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  H.B. No. 1919
 
 
 
  AN ACT
  relating to health benefit plan coverage for treatment for certain
  brain injuries and serious mental illnesses.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1352.001, Insurance Code, is amended to
  read as follows:
         Sec. 1352.001.  APPLICABILITY OF CHAPTER. (a) This chapter
  applies only to a health benefit plan, including, subject to this
  chapter, a small employer health benefit plan written under Chapter
  1501, 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 fraternal benefit society operating under
  Chapter 885;
               (4)  a stipulated premium company operating under
  Chapter 884;
               (5)  a reciprocal exchange operating under Chapter 942;
               (6)  a Lloyd's plan operating under Chapter 941;
               (7)  a health maintenance organization operating under
  Chapter 843;
               (8)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846; or
               (9)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844.
         (b)  Notwithstanding any provision in Chapter 1575, 1579, or
  1601 or any other law, this chapter applies to:
               (1)  a basic plan under Chapter 1575;
               (2)  a primary care coverage plan under Chapter 1579;
  and
               (3)  basic coverage under Chapter 1601.
         SECTION 2.  Section 1352.003, Insurance Code, is amended to
  read as follows:
         Sec. 1352.003.  REQUIRED COVERAGES--HEALTH BENEFIT PLANS
  OTHER THAN SMALL EMPLOYER HEALTH BENEFIT PLANS [EXCLUSION OF
  COVERAGE PROHIBITED]. (a) A health benefit plan must include [may
  not exclude] coverage for cognitive rehabilitation therapy,
  cognitive communication therapy, neurocognitive therapy and
  rehabilitation, neurobehavioral, neurophysiological,
  neuropsychological, and [or] psychophysiological testing and [or]
  treatment, neurofeedback therapy, and remediation required for and
  related to treatment of an acquired brain injury.
         (b)  A health benefit plan must include coverage for [,]
  post-acute transition services, [or] community reintegration
  services, including outpatient day treatment services, or other
  post-acute care treatment services necessary as a result of and
  related to an acquired brain injury.
         (c)  A health benefit plan may not include, in any lifetime
  limitation on the number of days of acute care treatment covered
  under the plan, any post-acute care treatment covered under the
  plan. Any limitation imposed under the plan on days of post-acute
  care treatment must be separately stated in the plan.
         (d)  Except as provided by Subsection (c), a health benefit
  plan must include the same payment limitations, deductibles,
  copayments, and coinsurance factors for coverage [(b) Coverage]
  required under this chapter as [may be subject to deductibles,
  copayments, coinsurance, or annual or maximum payment limits that
  are consistent with the deductibles, copayments, coinsurance, or
  annual or maximum payment limits] applicable to other similar
  coverage provided under the health benefit plan.
         (e)  To ensure that appropriate post-acute care treatment is
  provided, a health benefit plan must include coverage for
  reasonable expenses related to periodic reevaluation of the care of
  an individual covered under the plan who:
               (1)  has incurred an acquired brain injury;
               (2)  has been unresponsive to treatment; and
               (3)  becomes responsive to treatment at a later date.
         (f)  A determination of whether expenses, as described by
  Subsection (e), are reasonable may include consideration of factors
  including:
               (1)  cost;
               (2)  the time that has expired since the previous
  evaluation;
               (3)  any difference in the expertise of the physician
  or practitioner performing the evaluation;
               (4)  changes in technology; and
               (5)  advances in medicine.
         (g) [(c)]  The commissioner shall adopt rules as necessary
  to implement this chapter [section].
         (h)  This section does not apply to a small employer health
  benefit plan.
         SECTION 3.  Chapter 1352, Insurance Code, is amended by
  adding Section 1352.0035 to read as follows:
         Sec. 1352.0035.  REQUIRED COVERAGES--SMALL EMPLOYER HEALTH
  BENEFIT PLANS. (a) A small employer health benefit plan may not
  exclude coverage for cognitive rehabilitation therapy, cognitive
  communication therapy, neurocognitive therapy and rehabilitation,
  neurobehavioral, neurophysiological, neuropsychological, or
  psychophysiological testing or treatment, neurofeedback therapy,
  remediation, post-acute transition services, or community
  reintegration services necessary as a result of and related to an
  acquired brain injury.
         (b)  Coverage required under this section may be subject to
  deductibles, copayments, coinsurance, or annual or maximum payment
  limits that are consistent with the deductibles, copayments,
  coinsurance, or annual or maximum payment limits applicable to
  other similar coverage provided under the small employer health
  benefit plan.
         (c)  The commissioner shall adopt rules as necessary to
  implement this section.
         SECTION 4.  Section 1352.004(b), Insurance Code, is amended
  to read as follows:
         (b)  The commissioner by rule shall require a health benefit
  plan issuer to provide adequate training to personnel responsible
  for preauthorization of coverage or utilization review under the
  plan. The purpose of the training is to prevent denial of coverage
  in violation of Section 1352.003 and to avoid confusion of medical
  benefits with mental health benefits. The commissioner, in
  consultation with the Texas Traumatic Brain Injury Advisory
  Council, shall prescribe by rule the basic requirements for the
  training described by this subsection.
         SECTION 5.  Chapter 1352, Insurance Code, is amended by
  adding Sections 1352.005, 1352.006, 1352.007, and 1352.008 to read
  as follows:
         Sec. 1352.005.  NOTICE TO INSUREDS AND ENROLLEES. (a) A
  health benefit plan issuer subject to this chapter, other than a
  small employer health benefit plan issuer, must annually notify
  each insured or enrollee under the plan in writing about the
  coverages described by Section 1352.003.
         (b)  The commissioner, in consultation with the Texas
  Traumatic Brain Injury Advisory Council, shall prescribe by rule
  the specific contents and wording of the notice required under this
  section.
         (c)  The notice required under this section must include:
               (1)  a description of the benefits listed under Section
  1352.003;
               (2)  a statement that the fact that an acquired brain
  injury does not result in hospitalization or receipt of a specific
  treatment or service described by Section 1352.003 for acute care
  treatment does not affect the right of the insured or enrollee to
  receive benefits described by Section 1352.003 commensurate with
  the condition of the insured or enrollee; and
               (3)  a statement of the fact that benefits described by
  Section 1352.003 may be provided in a facility listed in Section
  1352.007.
         Sec. 1352.006.  DETERMINATION OF MEDICAL NECESSITY;
  EXTENSION OF COVERAGE. (a) In this section, "utilization review"
  has the meaning assigned by Section 4201.002.
         (b)  Notwithstanding Chapter 4201 or any other law relating
  to the determination of medical necessity under this code, a health
  benefit plan shall respond to a person requesting utilization
  review or appealing for an extension of coverage based on an
  allegation of medical necessity not later than three business days
  after the date on which the person makes the request or submits the
  appeal. The person must make the request or submit the appeal in
  the manner prescribed by the terms of the plan's health insurance
  policy or agreement, contract, evidence of coverage, or similar
  coverage document. To comply with the requirements of this
  section, the health benefit plan issuer must respond through a
  direct telephone contact made by a representative of the issuer.
  This subsection does not apply to a small employer health benefit
  plan.
         Sec. 1352.007.  TREATMENT FACILITIES. (a) A health benefit
  plan may not deny coverage under this chapter based solely on the
  fact that the treatment or services are provided at a facility other
  than a hospital. Treatment for an acquired brain injury may be
  provided under the coverage required by this chapter, as
  appropriate, at a facility at which appropriate services may be
  provided, including:
               (1)  a hospital regulated under Chapter 241, Health and
  Safety Code, including an acute or post-acute rehabilitation
  hospital; and
               (2)  an assisted living facility regulated under
  Chapter 247, Health and Safety Code.
         (b)  This section does not apply to a small employer health
  benefit plan.
         Sec. 1352.008.  CONSUMER INFORMATION. The commissioner
  shall prepare information for use by consumers, purchasers of
  health benefit plan coverage, and self-insurers regarding
  coverages recommended for acquired brain injuries. The department
  shall publish information prepared under this section on the
  department's Internet website.
         SECTION 6.  The heading to Subchapter A, Chapter 1355,
  Insurance Code, is amended to read as follows:
  SUBCHAPTER A. GROUP HEALTH BENEFIT PLAN COVERAGE
  FOR CERTAIN SERIOUS MENTAL ILLNESSES AND OTHER DISORDERS
         SECTION 7.  Section 1355.001, Insurance Code, is amended by
  amending Subdivision (1) and adding Subdivisions (3) and (4) to
  read as follows:
               (1)  "Serious mental illness" means the following
  psychiatric illnesses as defined by the American Psychiatric
  Association in the Diagnostic and Statistical Manual (DSM):
                     (A)  bipolar disorders (hypomanic, manic,
  depressive, and mixed);
                     (B)  depression in childhood and adolescence;
                     (C)  major depressive disorders (single episode
  or recurrent);
                     (D)  obsessive-compulsive disorders;
                     (E)  paranoid and other psychotic disorders;
                     (F)  [pervasive developmental disorders;
                     [(G)]  schizo-affective disorders (bipolar or
  depressive); and
                     (G) [(H)]  schizophrenia.
               (3)  "Autism spectrum disorder" means a
  neurobiological disorder that includes autism, Asperger's
  syndrome, or Pervasive Developmental Disorder--Not Otherwise
  Specified.
               (4)  "Neurobiological disorder" means an illness of the
  nervous system caused by genetic, metabolic, or other biological
  factors.
         SECTION 8.  Subchapter A, Chapter 1355, Insurance Code, is
  amended by adding Section 1355.015 to read as follows:
         Sec. 1355.015.  REQUIRED COVERAGE FOR CERTAIN CHILDREN. (a)
  At a minimum, a health benefit plan must provide coverage as
  provided by this section to an enrollee older than two years of age
  and younger than six years of age who is diagnosed with autism
  spectrum disorder. If an enrollee who is being treated for autism
  spectrum disorder becomes six years of age or older and continues to
  need treatment, this subsection does not preclude coverage of
  treatment and services described by Subsection (b).
         (b)  The health benefit plan must provide coverage under this
  section to the enrollee for all generally recognized services
  prescribed in relation to autism spectrum disorder by the
  enrollee's primary care physician in the treatment plan recommended
  by that physician. An individual providing treatment prescribed
  under this subsection must be a health care practitioner:
               (1)  who is licensed, certified, or registered by an
  appropriate agency of this state;
               (2)  whose professional credential is recognized and
  accepted by an appropriate agency of the United States; or
               (3)  who is certified as a provider under the TRICARE
  military health system.
         (c)  For purposes of Subsection (b), "generally recognized
  services" may include services such as:
               (1)  evaluation and assessment services;
               (2)  applied behavior analysis;
               (3)  behavior training and behavior management;
               (4)  speech therapy;
               (5)  occupational therapy;
               (6)  physical therapy; or
               (7)  medications or nutritional supplements used to
  address symptoms of autism spectrum disorder.
         (d)  Coverage under Subsection (b) may be subject to annual
  deductibles, copayments, and coinsurance that are consistent with
  annual deductibles, copayments, and coinsurance required for other
  coverage under the health benefit plan.
         (e)  Notwithstanding any other law, this section does not
  apply to a standard health benefit plan provided under Chapter
  1507.
         SECTION 9.  This Act applies only to a health benefit plan
  delivered, issued for delivery, or renewed on or after January 1,
  2008. A health benefit plan delivered, issued for delivery, or
  renewed before January 1, 2008, 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 10.  This Act takes effect September 1, 2007.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 1919 was passed by the House on May
  11, 2007, by the following vote:  Yeas 120, Nays 17, 2 present, not
  voting; that the House refused to concur in Senate amendments to
  H.B. No. 1919 on May 25, 2007, and requested the appointment of a
  conference committee to consider the differences between the two
  houses; and that the House adopted the conference committee report
  on H.B. No. 1919 on May 28, 2007, by the following vote:  Yeas 105,
  Nays 34, 3 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 1919 was passed by the Senate, with
  amendments, on May 23, 2007, by the following vote:  Yeas 28, Nays
  3; at the request of the House, the Senate appointed a conference
  committee to consider the differences between the two houses; and
  that the Senate adopted the conference committee report on H.B. No.
  1919 on May 28, 2007, by the following vote:  Yeas 22, Nays 8.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor