HBA-ATS H.B. 1406 76(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 1406 By: Coleman Insurance 3/2/1999 Introduced BACKGROUND AND PURPOSE In 1997, the Texas Legislature amended Article 3.51-14, Insurance Code, by expanding the definition of "serious mental illness" and requiring certain health maintenance organizations and group insurance plans to provide coverage for the medical treatment of serious mental illness. In addition, minimum requirements were established for inpatient and outpatient treatment coverage, with plans being prohibited from including a lifetime limit on these restrictions. Although Article 3.51-14 applies to both adults and children, children face mental health issues unique to them. In children, mental disorders impair the ability to learn, to develop normal peer relationships, and to function in a family. Moreover, the various developmental stages of children can mask the symptoms of mental disorders. H.B. 1406 creates a separate statutory provision tailored to children younger than age 19. It expands the definition of "serious mental illness" from that found in Article 3.51-14, Insurance Code, and it amends Article 3.51.14, Insurance Code, by deleting depression in childhood and adolescence from the list of psychiatric illnesses that constitute a "serious mental illness." In addition, this bill provides that a child does not suffer from a serious mental illness solely because the child has mental retardation or epilepsy, commits alcohol or substance abuse or experiences a brief period of intoxication, or commits criminal or delinquent acts. Like Article 3.51.14, this bill requires certain health maintenance organizations and group insurance plans to provide coverage for the medical treatment of serious mental illness, and it establishes minimum requirements for inpatient and outpatient treatment coverage, with plans being prohibited from including a lifetime limit on these restrictions. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that this bill does not expressly delegate any additional rulemaking authority to a state officer, department, agency, or institution. SECTION BY SECTION ANALYSIS SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding Article 21.53R, as follows: Art. 21.53R. COVERAGE FOR CERTAIN SERIOUS MENTAL ILLNESSES IN CHILDREN Sec. 1. DEFINITIONS. Defines "child," "health benefit plan," and "serious mental illness." For purposes of this article, a "serious mental illness" includes depression, schizophrenia, paranoia, bipolar disorders, major depressive disorders, schizo-affective disorders, pervasive developmental disorders, obsessive-compulsive disorders, and other psychotic disorders. Also included within the definition is a diagnosable behavioral or emotional disorder or a neuropsychiatric condition that satisfies three conditions. First, it results in a serious disability requiring sustained treatment interventions. Second, it is of sufficient duration to meet diagnostic criteria specified in the American Psychiatric Association's Diagnostic and Statistical Manual designated as DSM-IV-R. Third, it impairs the thought, perception, affect, or behavior of a person, substantially interfering with or limiting the person's role or functioning in the person's community, school, family, or peer group. Sec. 2. SCOPE OF ARTICLE. (a) Specifies that Article 21.53R applies only to a comprehensive health benefit plan that provides benefits for medical or surgical expenses incurred because of a health condition, accident, or sickness. These types of plans include an individual, group, blanket, or franchise insurance policy or insurance agreement. Also included is individual or group coverage offered by an insurance company; a group hospital service corporation; a fraternal benefit society; a stipulated premium insurance company; a reciprocal exchange; a health maintenance organization; a small employer carrier; a multiple employer welfare arrangement; or an approved nonprofit health corporation. (b) Provides that Article 21.53R does not apply to a plan that provides coverage only for a specific disease or other limited benefit; only for accidental death or dismemberment; for wages or payments for a period during which an employee is absent from work because of sickness or injury; as a supplement to liability insurance; for credit insurance; only for dental or vision care; only for hospital expenses; or only for indemnity for hospital confinement. Also excluded is a Medicare supplemental policy; workers' compensation insurance coverage; medical payment insurance coverage issued as part of a motor vehicle insurance policy; or a long-term care policy. Sec. 3. REQUIRED COVERAGE FOR SERIOUS MENTAL ILLNESSES IN CHILDREN. (a) Sets forth that a health benefit plan (plan) must provide coverage for a child enrollee for 45 days of inpatient treatment and 60 visits for outpatient treatment, including group and individual outpatient treatment, in each calendar year. Prohibits a plan from including a lifetime limit on the number of days of inpatient treatment or the number of outpatient visits covered under the plan. Provides that a plan must include the same amount limits, deductibles, and coinsurance factors for serious mental illness as for physical illness. (b) Prohibits an issuer of a plan from counting toward the number of outpatient visits required to be covered under Subsection (a) of this section an outpatient visit for the purpose of medication management. Provides that an issuer of a plan must cover an outpatient visit for the purpose of medication management under the same terms and conditions as it covers outpatient visits for treatment of physical illness. (c) Authorizes an issuer of a plan to provide or offer coverage required under this section through another plan that is a managed care plan. Sec. 4. CERTAIN CONDITIONS EXCLUDED. Provides that a child does not suffer from a serious mental illness solely because the child has mental retardation or epilepsy, commits alcohol or substance abuse or experiences a brief period of intoxication, or commits criminal or delinquent acts. SECTION 2. Amends Section 1(1), Article 3.51-14, Insurance Code, by deleting depression in childhood and adolescence from the list of psychiatric illnesses which constitute a "serious mental illness." Makes a conforming change. SECTION 3. Amends Article 3.51-14, Insurance Code, by adding Section 6, to provide that this article does not apply to an enrollee younger than age 19. SECTION 4. Effective date: September 1, 1999. SECTION 5. Makes application of this Act prospective for health benefit plans that are delivered, issued for delivery, or renewed on or after January 1, 2000. SECTION 6. Emergency clause.