HBA-ATS H.B. 1764 76(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 1764 By: Farabee Insurance 3/3/1999 Introduced 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 governs most group health plans and health maintenance organizations provided by private and governmental employers. The Act requires 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 for physical complications of all stages of mastectomy, including lymphedemas. Additionally, the law requires notice to be provided to each enrollee regarding the coverage. H.B. 1764 amends Article 21.53D, Insurance Code, to comply with these federal mandates. In addition, this bill prohibits an insurer from denying eligibility or continued eligibility to enroll or to renew coverage to avoid the coverage requirements, and from penalizing or limiting reimbursement or payment of a provider or providing incentives to a provider to induce the provider not to provide the required coverage. 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 Article 21.53D, 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 21.53D, Insurance Code) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Article 21.53D, Insurance Code, as follows: Sec. 1. DEFINITIONS. Adds the definition of "enrollee." Sec. 2. SCOPE OF ARTICLE. (a) Adds a reciprocal exchange operating under Chapter 19 (Reciprocal Exchanges) to the types of organizations which offer individual or group evidence of coverage subject to the requirements of Article 21.53D (Coverage for Reconstructive Surgery After Mastectomy). Makes nonsubstantive and conforming changes. (b) Sets forth that a plan that provides coverage only for a specific disease or 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 for specified accident, hospital indemnity, or other limited benefits health insurance policies, 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 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 breast reconstruction 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 physical complications at all stages of mastectomy including lymphedemas. Deletes the provision authorizing the coverage to be subject to the same deductible or copayment applicable to 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 annual deductibles, copayments and coinsurance provisions so long as they are consistent with annual deductibles, copayments and coinsurance provisions established for other 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. Sec. 4. PROHIBITIONS. (a) Prohibits a health benefit plan from conditioning, limiting, or denying eligibility or continued eligibility to an enrollee, to enroll or to renew coverage under the terms of the health benefit plan, solely for the purpose of avoiding the requirements of this article. Prohibits a health benefit plan from providing monetary payments or rebates to individuals to encourage enrollees to accept less than the minimum protections required under this article. Prohibits a health benefit plan from penalizing or otherwise reducing or limiting the reimbursement or payment of an attending physician or provider because such attending physician or provider provided care to an enrollee in accordance with this article. Prohibits a health benefit plan from providing financial incentives or other benefits to an attending physician or provider to induce such attending physician or provider to provide care to an enrollee in a manner inconsistent with this article. (b) Adds this subsection to provide that nothing in this section shall be construed to prevent a health benefit plan from negotiating the level and type of reimbursement with a physician or provider 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 to each enrollee regarding the coverage in accordance with rules adopted by the Commissioner of Insurance (commissioner). Sec. 6. Severability clause. Sec. 7. RULES. Redesignates existing Section 5 to this section and authorizes the commissioner to adopt rules to implement this article and to meet the minimum requirements of federal law. SECTION 2. Requires this Act to apply to health benefit plans currently in effect and to those issued or delivered on or after the date of enactment. SECTION 3.Emergency clause. Effective date: 90 days after adjournment.