Bill Text: TX HB2541 | 2015-2016 | 84th Legislature | Engrossed
Bill Title: Relating to health benefit plan coverage of certain treatments for enrollees diagnosed with a terminal illness; authorizing administrative and civil penalties.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Engrossed - Dead) 2015-05-06 - Referred to Business & Commerce [HB2541 Detail]
Download: Texas-2015-HB2541-Engrossed.html
84R20872 PMO-F | ||
By: Zerwas, Guillen | H.B. No. 2541 |
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relating to health benefit plan coverage of certain treatments for | ||
enrollees diagnosed with a terminal illness; authorizing | ||
administrative and civil penalties. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subtitle E, Title 8, Insurance Code, is amended | ||
by adding Chapter 1372 to read as follows: | ||
CHAPTER 1372. ACCESS TO TREATMENT FOR INDIVIDUALS WITH A TERMINAL | ||
ILLNESS | ||
Sec. 1372.001. DEFINITIONS. In this chapter: | ||
(1) "Enrollee" means an individual entitled to | ||
coverage under a health benefit plan. | ||
(2) "Physician" means an individual licensed to | ||
practice medicine in this state. | ||
(3) "Terminal illness" means an illness or physical | ||
condition, including a physical injury, that can reasonably be | ||
expected to result in death within not more than two years. | ||
Sec. 1372.002. APPLICABILITY OF CHAPTER. (a) This chapter | ||
applies only 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, group, | ||
blanket, or franchise insurance policy or insurance agreement, a | ||
group hospital service contract, or an individual or group evidence | ||
of coverage or similar coverage document that is offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a health maintenance organization operating under | ||
Chapter 843; | ||
(4) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844; | ||
(5) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846; | ||
(6) a stipulated premium company operating under | ||
Chapter 884; | ||
(7) a fraternal benefit society operating under | ||
Chapter 885; or | ||
(8) an exchange operating under Chapter 942. | ||
(b) This chapter applies to group health coverage made | ||
available by a school district in accordance with Section 22.004, | ||
Education Code. | ||
(c) Notwithstanding any provision in Chapter 1551, 1575, | ||
1579, or 1601 or any other law, this chapter applies to health | ||
benefit plan coverage provided under: | ||
(1) Chapter 1551; | ||
(2) Chapter 1575; | ||
(3) Chapter 1579; and | ||
(4) Chapter 1601. | ||
(d) Notwithstanding Section 1501.251 or any other law, this | ||
chapter applies to coverage under a small employer health benefit | ||
plan subject to Chapter 1501. | ||
(e) This chapter applies to a consumer choice of benefits | ||
plan issued under Chapter 1507. | ||
(f) To the extent allowed by federal law, the child health | ||
plan program operated under Chapter 62, Health and Safety Code, the | ||
health benefits plan for children operated under Chapter 63, Health | ||
and Safety Code, the state Medicaid program, and a managed care | ||
organization that contracts with the Health and Human Services | ||
Commission to provide health care services to recipients through a | ||
managed care plan shall provide coverage to a recipient in | ||
accordance with this chapter. | ||
Sec. 1372.003. EXCEPTION TO APPLICABILITY OF CHAPTER. This | ||
chapter does not apply to: | ||
(1) a health benefit plan that provides coverage: | ||
(A) only for a specified disease or for another | ||
limited benefit; | ||
(B) only for accidental death or dismemberment; | ||
(C) for wages or payments in lieu of wages for a | ||
period during which an employee is absent from work because of | ||
sickness or injury; | ||
(D) as a supplement to a liability insurance | ||
policy; | ||
(E) for credit insurance; | ||
(F) only for dental or vision care; | ||
(G) only for hospital expenses; or | ||
(H) only for indemnity for hospital confinement; | ||
(2) a Medicare supplemental policy as defined by | ||
Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); | ||
(3) a workers' compensation insurance policy; | ||
(4) medical payment insurance coverage provided under | ||
a motor vehicle insurance policy; or | ||
(5) a long-term care insurance policy, including a | ||
nursing home fixed indemnity policy, unless the commissioner | ||
determines that the policy provides benefit coverage so | ||
comprehensive that the policy is a health benefit plan as described | ||
by Section 1372.002. | ||
Sec. 1372.004. APPLICABILITY TO CERTAIN TREATMENT. This | ||
chapter applies to treatment for an enrollee diagnosed by a | ||
physician with a terminal illness: | ||
(1) that is: | ||
(A) medically accepted as treatment for the | ||
terminal illness or another illness or condition with which the | ||
enrollee has been diagnosed by a physician; and | ||
(B) prescribed by a physician to treat the | ||
terminal illness or other illness or condition; and | ||
(2) to which the enrollee or the enrollee's legal | ||
guardian or other legal representative consents. | ||
Sec. 1372.005. CERTAIN DENIALS OF COVERAGE PROHIBITED. | ||
Notwithstanding any other law, a health benefit plan may not deny | ||
coverage for a treatment to which this chapter applies based solely | ||
on the enrollee's diagnosis with a terminal illness. | ||
Sec. 1372.006. PROHIBITED CONDUCT. A health benefit plan | ||
issuer or third-party administrator may not with respect to a | ||
treatment to which this chapter applies: | ||
(1) refuse to accept a physician's recommendation of | ||
the treatment based solely on the enrollee's diagnosis with a | ||
terminal illness; or | ||
(2) reduce, prohibit, or deny payment or other forms | ||
of reimbursement for the treatment based solely on the enrollee's | ||
diagnosis with a terminal illness. | ||
Sec. 1372.007. UNFAIR OR DECEPTIVE ACT OR PRACTICE; UNFAIR | ||
CLAIM SETTLEMENT PRACTICE. A violation of this chapter is an unfair | ||
or deceptive act or practice in the business of insurance for | ||
purposes of Chapter 541 and an unfair claim settlement practice for | ||
purposes of Chapter 542. | ||
Sec. 1372.008. ADMINISTRATIVE PENALTIES. A health benefit | ||
plan issuer or third-party administrator that commits a violation | ||
of this chapter is subject to administrative penalties under | ||
Chapters 82 and 84. | ||
SECTION 2. Chapter 1372, 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 September 1, 2015. A plan | ||
delivered, issued for delivery, or renewed before September 1, | ||
2015, 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 3. This Act takes effect September 1, 2015. |