Bill Text: TX HB16 | 2021 | 87th Legislature 1st Special Session | Introduced
Bill Title: Relating to health benefit plan coverage for hair prostheses for breast cancer patients.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced - Dead) 2021-07-07 - Filed [HB16 Detail]
Download: Texas-2021-HB16-Introduced.html
| 87S10064 RDS-F | ||
| By: Gervin-Hawkins | H.B. No. 16 | |
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| relating to health benefit plan coverage for hair prostheses for | ||
| breast cancer patients. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. The heading to Chapter 1371, Insurance Code, is | ||
| amended to read as follows: | ||
| CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES AND OTHER | ||
| PROSTHESES, ORTHOTIC DEVICES, AND RELATED SERVICES | ||
| SECTION 2. Chapter 1371, Insurance Code, is amended by | ||
| designating Sections 1371.001 and 1371.002 as Subchapter A and | ||
| adding a subchapter heading to read as follows: | ||
| SUBCHAPTER A. GENERAL PROVISIONS | ||
| SECTION 3. Chapter 1371, Insurance Code, is amended by | ||
| designating Sections 1371.003 through 1371.005 as Subchapter B and | ||
| adding a subchapter heading to read as follows: | ||
| SUBCHAPTER B. PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED | ||
| SERVICES | ||
| SECTION 4. Sections 1371.003(b), (c), and (e), Insurance | ||
| Code, are amended to read as follows: | ||
| (b) Covered benefits under this subchapter [ |
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| limited to the most appropriate model of prosthetic device or | ||
| orthotic device that adequately meets the medical needs of the | ||
| enrollee as determined by the enrollee's treating physician or | ||
| podiatrist and prosthetist or orthotist, as applicable. | ||
| (c) Subject to applicable copayments and deductibles, the | ||
| repair and replacement of a prosthetic device or orthotic device is | ||
| a covered benefit under this subchapter [ |
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| or replacement is necessitated by misuse or loss by the enrollee. | ||
| (e) Covered benefits under this subchapter [ |
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| provided by a pharmacy that has employees who are qualified under | ||
| the Medicare system and applicable Medicaid regulations to service | ||
| and bill for orthotic services. This subchapter [ |
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| preclude a pharmacy from being reimbursed by a health benefit plan | ||
| for the provision of orthotic services. | ||
| SECTION 5. Section 1371.005, Insurance Code, is amended to | ||
| read as follows: | ||
| Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan | ||
| provider may require that, if coverage is provided through a | ||
| managed care plan, the benefits mandated under this subchapter | ||
| [ |
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| orthotic devices are provided by a vendor or a provider, and related | ||
| services are rendered by a provider, that contracts with or is | ||
| designated by the health benefit plan provider. If the health | ||
| benefit plan provider provides in-network and out-of-network | ||
| services, the coverage for prosthetic devices or orthotic devices | ||
| provided through out-of-network services must be comparable to that | ||
| provided through in-network services. | ||
| SECTION 6. Chapter 1371, Insurance Code, is amended by | ||
| adding Subchapter C to read as follows: | ||
| SUBCHAPTER C. HAIR PROSTHESES FOR BREAST CANCER PATIENTS | ||
| Sec. 1371.051. APPLICABILITY OF SUBCHAPTER. (a) In | ||
| addition to a health benefit plan subject to this chapter under | ||
| Section 1371.002, this subchapter applies to a health benefit plan | ||
| that provides benefits for medical or surgical expenses incurred as | ||
| a result of a health condition, accident, or sickness, including an | ||
| individual or group evidence of coverage or similar coverage | ||
| document that is issued by an approved nonprofit health corporation | ||
| that holds a certificate of authority under Chapter 844. | ||
| (b) Notwithstanding any other law, this subchapter applies | ||
| to: | ||
| (1) a standard health benefit plan issued under | ||
| Chapter 1507; | ||
| (2) health benefits provided by or through a church | ||
| benefits board under Subchapter I, Chapter 22, Business | ||
| Organizations Code; | ||
| (3) group health coverage made available by a school | ||
| district in accordance with Section 22.004, Education Code; | ||
| (4) the state Medicaid program, including the Medicaid | ||
| managed care program operated under Chapter 533, Government Code; | ||
| (5) the child health plan program under Chapter 62, | ||
| Health and Safety Code; | ||
| (6) a regional or local health care program operated | ||
| under Section 75.104, Health and Safety Code; and | ||
| (7) a self-funded health benefit plan sponsored by a | ||
| professional employer organization under Chapter 91, Labor Code. | ||
| (c) This subchapter applies to coverage under a group health | ||
| benefit plan provided to a resident of this state regardless of | ||
| whether the group policy, agreement, or contract is delivered, | ||
| issued for delivery, or renewed in this state. | ||
| Sec. 1371.052. CONDITIONAL EXCEPTION. This subchapter does | ||
| not apply to a qualified health plan if a determination is made | ||
| under 45 C.F.R. Section 155.170 that: | ||
| (1) this subchapter requires the plan to offer | ||
| benefits in addition to the essential health benefits required | ||
| under 42 U.S.C. Section 18022(b); and | ||
| (2) this state is required to defray the cost of the | ||
| benefits mandated under this subchapter. | ||
| Sec. 1371.053. REQUIRED COVERAGE FOR HAIR PROSTHESES FOR | ||
| CERTAIN CANCER PATIENTS. (a) A health benefit plan must provide | ||
| coverage for: | ||
| (1) a hair prosthesis: | ||
| (A) for an enrollee who is undergoing or has | ||
| undergone medical treatment for breast cancer; and | ||
| (B) determined by the enrollee's treating | ||
| physician to be appropriate for the enrollee in connection with the | ||
| side effects of the treatment described by Paragraph (A); and | ||
| (2) repair or replacement of a hair prosthesis | ||
| described by Subdivision (1) unless the repair or replacement is | ||
| necessitated by misuse or loss by the enrollee. | ||
| (b) The benefit amount for the coverage required under | ||
| Subsection (a) must be not less than $100 for a hair prosthesis or | ||
| the repair or replacement of a hair prosthesis. | ||
| (c) An additional premium may not be charged for the | ||
| coverage required by Subsection (a). | ||
| (d) Coverage required under Subsection (a) may be subject to | ||
| the annual deductibles, copayments, and coinsurance that are | ||
| consistent with annual deductibles, copayments, and coinsurance | ||
| for other coverage under the health benefit plan. | ||
| SECTION 7. If before implementing any provision of this Act | ||
| a state agency determines that a waiver or authorization from a | ||
| federal agency is necessary for implementation of that provision, | ||
| the agency affected by the provision shall request the waiver or | ||
| authorization and may delay implementing that provision until the | ||
| waiver or authorization is granted. | ||
| SECTION 8. Subchapter C, Chapter 1371, Insurance Code, as | ||
| added by this Act, applies only to a health benefit plan that is | ||
| delivered, issued for delivery, or renewed on or after April 1, | ||
| 2022. A health benefit plan delivered, issued for delivery, or | ||
| renewed before April 1, 2022, 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 9. This Act takes effect December 1, 2021. | ||
