HB233 - Relating to health benefit plan coverage for hair prostheses for breast cancer patients.

  89R4203 RDS-F     By: Gervin-Hawkins H.B. No. 233       A BILL TO BE ENTITLED   AN ACT   relating to health benefit plan coverage for hair prostheses for   breast cancer patients.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  The heading to Chapter 1371, Insurance Code, is   amended to read as follows:   CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES AND OTHER   PROSTHESES , ORTHOTIC DEVICES, AND RELATED SERVICES          SECTION 2.  Chapter 1371, Insurance Code, is amended by   designating Sections 1371.001 and 1371.002 as Subchapter A and   adding a subchapter heading to read as follows:   SUBCHAPTER A. GENERAL PROVISIONS          SECTION 3.  Chapter 1371, Insurance Code, is amended by   designating Sections 1371.003 through 1371.005 as Subchapter B and   adding a subchapter heading to read as follows:   SUBCHAPTER B. PROSTHETIC DEVICES, ORTHOTIC DEVICES, AND RELATED   SERVICES          SECTION 4.  Sections 1371.003(b), (c), and (e), Insurance   Code, are amended to read as follows:          (b)  Covered benefits under this subchapter [ chapter ] are   limited to the most appropriate model of prosthetic device or   orthotic device that adequately meets the medical needs of the   enrollee as determined by the enrollee's treating physician or   podiatrist and prosthetist or orthotist, as applicable.          (c)  Subject to applicable copayments and deductibles, the   repair and replacement of a prosthetic device or orthotic device is   a covered benefit under this subchapter [ chapter ] unless the repair   or replacement is necessitated by misuse or loss by the enrollee.          (e)  Covered benefits under this subchapter [ chapter ] may be   provided by a pharmacy that has employees who are qualified under   the Medicare system and applicable Medicaid regulations to service   and bill for orthotic services.  This subchapter [ chapter ] does not   preclude a pharmacy from being reimbursed by a health benefit plan   for the provision of orthotic services.          SECTION 5.  Section 1371.005, Insurance Code, is amended to   read as follows:          Sec. 1371.005.  MANAGED CARE PLAN. A health benefit plan   provider may require that, if coverage is provided through a   managed care plan, the benefits mandated under this subchapter   [ chapter ] are covered benefits only if the prosthetic devices or   orthotic devices are provided by a vendor or a provider, and related   services are rendered by a provider, that contracts with or is   designated by the health benefit plan provider.  If the health   benefit plan provider provides in-network and out-of-network   services, the coverage for prosthetic devices or orthotic devices   provided through out-of-network services must be comparable to that   provided through in-network services.          SECTION 6.  Chapter 1371, Insurance Code, is amended by   adding Subchapter C to read as follows:   SUBCHAPTER C. HAIR PROSTHESES FOR BREAST CANCER PATIENTS           Sec.   1371.051.     APPLICABILITY OF SUBCHAPTER.   (a) In   addition to a health benefit plan subject to this chapter under   Section 1371.002, this subchapter applies 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 or group evidence of coverage or similar coverage   document that is issued by an approved nonprofit health corporation   that holds a certificate of authority under Chapter 844.           (b)     Notwithstanding any other law, this subchapter applies   to:                 (1)     a standard health benefit plan issued under   Chapter 1507;                 (2)     nonprofit agricultural organization health   benefits offered by a nonprofit agricultural organization under   Chapter 1682;                 (3)     alternative health benefit coverage offered by a   subsidiary of the Texas Mutual Insurance Company under Subchapter   M, Chapter 2054;                 (4)     group health coverage made available by a school   district in accordance with Section 22.004, Education Code;                 (5)     the state Medicaid program, including the Medicaid   managed care program operated under Chapter 540, Government Code;                 (6)     the child health plan program under Chapter 62,   Health and Safety Code;                 (7)     a regional or local health care program operated   under Section 75.104, Health and Safety Code; and                 (8)     a self-funded health benefit plan sponsored by a   professional employer organization under Chapter 91, Labor Code.           (c)     This subchapter applies to coverage under a group health   benefit plan provided to a resident of this state regardless of   whether the group policy, agreement, or contract is delivered,   issued for delivery, or renewed in this state.           Sec.   1371.052.     REQUIRED COVERAGE FOR HAIR PROSTHESES FOR   CERTAIN CANCER PATIENTS. (a) A health benefit plan must provide   coverage for:                 (1)  a hair prosthesis:                       (A)     for an enrollee who is undergoing or has   undergone medical treatment for breast cancer; and                       (B)     determined by the enrollee's treating   physician to be appropriate for the enrollee in connection with the   side effects of the treatment described by Paragraph (A); and                 (2)     repair or replacement of a hair prosthesis   described by Subdivision (1) unless the repair or replacement is   necessitated by misuse or loss by the enrollee.           (b)     The benefit amount for the coverage required under   Subsection (a) must be not less than $100 for a hair prosthesis or   the repair or replacement of a hair prosthesis.           (c)     An additional premium may not be charged for the   coverage required by Subsection (a).           (d)     Coverage required under Subsection (a) may be subject to   the annual deductibles, copayments, and coinsurance that are   consistent with annual deductibles, copayments, and coinsurance   for other coverage under the health benefit plan.          SECTION 7.  If before implementing any provision of this Act   a state agency determines that a waiver or authorization from a   federal agency is necessary for implementation of that provision,   the agency affected by the provision shall request the waiver or   authorization and may delay implementing that provision until the   waiver or authorization is granted.          SECTION 8.  Subchapter C, Chapter 1371, 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 January 1,   2026. A health benefit plan delivered, issued for delivery, or   renewed before January 1, 2026, 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 9.  This Act takes effect September 1, 2025.