Bill Text: TX HB3523 | 2017-2018 | 85th Legislature | Comm Sub

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Bill Title: Relating to health benefit plan coverage for hair prostheses for cancer patients.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2017-05-08 - Committee report sent to Calendars [HB3523 Detail]

Download: Texas-2017-HB3523-Comm_Sub.html

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85R27442 PMO-F
By: Gervin-Hawkins H.B. No. 3523
Substitute the following for H.B. No. 3523:
By: Phillips C.S.H.B. No. 3523

A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan coverage for hair prostheses for
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 [chapter] are
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 [chapter] unless the repair
or replacement is necessitated by misuse or loss by the enrollee.
(e) Covered benefits under this subchapter [chapter] may be
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 [chapter] does not
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
[chapter] are covered benefits only if the prosthetic devices or
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 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 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 January 1,
2018. A health benefit plan delivered, issued for delivery, or
renewed before January 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 9. This Act takes effect September 1, 2017.