By: Zaffirini S.B. No. 2218
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 1355.002, 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) an 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 any other law, this subchapter applies
to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter; and
(2) a standard health benefit plan issued under
Chapter 1507.
SECTION 3. The heading to Section 1355.003, Insurance Code,
is amended to read as follows:
Sec. 1355.003. EXCEPTIONS [EXCEPTION].
SECTION 4. 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 5. Section 1355.004, Insurance Code, is amended to
read as follows:
Sec. 1355.004. REQUIRED COVERAGE FOR SERIOUS MENTAL
ILLNESS. (a) A [group] health benefit plan:
(1) must provide coverage, based on medical necessity,
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
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 6. 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 7. 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 8. 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 a 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) an 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 any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter; and
(2) a standard health benefit plan issued under
Chapter 1507.
SECTION 9. 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 10. 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 11. 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 12. Section 1355.007, Insurance Code, is repealed.
SECTION 13. 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, 2020. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2020,
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 14. This Act takes effect September 1, 2019.