HBA-TYH C.S.H.B. 969 76(R)BILL ANALYSIS Office of House Bill AnalysisC.S.H.B. 969 By: Van de Putte Insurance 4/26/1999 Committee Report (Substituted) 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. However, 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. C.S.H.B. 969 provides that a health benefit plan that provides benefits to a child who is younger than 18 years of age must define reconstructive surgery for craniofacial abnormalities under the plan to mean surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease. 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 4, 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: ARTICLE 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. Provides that a health benefit plan that provides benefits to a child who is younger than 18 years of age must define reconstructive surgery for craniofacial abnormalities under the plan to mean surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease. Sec. 4. RULES. Provides that the commissioner shall adopt rules as necessary to administer this article. SECTION 2. Effective date: September 1, 1999. Makes application of this Act prospective, as of January 1, 2000. SECTION 3. Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE The substitute modifies the original bill by changing the caption from "relating to coverage under certain health benefit plans for treatment of a child for craniofacial abnormalities" to "relating to the definition under certain health benefit plans of treatment for craniofacial abnormalities of a child." The substitute modifies the original bill in SECTION 1 (proposed Section 3, Article 21.53W, Insurance Code) by providing that a health benefit plan that provides benefits to a child who is younger than 18 years of age must define reconstructive surgery for craniofacial abnormalities under the plan to mean surgery to improve the function of, or to attempt to create a normal appearance of, an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease. Proposed Section 3(a) of the original bill provided that a health benefit plan must provide coverage for treatment of craniofacial abnormalities of a child. The substitute modifies the original bill in SECTION 1 by removing Sections 3(b) (relating to the child's entitlement to benefits), 4 (Preexisting Condition Restriction Prohibited), 5 (Deductible, Coinsurance, and Copayment Requirements), 6 (Limitations), and 7 (Notice) of the original bill. The substitute modifies the original bill in SECTION 1 by redesignating Section 8 (Rules) of the original bill to Section 4.