HBA-TYH, ATS H.B. 1764 76(R)BILL ANALYSIS Office of House Bill AnalysisH.B. 1764 By: Farabee Insurance 7/21/1999 Enrolled BACKGROUND AND PURPOSE On October 21, 1998, President Clinton signed the Women's Health and Cancer Rights Act of 1998 (Act) into law as part of the Omnibus Appropriations Act of 1998. The federal legislation governed most group health plans and health maintenance organizations provided by private and governmental employers. The Act required that if an eligible participant or beneficiary elects breast reconstruction in connection with a mastectomy, coverage must be provided for: reconstruction of the breast on which mastectomy has been performed, surgery on and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications, including lymphedemas, at all stages of mastectomy. Additionally, the law required notice to be provided to each enrollee regarding the coverage. H.B. 1764 amends Article 21.53D, Insurance Code, and redesignates it as Article 21.53I, to comply with these federal mandates. In addition, this bill prohibits a health benefit plan from conditioning, limiting, or denying the eligibility of an enrollee to enroll in the health benefit plan or to renew coverage under the terms of the plan solely to avoid the coverage requirements, and from reducing or limiting the reimbursement or payment of, or otherwise penalizing, an attending physician or provider or providing financial incentives or other benefits to an attending physician or provider to induce the attending physician or provider to provide care to an enrollee not permitted under Article 21.53I. This bill also adds a reciprocal exchange insurance company to the types of organizations which offer individual or group evidence of coverage subject to the requirements of redesignated Article 21.53I, Insurance Code. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority previously delegated to the commissioner of insurance is modified in SECTION 1 (Article 21.53I, Insurance Code) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Article 21.53D, Insurance Code, as added by Chapter 84, Acts of the 75th Legislature, Regular Session, 1997, by redesignating it as Article 21.53I and amending it, as follows: Art. 21.53I. COVERAGE FOR RECONSTRUCTIVE SURGERY AFTER MASTECTOMY Sec. 1. DEFINITIONS. Adds the definition of "enrollee." Sec. 2. SCOPE OF ARTICLE. (a) Includes a similar coverage document offered by an enumerated list of organizations among the types of documents that evidence coverage provided under a health benefit plan to which only Article 21.53I applies. Adds a reciprocal exchange operating under Chapter 19 (Reciprocal Exchanges) to the types of organizations that offer individual or group evidence of coverage subject to the requirements of Article 21.53I. Makes nonsubstantive and conforming changes. (b) Sets forth that a plan that provides coverage only for a specific disease or other limited benefit except for cancer is not governed by this article. Sets forth that a plan that provides coverage only for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury is not governed by this article. Sets forth that a plan that provides coverage only for indemnity for hospital confinement, rather than indemnity coverage only, is not governed by this article. Sets forth that a plan that provides coverage only for credit insurance is not governed by this article. Sets forth that a plan that provides coverage only for hospital expenses, rather than for specified accident, hospital indemnity, or other limited benefits health insurance policies, is not governed by this article. Removes small employer plans written under Chapter 26 (Health Insurance Availability) from the types of plans not governed by this article. Makes conforming and nonsubstantive changes. Sec. 3. COVERAGE REQUIRED. (a) Provides that a health benefit plan that provides coverage for mastectomy must provide coverage for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to achieve a symmetrical appearance, and prostheses and treatment of physical complications, including lymphedemas, at all stages of mastectomy. (b) Requires the coverage described in this section to be provided in the manner determined to be appropriate in consultation with the attending physician and the enrollee. (c) Authorizes the coverage described in this section to be subject to deductibles, copayments, and coinsurance provisions that are consistent with deductibles, copayments, and coinsurance required for analogous benefits under the health benefit plan. (d) Prohibits the benefits required by this subchapter from being subject to dollar limitations other than the health benefit plan's lifetime maximum benefits. Deletes the provision authorizing the coverage to be subject to the same deductible or copayment applicable to mastectomy. Sec. 4. New title: PROHIBITIONS. (a) Prohibits a health benefit plan from conditioning, limiting, or denying the eligibility of an enrollee to enroll in the health benefit plan or to renew coverage under the terms of the plan solely for the purpose of avoiding the requirements of this article. Prohibits a health benefit plan from reducing or limiting the reimbursement or payment of, or otherwise penalizing, an attending physician or provider or providing financial incentives or other benefits to an attending physician or provider to induce the attending physician or provider to provide care to an enrollee in a manner inconsistent with this article. (b) Adds this subsection to prohibit the construction of this section to prevent a health benefit plan from negotiating with a physician or provider the level and type of reimbursement that physician or provider will receive for care provided in accordance with this article. Sec. 5. NOTICE. Adds this section to require a health benefit plan that provides coverage under this article to give notice of the availability of that coverage to each enrollee in accordance with rules adopted by the commissioner of insurance (commissioner). Sec. 6. SEVERABILITY. Severability clause. Sec. 7. RULES. Authorizes the commissioner to adopt rules to implement this article and to meet the minimum requirements of federal law. SECTION 2. Provides that this Act applies to a health benefit plan in effect on the effective date of this Act or that is delivered, or issued for delivery, on or after the effective date of this Act. SECTION 3. Emergency clause. Effective date: upon passage.