87(1) HB 16 - Introduced version - Bill Text
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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 hair prostheses for |
 
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breast cancer patients. |
 
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             BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
 
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             SECTION  1.    The heading to Chapter 1371, Insurance Code, is |
 
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amended to read as follows: |
 
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CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES AND OTHER |
 
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PROSTHESES, ORTHOTIC DEVICES, AND RELATED SERVICES |
 
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             SECTION  2.    Chapter 1371, Insurance Code, is amended by |
 
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designating Sections 1371.001 and 1371.002 as Subchapter A and |
 
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adding a subchapter heading to read as follows: |
 
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SUBCHAPTER A. GENERAL PROVISIONS |
 
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             SECTION  3.    Chapter 1371, Insurance Code, is amended by |
 
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designating Sections 1371.003 through 1371.005 as Subchapter B and |
 
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adding a subchapter heading to read as follows: |
 
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SUBCHAPTER B. PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED |
 
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SERVICES |
 
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             SECTION  4.    Sections 1371.003(b), (c), and (e), Insurance |
 
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Code, are amended to read as follows: |
 
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             (b)    Covered benefits under this subchapter [chapter] are |
 
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limited to the most appropriate model of prosthetic device or |
 
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orthotic device that adequately meets the medical needs of the |
 
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enrollee as determined by the enrollee's treating physician or |
 
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podiatrist and prosthetist or orthotist, as applicable. |
 
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             (c)    Subject to applicable copayments and deductibles, the |
 
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repair and replacement of a prosthetic device or orthotic device is |
 
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a covered benefit under this subchapter [chapter] unless the repair |
 
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or replacement is necessitated by misuse or loss by the enrollee. |
 
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             (e)    Covered benefits under this subchapter [chapter] may be |
 
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provided by a pharmacy that has employees who are qualified under |
 
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the Medicare system and applicable Medicaid regulations to service |
 
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and bill for orthotic services.  This subchapter [chapter] does not |
 
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preclude a pharmacy from being reimbursed by a health benefit plan |
 
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for the provision of orthotic services. |
 
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             SECTION  5.    Section 1371.005, Insurance Code, is amended to |
 
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read as follows: |
 
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             Sec.  1371.005.    MANAGED CARE PLAN. A health benefit plan |
 
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provider may require that, if coverage is provided through a |
 
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managed care plan, the benefits mandated under this subchapter |
 
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[chapter] are covered benefits only if the prosthetic devices or |
 
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orthotic devices are provided by a vendor or a provider, and related |
 
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services are rendered by a provider, that contracts with or is |
 
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designated by the health benefit plan provider.  If the health |
 
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benefit plan provider provides in-network and out-of-network |
 
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services, the coverage for prosthetic devices or orthotic devices |
 
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provided through out-of-network services must be comparable to that |
 
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provided through in-network services. |
 
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             SECTION  6.    Chapter 1371, Insurance Code, is amended by |
 
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adding Subchapter C to read as follows: |
 
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SUBCHAPTER C. HAIR PROSTHESES FOR BREAST CANCER PATIENTS |
 
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             Sec.  1371.051.    APPLICABILITY OF SUBCHAPTER.  (a) In |
 
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addition to a health benefit plan subject to this chapter under |
 
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Section 1371.002, this subchapter applies to a health benefit plan |
 
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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 or group evidence of coverage or similar coverage |
 
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document that is issued by an approved nonprofit health corporation |
 
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that holds a certificate of authority under Chapter 844. |
 
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             (b)    Notwithstanding any other law, this subchapter applies |
 
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to: |
 
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                         (1)    a standard health benefit plan issued under |
 
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Chapter 1507; |
 
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                         (2)    health benefits provided by or through a church |
 
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benefits board under Subchapter I, Chapter 22, Business |
 
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Organizations Code; |
 
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                         (3)    group health coverage made available by a school |
 
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district in accordance with Section 22.004, Education Code; |
 
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                         (4)    the state Medicaid program, including the Medicaid |
 
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managed care program operated under Chapter 533, Government Code; |
 
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                         (5)    the child health plan program under Chapter 62, |
 
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Health and Safety Code; |
 
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                         (6)    a regional or local health care program operated |
 
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under Section 75.104, Health and Safety Code; and |
 
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                         (7)    a self-funded health benefit plan sponsored by a |
 
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professional employer organization under Chapter 91, Labor Code. |
 
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             (c)    This subchapter applies to coverage under a group health |
 
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benefit plan provided to a resid
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