84R8575 PMO-F
 
  By: Zerwas H.B. No. 2541
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit plan coverage of certain treatments for
  enrollees diagnosed with a terminal illness; authorizing
  administrative and civil penalties.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle E, Title 8, Insurance Code, is amended
  by adding Chapter 1372 to read as follows:
  CHAPTER 1372. ACCESS TO TREATMENT FOR INDIVIDUALS WITH A TERMINAL
  ILLNESS
         Sec. 1372.001.  DEFINITIONS. In this chapter:
               (1)  "Enrollee" means an individual entitled to
  coverage under a health benefit plan.
               (2)  "Physician" means an individual licensed to
  practice medicine in this state.
               (3)  "Terminal illness" means an illness or physical
  condition, including a physical injury, that can reasonably be
  expected to result in death within not more than two years.
         Sec. 1372.002.  APPLICABILITY OF CHAPTER. (a) This chapter
  applies only to a health benefit plan that provides benefits for
  medical or surgical expenses incurred as a result of a health
  condition, accident, or sickness, including an individual, group,
  blanket, or franchise insurance policy or insurance agreement, a
  group hospital service contract, or an individual or group evidence
  of coverage or similar coverage document that is offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a health maintenance organization operating under
  Chapter 843;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846;
               (6)  a stipulated premium company operating under
  Chapter 884;
               (7)  a fraternal benefit society operating under
  Chapter 885; or
               (8)  an exchange operating under Chapter 942.
         (b)  Notwithstanding Section 172.014, Local Government Code,
  or any other law, this chapter applies to health and accident
  coverage provided by a risk pool created under Chapter 172, Local
  Government Code.
         (c)  This chapter applies to group health coverage made
  available by a school district in accordance with Section 22.004,
  Education Code.
         (d)  Notwithstanding any provision in Chapter 1551, 1575,
  1579, or 1601 or any other law, this chapter applies to health
  benefit plan coverage provided under:
               (1)  Chapter 1551;
               (2)  Chapter 1575;
               (3)  Chapter 1579; and
               (4)  Chapter 1601.
         (e)  Notwithstanding Section 1501.251 or any other law, this
  chapter applies to coverage under a small employer health benefit
  plan subject to Chapter 1501.
         (f)  This chapter applies to a consumer choice of benefits
  plan issued under Chapter 1507.
         (g)  To the extent allowed by federal law, the child health
  plan program operated under Chapter 62, Health and Safety Code, the
  health benefits plan for children operated under Chapter 63, Health
  and Safety Code, the state Medicaid program, and a managed care
  organization that contracts with the Health and Human Services
  Commission to provide health care services to recipients through a
  managed care plan shall provide coverage to a recipient in
  accordance with this chapter.
         Sec. 1372.003.  EXCEPTION TO APPLICABILITY OF CHAPTER. This
  chapter does not apply to:
               (1)  a health benefit plan that provides coverage:
                     (A)  only for a specified disease or for another
  limited benefit;
                     (B)  only for accidental death or dismemberment;
                     (C)  for wages or payments in lieu of wages for a
  period during which an employee is absent from work because of
  sickness or injury;
                     (D)  as a supplement to a liability insurance
  policy;
                     (E)  for credit insurance;
                     (F)  only for dental or vision care;
                     (G)  only for hospital expenses; or
                     (H)  only for indemnity for hospital confinement;
               (2)  a Medicare supplemental policy as defined by
  Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
               (3)  a workers' compensation insurance policy;
               (4)  medical payment insurance coverage provided under
  a motor vehicle insurance policy; or
               (5)  a long-term care insurance 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 Section 1372.002.
         Sec. 1372.004.  APPLICABILITY TO CERTAIN TREATMENT. This
  chapter applies to treatment for an enrollee diagnosed by a
  physician with a terminal illness:
               (1)  that is:
                     (A)  medically accepted as treatment for the
  terminal illness or another illness or condition with which the
  enrollee has been diagnosed by a physician; and
                     (B)  prescribed by a physician to treat the
  terminal illness or other illness or condition; and
               (2)  to which the enrollee or the enrollee's legal
  guardian or other legal representative consents.
         Sec. 1372.005.  CERTAIN DENIALS OF COVERAGE PROHIBITED.
  Notwithstanding any other law, a health benefit plan may not deny
  coverage for a treatment to which this chapter applies based solely
  on the enrollee's diagnosis with a terminal illness.
         Sec. 1372.006.  PROHIBITED CONDUCT. A health benefit plan
  issuer or third-party administrator may not with respect to a
  treatment to which this chapter applies:
               (1)  refuse to accept a physician's recommendation of
  the treatment based solely on the enrollee's diagnosis with a
  terminal illness; or
               (2)  reduce, prohibit, or deny payment or other forms
  of reimbursement for the treatment based solely on the enrollee's
  diagnosis with a terminal illness.
         Sec. 1372.007.  UNFAIR OR DECEPTIVE ACT OR PRACTICE; UNFAIR
  CLAIM SETTLEMENT PRACTICE. A violation of this chapter is an unfair
  or deceptive act or practice in the business of insurance for
  purposes of Chapter 541 and an unfair claim settlement practice for
  purposes of Chapter 542.
         Sec. 1372.008.  ADMINISTRATIVE PENALTIES. A health benefit
  plan issuer or third-party administrator that commits a violation
  of this chapter is subject to administrative penalties under
  Chapters 82 and 84.
         SECTION 2.  Chapter 1372, Insurance Code, as added by this
  Act, applies only to a health benefit plan that is delivered, issued
  for delivery, or renewed on or after September 1, 2015. A plan
  delivered, issued for delivery, or renewed before September 1,
  2015, 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.  This Act takes effect September 1, 2015.