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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan coverage for brain injury. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1352.001, Insurance Code, is amended by |
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amending Subsection (b) and adding Subsections (c) and (d) to read |
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as follows: |
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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) [(2)] a primary care coverage plan under Chapter |
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1579; and |
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(4) [(3)] basic coverage under Chapter 1601. |
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(c) This chapter applies to group health coverage made |
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available by a school district in accordance with Section 22.004, |
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Education Code. |
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(d) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this chapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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SECTION 2. Section 1352.003, Insurance Code, is amended by |
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amending Subsections (c) and (d) and adding Subsections (c-1) and |
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(c-2) to read as follows: |
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(c) A health benefit plan may not include, in any annual or |
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lifetime limitation on the number of days of acute care treatment |
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covered under the plan, any post-acute care treatment covered under |
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the plan. Any limitation imposed under the plan on days of the |
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post-acute care treatment required by this chapter is subject to |
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Subsections (c-1) and (c-2) and must be clearly and separately |
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stated in the plan using language that specifically identifies each |
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therapy or treatment or rehabilitation, testing, remediation, or |
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other service described by Subsections (a) and (b) that is subject |
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to the limitation. A provision that purports to limit the number of |
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days of treatment under a health benefit plan that does not |
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specifically identify a particular therapy or treatment or testing, |
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remediation, or other service described by Subsection (a) or (b) is |
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void as applied to that therapy, treatment, or service. This |
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subsection does not authorize a limitation on the number of days of |
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treatment that is otherwise prohibited by state or federal law. |
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(c-1) Notwithstanding Subsection (c), a health benefit plan |
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may not limit the number of days of covered post-acute care, |
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including any therapy or treatment or rehabilitation, testing, |
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remediation, or other service described by Subsections (a) and (b), |
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or the number of days of covered inpatient care to the extent that |
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the treatment or care is determined to be medically necessary as a |
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result of and related to an acquired brain injury. The insured's or |
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enrollee's treating physician shall determine whether treatment or |
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care is medically necessary for purposes of this subsection in |
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consultation with the treatment or care provider, the insured or |
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enrollee, and, if appropriate, members of the insured's or |
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enrollee's family. The determination is subject to review under |
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Section 1352.006. |
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(c-2) A health benefit plan must provide coverage for |
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custodial care for an insured or enrollee if custodial care is |
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determined to be the appropriate level of care for the insured or |
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enrollee as a result of and related to an acquired brain injury. |
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Notwithstanding Subsection (c), a health benefit plan may not limit |
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the number of days of covered custodial care under this subsection. |
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The insured's or enrollee's treating physician shall determine |
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whether custodial care is the appropriate level of care for |
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purposes of this subsection in consultation with the care provider, |
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the insured or enrollee, and, if appropriate, members of the |
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insured's or enrollee's family. The determination is subject to |
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review under Section 1352.006 as if it were a determination of |
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medical necessity. |
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(d) Except as provided by Subsection (c), (c-1), or (c-2), a |
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health benefit plan must include the same payment limitations, |
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deductibles, copayments, and coinsurance factors for coverage |
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required under this chapter as applicable to other similar coverage |
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provided under the health benefit plan. |
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SECTION 3. Section 1352.007, Insurance Code, is amended by |
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adding Subsections (c), (d), (e), and (f) to read as follows: |
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(c) The issuer of a health benefit plan, including a |
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preferred provider benefit plan or health maintenance organization |
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plan, that contracts with a hospital to provide services under this |
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chapter to insureds and enrollees may not, solely because a |
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facility is an assisted living facility, refuse to contract with |
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that facility to provide services that are: |
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(1) required under this chapter; and |
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(2) within the scope of the license of the assisted |
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living facility. |
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(d) The issuer of a health benefit plan that requires or |
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encourages insureds or enrollees to use health care providers |
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designated by the plan shall ensure that the services required by |
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this chapter that are within the scope of the license of an assisted |
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living facility are made available and accessible to the insureds |
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or enrollees at an adequate number of assisted living facilities. |
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(e) A health benefit plan may not treat care provided in |
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accordance with this subchapter as custodial care solely because it |
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is provided by an assisted living facility. |
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(f) To ensure the health and safety of insureds and |
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enrollees, the commissioner by rule may require that an assisted |
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living facility that provides covered post-acute care other than |
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custodial care under this chapter to an insured or enrollee with |
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acquired brain injury meet specific criteria in addition to |
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licensure or obtain a nationally recognized accreditation |
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specified by the commissioner. |
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SECTION 4. Chapter 1352, Insurance Code, as amended by this |
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Act, applies only to a health benefit plan delivered, issued for |
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delivery, or renewed on or after January 1, 2014. A health benefit |
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plan delivered, issued for delivery, or renewed before January 1, |
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2014, is governed by the law in effect immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 5. This Act takes effect September 1, 2013. |