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AN ACT
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relating to health benefit plan coverage for certain amino |
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acid-based elemental formulas. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle E, Title 8, Insurance Code, is amended |
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by adding Chapter 1377 to read as follows: |
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CHAPTER 1377. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL |
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FORMULAS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1377.001. DEFINITION. In this chapter, "enrollee" |
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means an individual entitled to coverage under a health benefit |
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plan. |
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Sec. 1377.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan, including a small employer |
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health benefit plan written under Chapter 1501 or coverage provided |
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by a health group cooperative under Subchapter B of that chapter, |
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that provides benefits for medical or surgical expenses incurred as |
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a result of a health condition, accident, or sickness, including an |
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individual, group, blanket, or franchise insurance policy or |
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insurance agreement, a group hospital service contract, or an |
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individual or group evidence of coverage or similar coverage |
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document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) an exchange operating under Chapter 942; |
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(6) a Lloyd's plan operating under Chapter 941; |
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(7) a health maintenance organization operating under |
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Chapter 843; |
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(8) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(9) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this chapter applies to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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and |
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(4) basic coverage under Chapter 1601. |
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Sec. 1377.003. EXCEPTION. This chapter does not apply to: |
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(1) a plan that provides coverage: |
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(A) only for benefits for a specified disease or |
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for another limited benefit, other than a plan that provides |
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benefits for a disease or disorder listed in Section 1377.051(a); |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) only for dental or vision care; or |
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(F) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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an automobile insurance policy; |
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(5) a credit insurance policy; |
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(6) a limited benefit policy that does not provide |
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coverage for physical examinations or wellness exams; or |
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(7) a long-term care insurance policy, including a |
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nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1377.002. |
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[Sections 1377.004-1377.050 reserved for expansion] |
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SUBCHAPTER B. COVERAGE FOR CERTAIN AMINO ACID-BASED ELEMENTAL |
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FORMULAS |
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Sec. 1377.051. REQUIRED COVERAGE FOR CERTAIN AMINO |
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ACID-BASED ELEMENTAL FORMULAS. (a) A health benefit plan must |
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provide coverage as provided by this chapter for amino acid-based |
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elemental formulas, regardless of the formula delivery method, that |
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are used for the diagnosis and treatment of: |
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(1) immunoglobulin E and non-immunoglobulin E |
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mediated allergies to multiple food proteins; |
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(2) severe food protein-induced enterocolitis |
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syndrome; |
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(3) eosinophilic disorders, as evidenced by the |
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results of a biopsy; and |
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(4) impaired absorption of nutrients caused by |
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disorders affecting the absorptive surface, functional length, and |
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motility of the gastrointestinal tract. |
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(b) Subject to Subsection (c), the coverage required under |
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Subsection (a) is required if the treating physician has issued a |
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written order stating that the amino acid-based elemental formula |
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is medically necessary for the treatment of an enrollee who is |
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diagnosed with a disease or disorder listed in Subsection (a). The |
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coverage must include coverage of any medically necessary services |
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associated with the administration of the formula. |
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(c) A health benefit plan must provide the coverage |
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described by Subsection (a) on a basis no less favorable than the |
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basis on which prescription drugs and other medications and related |
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services are covered by the plan, and to the same extent that the |
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plan provides coverage for drugs that are available only on the |
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orders of a physician. |
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Sec. 1377.052. UTILIZATION REVIEW. (a) A utilization |
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review agent acting on behalf of a health benefit plan issuer may |
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review a treating physician's determination of the medical |
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necessity of the use of an amino acid-based elemental formula for |
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the treatment of an enrollee who is diagnosed with a disease or |
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disorder listed in Section 1377.051(a). |
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(b) Utilization review under this section is subject to |
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Chapter 4201. |
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SECTION 2. Chapter 1377, Insurance Code, as added by this |
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Act, applies only to a health benefit plan that is delivered, issued |
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for delivery, or renewed on or after January 1, 2010. A health |
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benefit plan that is delivered, issued for delivery, or renewed |
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before January 1, 2010, is covered by the law in effect at the time |
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the plan was delivered, issued for delivery, or renewed, and that |
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law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2009. |
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______________________________ |
______________________________ |
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President of the Senate |
Speaker of the House |
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I certify that H.B. No. 2000 was passed by the House on May |
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14, 2009, by the following vote: Yeas 99, Nays 28, 1 present, not |
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voting; that the House refused to concur in Senate amendments to |
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H.B. No. 2000 on May 29, 2009, and requested the appointment of a |
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conference committee to consider the differences between the two |
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houses; and that the House adopted the conference committee report |
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on H.B. No. 2000 on May 31, 2009, by the following vote: Yeas 142, |
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Nays 0, 1 present, not voting. |
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______________________________ |
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Chief Clerk of the House |
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I certify that H.B. No. 2000 was passed by the Senate, with |
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amendments, on May 25, 2009, by the following vote: Yeas 28, Nays |
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3; at the request of the House, the Senate appointed a conference |
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committee to consider the differences between the two houses; and |
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that the Senate adopted the conference committee report on H.B. No. |
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2000 on May 31, 2009, by the following vote: Yeas 28, Nays 3. |
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______________________________ |
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Secretary of the Senate |
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APPROVED: __________________ |
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Date |
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__________________ |
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Governor |