85S10492 PMO-F
By: Thompson of Harris H.B. No. 126
A BILL TO BE ENTITLED
AN ACT
relating to the requirement and study of insurance coverage for
serious emotional disturbance of a child.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1355.001, Insurance Code, is amended by
adding Subdivision (5) to read as follows:
(5) "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
three years of age and younger than 18 years of age; and
(B) meets at least one of the following criteria:
(i) the disorder or condition 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 or condition 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 or condition 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 or condition results in
the person meeting state special education eligibility
requirements for emotional disturbance.
SECTION 2. Subchapter A, Chapter 1355, Insurance Code, is
amended by adding Section 1355.0041 to read as follows:
Sec. 1355.0041. REQUIRED COVERAGE FOR SERIOUS EMOTIONAL
DISTURBANCE OF A CHILD. (a) Notwithstanding Section 1355.002,
this section does not apply to:
(1) a basic plan under Chapter 1575; or
(2) a primary care coverage plan under Chapter 1579.
(b) A group health benefit plan:
(1) must provide coverage for serious emotional
disturbance of a child, based on medical necessity, for not less
than the following treatments 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 as the plan includes for physical
illness.
(c) 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 (b)(1)(B); and
(2) must provide coverage for an outpatient visit
described by Subsection (b)(1)(B) under the same terms as the
coverage the issuer provides for an outpatient visit for the
treatment of physical illness.
(d) The department shall conduct a study to determine and
evaluate the extent to which enrollees make claims under coverage
for serious emotional disturbance of a child and the impact, if any,
the coverage for serious emotional disturbance of a child and the
claims have on the cost of the coverage for group health benefit
plans.
(e) Not later than August 1, 2018, the department shall
submit to the governor, the lieutenant governor, the speaker of the
house of representatives, and the appropriate standing committees
of the legislature a report regarding the results of the study
required by Subsection (d), together with any recommendations for
legislation.
(f) This subsection and Subsections (d) and (e) expire
September 1, 2019.
SECTION 3. Sections 1355.005 and 1355.007, Insurance Code,
are 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 or 1355.0041 through a managed care plan.
Sec. 1355.007. SMALL EMPLOYER COVERAGE. An issuer of a
group health benefit plan to a small employer must offer the
coverage described by Section 1355.004 or 1355.0041 to the employer
but is not required to provide the coverage if the employer rejects
the coverage.
SECTION 4. Section 1355.051, Insurance Code, is amended by
adding Subdivision (4) to read as follows:
(4) "Serious emotional disturbance of a child" has the
meaning assigned by Section 1355.001.
SECTION 5. Section 1355.053, Insurance Code, is amended to
read as follows:
Sec. 1355.053. REQUIRED COVERAGE FOR CERTAIN ILLNESSES,
[AND] DISORDERS, AND CONDITIONS. A group health benefit plan that
provides coverage for treatment of mental or emotional illness or
disorder or serious emotional disturbance of a child for a covered
individual when the individual is confined in a hospital must also
provide coverage for treatment in a residential treatment center
for children and adolescents or a crisis stabilization unit that is
at least as favorable as the coverage the plan provides for
treatment of mental or emotional illness or disorder or serious
emotional disturbance of a child in a hospital.
SECTION 6. 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 7. The change in law made by this Act applies only
to a group health benefit plan that is delivered, issued for
delivery, or renewed on or after April 1, 2018. A group health
benefit plan that is delivered, issued for delivery, or renewed
before April 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 8. This Act takes effect December 1, 2017.