]
215	215	(F) a reciprocal exchange operating under
216	216	Chapter 942;
217	217	(G) a Lloyd's plan operating under Chapter 941;
218	218	(H) an approved nonprofit health corporation
219	219	that holds a certificate of authority under Chapter 844; or
220	220	(I) a multiple employer welfare arrangement that
221	221	holds a certificate of authority under Chapter 846; and
222	222	(2) to the extent permitted by the Employee Retirement
223	223	Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan
224	224	offered under:
225	225	(A) a multiple employer welfare arrangement as
226	226	defined by Section 3 of that Act; or
227	227	(B) another analogous benefit arrangement.
228	228	(c) Notwithstanding Section 1501.251 or any other law, this
229	229	subchapter applies to coverage under a small employer health
230	230	benefit plan subject to Chapter 1501.
231	231	(d) This subchapter applies to a standard health benefit
232	232	plan issued under Chapter 1507.
233	233	SECTION 5. The heading to Section 1355.003, Insurance Code,
234	234	is amended to read as follows:
235	235	Sec. 1355.003. EXCEPTIONS [EXCEPTION].
236	236	SECTION 6. Section 1355.003, Insurance Code, is amended by
237	237	amending Subsection (a) and adding Subsection (c) to read as
238	238	follows:
239	239	(a) This subchapter does not apply to coverage under:
240	240	(1) [a blanket accident and health insurance policy,
241	241	as described by Chapter 1251;
242	242	[(2)] a short-term travel policy;
243	243	(2) [(3)] an accident-only policy;
244	244	(3) [(4)] a limited or specified-disease policy that
245	245	does not provide benefits for mental health care or similar
246	246	services;
247	247	(4) [(5)] except as provided by Subsection (b), a plan
248	248	offered under Chapter 1551 or Chapter 1601;
249	249	(5) [(6)] a plan offered in accordance with Section
250	250	1355.151; or
251	251	(6) [(7)] a Medicare supplement benefit plan, as
252	252	defined by Section 1652.002.
253	253	(c) To the extent that this section would otherwise require
254	254	this state to make a payment under 42 U.S.C. Section
255	255	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
256	256	C.F.R. Section 155.20, is not required to provide a benefit under
257	257	this subchapter that exceeds the specified essential health
258	258	benefits required under 42 U.S.C. Section 18022(b).
259	259	SECTION 7. Section 1355.004, Insurance Code, is amended to
260	260	read as follows:
261	261	Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS EMOTIONAL
262	262	DISTURBANCE OF A CHILD AND SERIOUS MENTAL ILLNESS. (a) A [group]
263	263	health benefit plan:
264	264	(1) must provide coverage for serious emotional
265	265	disturbance of a child diagnosed as described by Section 1355.001
266	266	and coverage, based on medical necessity, for serious mental
267	267	illness for not less than the following treatments [of serious
268	268	mental illness] in each calendar year:
269	269	(A) 45 days of inpatient treatment; and
270	270	(B) 60 visits for outpatient treatment,
271	271	including group and individual outpatient treatment;
272	272	(2) may not include a lifetime limitation on the
273	273	number of days of inpatient treatment or the number of visits for
274	274	outpatient treatment covered under the plan; and
275	275	(3) must include the same amount limitations,
276	276	deductibles, copayments, and coinsurance factors for serious
277	277	emotional disturbance of a child and serious mental illness as the
278	278	plan includes for physical illness.
279	279	(b) A [group] health benefit plan issuer:
280	280	(1) may not count an outpatient visit for medication
281	281	management against the number of outpatient visits required to be
282	282	covered under Subsection (a)(1)(B); and
283	283	(2) must provide coverage for an outpatient visit
284	284	described by Subsection (a)(1)(B) under the same terms as the
285	285	coverage the issuer provides for an outpatient visit for the
286	286	treatment of physical illness.
287	287	SECTION 8. Section 1355.005, Insurance Code, is amended to
288	288	read as follows:
289	289	Sec. 1355.005. MANAGED CARE PLAN AUTHORIZED. A [group]
290	290	health benefit plan issuer may provide or offer coverage required
291	291	by Section 1355.004 through a managed care plan.
292	292	SECTION 9. Section 1355.006(b), Insurance Code, is amended
293	293	to read as follows:
294	294	(b) This subchapter does not require a [group] health
295	295	benefit plan to provide coverage for the treatment of:
296	296	(1) addiction to a controlled substance or marihuana
297	297	that is used in violation of law; or
298	298	(2) mental illness that results from the use of a
299	299	controlled substance or marihuana in violation of law.
300	300	SECTION 10. Subchapter A, Chapter 1355, Insurance Code, is
301	301	amended by adding Section 1355.008 to read as follows:
302	302	Sec. 1355.008. REQUIRED COVERAGE FOR EATING DISORDERS. (a)
303	303	A health benefit plan must provide coverage, based on medical
304	304	necessity, for the diagnosis and treatment of an eating disorder.
305	305	(b) Coverage required under Subsection (a) is limited to a
306	306	service or medication, to the extent the service or medication is
307	307	covered by the health benefit plan, ordered by a licensed
308	308	physician, psychiatrist, psychologist, or therapist within the
309	309	scope of the practitioner's license and in accordance with a
310	310	treatment plan.
311	311	(c) On request from the health benefit plan issuer, an
312	312	eating disorder treatment plan must include all elements necessary
313	313	for the issuer to pay a claim under the health benefit plan, which
314	314	may include a diagnosis, goals, and proposed treatment by type,
315	315	frequency, and duration.
316	316	(d) Coverage required under Subsection (a) is not subject to
317	317	a limit on the number of days of medically necessary treatment
318	318	except as provided by the treatment plan.
319	319	(e) A health benefit plan issuer may conduct a utilization
320	320	review of an eating disorder treatment plan not more than once each
321	321	six months unless the physician, psychiatrist, psychologist, or
322	322	therapist treating the enrollee under the treatment plan agrees
323	323	that a more frequent review is necessary. An agreement to conduct
324	324	more frequent review under this subsection applies only to the
325	325	enrollee who is the subject of the agreement.
326	326	(f) A health benefit plan issuer shall pay any costs of
327	327	conducting a utilization review of coverage required under
328	328	Subsection (a) or obtaining a treatment plan.
329	329	(g) In conducting a utilization review of treatment for an
330	330	eating disorder, including review of medical necessity or the
331	331	treatment plan, a utilization review agent shall consider:
332	332	(1) the overall medical and mental health needs of the
333	333	individual with the eating disorder;
334	334	(2) factors in addition to weight; and
335	335	(3) the most recent Practice Guideline for the
336	336	Treatment of Patients with Eating Disorders adopted by the American
337	337	Psychiatric Association.
338	338	SECTION 11. Section 1355.054(a), Insurance Code, is amended
339	339	to read as follows:
340	340	(a) Benefits of coverage provided under this subchapter may
341	341	be used only in a situation in which:
342	342	(1) the covered individual has a serious mental
343	343	illness or serious emotional disturbance of a child that requires
344	344	confinement of the individual in a hospital unless treatment is
345	345	available through a residential treatment center for children and
346	346	adolescents or a crisis stabilization unit; and
347	347	(2) the covered individual's mental illness or
348	348	emotional disturbance:
349	349	(A) substantially impairs the individual's
350	350	thought, perception of reality, emotional process, or judgment; or
351	351	(B) as manifested by the individual's recent
352	352	disturbed behavior, grossly impairs the individual's behavior.
353	353	SECTION 12. Chapter 1355, Insurance Code, is amended by
354	354	adding Subchapter F to read as follows:
355	355	SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE
356	356	USE DISORDERS
357	357	Sec. 1355.251. DEFINITIONS. In this subchapter:
358	358	(1) "Financial requirement" includes a requirement
359	359	relating to a deductible, copayment, coinsurance, or other
360	360	out-of-pocket expense or an annual or lifetime limit.
361	361	(2) "Mental health benefit" means a benefit relating
362	362	to an item or service for a mental health condition, as defined
363	363	under the terms of a health benefit plan and in accordance with
364	364	applicable federal and state law.
365	365	(3) "Nonquantitative treatment limitation" includes:
366	366	(A) a medical management standard limiting or
367	367	excluding benefits based on medical necessity or medical
368	368	appropriateness or based on whether a treatment is experimental or
369	369	investigational;
370	370	(B) formulary design for prescription drugs;
371	371	(C) network tier design;
372	372	(D) a standard for provider participation in a
373	373	network, including reimbursement rates;
374	374	(E) a method used by a health benefit plan to
375	375	determine usual, customary, and reasonable charges;
376	376	(F) a step therapy protocol;
377	377	(G) an exclusion based on failure to complete a
378	378	course of treatment; and
379	379	(H) a restriction based on geographic location,
380	380	facility type, provider specialty, and other criteria that limit
381	381	the scope or duration of a benefit.
382	382	(4) "Substance use disorder benefit" means a benefit
383	383	relating to an item or service for a substance use disorder, as
384	384	defined under the terms of a health benefit plan and in accordance
385	385	with applicable federal and state law.
386	386	(5) "Treatment limitation" includes a limit on the
387	387	frequency of treatment, number of visits, days of coverage, or
388	388	other similar limit on the scope or duration of treatment. The term
389	389	includes a nonquantitative treatment limitation.
390	390	Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
391	391	subchapter applies only to a health benefit plan that provides
392	392	benefits for medical or surgical expenses incurred as a result of a
393	393	health condition, accident, or sickness, including an individual,
394	394	group, blanket, or franchise insurance policy or insurance
395	395	agreement, a group hospital service contract, an individual or
396	396	group evidence of coverage, or a similar coverage document, that is
397	397	offered by:
398	398	(1) an insurance company;
399	399	(2) a group hospital service corporation operating
400	400	under Chapter 842;
401	401	(3) a fraternal benefit society operating under
402	402	Chapter 885;
403	403	(4) a stipulated premium company operating under
404	404	Chapter 884;
405	405	(5) a health maintenance organization operating under
406	406	Chapter 843;
407	407	(6) a reciprocal exchange operating under Chapter 942;
408	408	(7) a Lloyd's plan operating under Chapter 941;
409	409	(8) an approved nonprofit health corporation that
410	410	holds a certificate of authority under Chapter 844; or
411	411	(9) a multiple employer welfare arrangement that holds
412	412	a certificate of authority under Chapter 846.
413	413	(b) Notwithstanding Section 1501.251 or any other law, this
414	414	subchapter applies to coverage under a small employer health
415	415	benefit plan subject to Chapter 1501.
416	416	(c) This subchapter applies to a standard health benefit
417	417	plan issued under Chapter 1507.
418	418	Sec. 1355.253. EXCEPTIONS. (a) This subchapter does not
419	419	apply to:
420	420	(1) a plan that provides coverage:
421	421	(A) for wages or payments in lieu of wages for a
422	422	period during which an employee is absent from work because of
423	423	sickness or injury;
424	424	(B) as a supplement to a liability insurance
425	425	policy;
426	426	(C) for credit insurance;
427	427	(D) only for dental or vision care;
428	428	(E) only for hospital expenses; or
429	429	(F) only for indemnity for hospital confinement;
430	430	(2) a Medicare supplemental policy as defined by
431	431	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
432	432	1395ss(g)(1));
433	433	(3) a workers' compensation insurance policy;
434	434	(4) medical payment insurance coverage provided under
435	435	a motor vehicle insurance policy; or
436	436	(5) a long-term care policy, including a nursing home
437	437	fixed indemnity policy, unless the commissioner determines that the
438	438	policy provides benefit coverage so comprehensive that the policy
439	439	is a health benefit plan as described by Section 1355.252.
440	440	(b) To the extent that this section would otherwise require
441	441	this state to make a payment under 42 U.S.C. Section
442	442	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
443	443	C.F.R. Section 155.20, is not required to provide a benefit under
444	444	this subchapter that exceeds the specified essential health
445	445	benefits required under 42 U.S.C. Section 18022(b).
446	446	Sec. 1355.254. REQUIRED COVERAGE FOR MENTAL HEALTH
447	447	CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health benefit plan
448	448	must provide benefits for mental health conditions and substance
449	449	use disorders under the same terms and conditions applicable to
450	450	benefits for medical or surgical expenses.
451	451	(b) Coverage under Subsection (a) may not impose treatment
452	452	limitations or financial requirements on benefits for a mental
453	453	health condition or substance use disorder that are generally more
454	454	restrictive than treatment limitations or financial requirements
455	455	imposed on coverage of benefits for medical or surgical expenses.
456	456	Sec. 1355.255. DEFINITIONS UNDER PLAN. (a) A health
457	457	benefit plan must define a condition to be a mental health condition
458	458	or not a mental health condition in a manner consistent with
459	459	generally recognized independent standards of medical practice.
460	460	(b) A health benefit plan must define a condition to be a
461	461	substance use disorder or not a substance use disorder in a manner
462	462	consistent with generally recognized independent standards of
463	463	medical practice.
464	464	Sec. 1355.256. COORDINATION WITH OTHER LAW; INTENT OF
465	465	LEGISLATURE. This subchapter supplements Subchapters A and B of
466	466	this chapter and Chapter 1368 and the department rules adopted
467	467	under those statutes. It is the intent of the legislature that
468	468	Subchapter A or B of this chapter or Chapter 1368 or the department
469	469	rules adopted under those statutes controls in any circumstance in
470	470	which that other law requires:
471	471	(1) a benefit that is not required by this subchapter;
472	472	or
473	473	(2) a more extensive benefit than is required by this
474	474	subchapter.
475	475	Sec. 1355.257. RULES. The commissioner shall adopt rules
476	476	necessary to implement this subchapter.
477	477	SECTION 13. Section 1368.002, Insurance Code, is amended to
478	478	read as follows:
479	479	Sec. 1368.002. APPLICABILITY OF CHAPTER. (a) This chapter
480	480	applies only to a [group] health benefit plan that provides
481	481	hospital and medical coverage or services on an expense incurred,
482	482	service, or prepaid basis, including an individual, [a] group,
483	483	blanket, or franchise insurance policy or insurance agreement, a
484	484	group hospital service contract, an individual or group evidence of
485	485	coverage, or a similar coverage document, or self-funded or
486	486	self-insured plan or arrangement, that is offered in this state by:
487	487	(1) an insurer;
488	488	(2) a group hospital service corporation operating
489	489	under Chapter 842;
490	490	(3) a health maintenance organization operating under
491	491	Chapter 843; [or]
492	492	(4) an employer, trustee, or other self-funded or
493	493	self-insured plan or arrangement;
494	494	(5) a fraternal benefit society operating under
495	495	Chapter 885;
496	496	(6) a stipulated premium company operating under
497	497	Chapter 884;
498	498	(7) a reciprocal exchange operating under Chapter 942;
499	499	(8) a Lloyd's plan operating under Chapter 941;
500	500	(9) an approved nonprofit health corporation that
501	501	holds a certificate of authority under Chapter 844; or
502	502	(10) a multiple employer welfare arrangement that
503	503	holds a certificate of authority under Chapter 846.
504	504	(b) Notwithstanding Section 1501.251 or any other law, this
505	505	chapter applies to coverage under a small employer health benefit
506	506	plan subject to Chapter 1501.
507	507	(c) This chapter applies to a standard health benefit plan
508	508	issued under Chapter 1507.
509	509	SECTION 14. Section 1368.003, Insurance Code, is amended to
510	510	read as follows:
511	511	Sec. 1368.003. EXCEPTIONS [EXCEPTION]. (a) This chapter
512	512	does not apply to:
513	513	(1) an employer, trustee, or other self-funded or
514	514	self-insured plan or arrangement with 250 or fewer employees or
515	515	members;
516	516	(2) [an individual insurance policy;
517	517	[(3) an individual evidence of coverage issued by a
518	518	health maintenance organization;
519	519	[(4)] a health insurance policy that provides only:
520	520	(A) cash indemnity for hospital or other
521	521	confinement benefits;
522	522	(B) supplemental or limited benefit coverage;
523	523	(C) coverage for specified diseases or
524	524	accidents;
525	525	(D) disability income coverage; or
526	526	(E) any combination of those benefits or
527	527	coverages;
528	528	(3) [(5) a blanket insurance policy;
529	529	[(6)] a short-term travel insurance policy;
530	530	(4) [(7)] an accident-only insurance policy;
531	531	(5) [(8)] a limited or specified disease insurance
532	532	policy;
533	533	(6) [(9) an individual conversion insurance policy or
534	534	contract;
535	535	[(10)] a policy or contract designed for issuance to a
536	536	person eligible for Medicare coverage or other similar coverage
537	537	under a state or federal government plan; or
538	538	(7) [(11)] an evidence of coverage provided by a
539	539	health maintenance organization if the plan holder is the subject
540	540	of a collective bargaining agreement that was in effect on January
541	541	1, 1982, and that has not expired since that date.
542	542	(b) To the extent that this section would otherwise require
543	543	this state to make a payment under 42 U.S.C. Section
544	544	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
545	545	C.F.R. Section 155.20, is not required to provide a benefit under
546	546	this chapter that exceeds the specified essential health benefits
547	547	required under 42 U.S.C. Section 18022(b).
548	548	SECTION 15. Section 1368.004, Insurance Code, is amended to
549	549	read as follows:
550	550	Sec. 1368.004. COVERAGE REQUIRED. (a) A [group] health
551	551	benefit plan shall provide coverage for the necessary care and
552	552	treatment of chemical dependency.
553	553	(b) Coverage required under this section may be provided:
554	554	(1) directly by the [group] health benefit plan
555	555	issuer; or
556	556	(2) by another entity, including a single service
557	557	health maintenance organization, under contract with the [group]
558	558	health benefit plan issuer.
559	559	SECTION 16. Section 1368.005(b), Insurance Code, is amended
560	560	to read as follows:
561	561	(b) A [group] health benefit plan may set dollar or
562	562	durational limits for coverage required under this chapter that are
563	563	less favorable than for coverage provided for physical illness
564	564	generally under the plan if those limits are sufficient to provide
565	565	appropriate care and treatment under the guidelines and standards
566	566	adopted under Section 1368.007. If guidelines and standards
567	567	adopted under Section 1368.007 are not in effect, the dollar and
568	568	durational limits may not be less favorable than for physical
569	569	illness generally.
570	570	SECTION 17. Section 1355.007, Insurance Code, is repealed.
571	571	SECTION 18. (a) The Texas Department of Insurance shall
572	572	conduct a study and prepare a report on benefits for medical or
573	573	surgical expenses and for mental health conditions and substance
574	574	use disorders.
575	575	(b) In conducting the study, the department must collect and
576	576	compare data from health benefit plan issuers subject to Subchapter
577	577	F, Chapter 1355, Insurance Code, as added by this Act, on medical or
578	578	surgical benefits and mental health condition or substance use
579	579	disorder benefits that are:
580	580	(1) subject to prior authorization or utilization
581	581	review;
582	582	(2) denied as not medically necessary or experimental
583	583	or investigational;
584	584	(3) internally appealed, including data that
585	585	indicates whether the appeal was denied; or
586	586	(4) subject to an independent external review,
587	587	including data that indicates whether the denial was upheld.
588	588	(c) Not later than September 1, 2018, the department shall
589	589	report the results of the study and the department's findings.
590	590	SECTION 19. (a) The Health and Human Services Commission
591	591	shall conduct a study and prepare a report on benefits for medical
592	592	or surgical expenses and for mental health conditions and substance
593	593	use disorders provided by Medicaid managed care organizations.
594	594	(b) In conducting the study, the commission must collect and
595	595	compare data from Medicaid managed care organizations on medical or
596	596	surgical benefits and mental health condition or substance use
597	597	disorder benefits that are:
598	598	(1) subject to prior authorization or utilization
599	599	review;
600	600	(2) denied as not medically necessary or experimental
601	601	or investigational;
602	602	(3) internally appealed, including data that
603	603	indicates whether the appeal was denied; or
604	604	(4) subject to an independent external review,
605	605	including data that indicates whether the denial was upheld.
606	606	(c) Not later than September 1, 2018, the commission shall
607	607	report the results of the study and the commission's findings.
608	608	SECTION 20. The changes in law made by this Act to Chapters
609	609	1355 and 1368, Insurance Code, apply only to a health benefit plan
610	610	delivered, issued for delivery, or renewed on or after January 1,
611	611	2018. A health benefit plan delivered, issued for delivery, or
612	612	renewed before January 1, 2018, is governed by the law as it existed
613	613	immediately before the effective date of this Act, and that law is
614	614	continued in effect for that purpose.
615	615	SECTION 21. This Act takes effect September 1, 2017.