HBA-TYH H.B. 969 76(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 969 By: Van de Putte Insurance 3/1/1999 Introduced BACKGROUND AND PURPOSE Currently, Texas law does not require health benefit plans to cover the treatment of a child for congenital developmental defects or diseases, except that policies that provide maternity or dependent coverage must provide automatic coverage to a newborn child for congenital defects or abnormalities for the initial 31 days. H.B. 969 provides coverage to a child from birth until 18 years of age for medical procedures to treat abnormal structures of the head and neck, including craniofacial deformities caused by congenital defects or abnormalities. A health benefit plan is not required to provide coverage for cosmetic surgery procedures under this article. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority is expressly delegated to the Commissioner of Insurance in SECTION 1 (Section 8, Article 21.53W, Insurance Code) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding Article 21.53W, as follows: Art. 21.53W. COVERAGE FOR CRANIOFACIAL ABNORMALITIES Sec. 1. DEFINITIONS. Defines "enrollee" and "health benefit plan." Sec. 2. SCOPE OF ARTICLE. (a) Provides that this article applies to a health benefit plan that: (1) provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including: (A) an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group that has coverage under the enumerated entities; or (B) a health benefit plan that is offered by the enumerated entities, to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.) (Congressional Findings and Declaration of Policy); or (2) is offered by an approved nonprofit health corporation that is certified under Section 5.01(a), Medical Practice Act (Article 4495b, V.T.C.S.) (Medical Practice Act), and that holds a certificate of authority issued by the Commissioner of Insurance (commissioner) under Article 21.52F (Certification of Certain Nonprofit Health Corporations) of this code. (b) Provides that this article does not apply to: (1) a plan that provides coverage only for a specified disease or other limited benefit, only for accidental death or dismemberment, for wages or payments in lieu of wages 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; or only for indemnity for hospital confinement or other hospital expenses; (2) a small employer health benefit plan written under Chapter 26 (Health Insurance Availability) of this code; (3) a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss) (Certification of Medicare Supplemental Health Insurance Policies); (4) workers' compensation insurance coverage; (5) medical payment insurance issued as part of a motor vehicle insurance policy; or (6) a long-term care 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 Subsection (a) of this section. Sec. 3. COVERAGE REQUIRED. (a) Provides that a health benefit plan that provides benefits for a family member of an enrollee must provide coverage for each covered child described by Subsection (c) of this section, from birth through the date the child is 18 years of age, for medical procedures, including reconstructive surgery, to treat abnormal structures of the head and neck, including craniofacial abnormalities, caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease if the treatment is necessary in the opinion of the treating physician to improve the function of the structure or provide secondary and follow-up treatment, including additional surgery, to improve the function of the structure or to create a more normal appearance for the structure. (b) Provides that a child is entitled to benefits under this section if the child, as a result of the child's relationship to the enrollee in the health benefit plan, would be entitled to benefits under an accident and sickness insurance policy under Subsection (K), (L), or (M), Section 2, Chapter 397, Acts of the 54th Legislature, Regular Session, 1955 (Article 3.70-2, Vernon's Texas Insurance Code) (Form of Policy). Sec. 4. PREEXISTING CONDITION RESTRICTION PROHIBITED. Prohibits the benefits required under this article from being made subject to a provision that denies, excludes, or limits coverage of those benefits for a specified period after the effective date of coverage. Sec. 5. DEDUCTIBLE, COINSURANCE, AND COPAYMENT REQUIREMENTS. Prohibits the benefits required under this article from being made subject to a deductible, coinsurance, or copayment requirement that exceeds the deductible, coinsurance, or copayment requirements applicable to other similar benefits provided under the health benefit plan. Sec. 6. LIMITATIONS. Provides that a health benefit plan is not required to provide coverage under this article for cosmetic surgery procedures performed to reshape normal healthy structures of the body solely to improve an enrollee's appearance or self-esteem, unless it is a secondary or follow-up treatment, as provided by Section 3(a). Sec. 7. NOTICE. Requires each health benefit plan to provide to each enrollee under the plan written notice regarding the coverage required by this article in accordance with rules adopted by the commissioner. Sec. 8. RULES. Provides that the commissioner shall adopt rules as necessary to administer this article. SECTION 2. Provides that this Act takes effect September 1, 1999, and applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2000. Provides that a health benefit plan that is delivered, issued for delivery, or renewed before January 1, 2000, 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. Emergency clause.