HB709 - Relating to the requirement and study of insurance coverage for serious emotional disturbance of a child.

  89R679 MEW-F     By: Thompson H.B. No. 709       A BILL TO BE ENTITLED   AN ACT   relating to the requirement and study of insurance coverage for   serious emotional disturbance of a child.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 1355.001, Insurance Code, is amended by   adding Subdivision (5) to read as follows:                 (5)     "Serious emotional disturbance of a child" means a   diagnosable mental, behavioral, or emotional disorder of   sufficient duration to meet diagnostic criteria specified in the   Diagnostic and Statistical Manual of Mental Disorders that results   in functional impairment that substantially interferes with or   limits a child's role or functioning in family, school, or   community services and that:                       (A)     has been diagnosed or identified, as   applicable, in a person who is at least three years of age and   younger than 18 years of age by:                             (i)     a physician licensed to practice   medicine in this state and practicing within the scope of the   physician's license; or                             (ii)     a psychologist, licensed professional   counselor, licensed marriage and family therapist, or licensed   clinical social worker licensed to practice in this state and   practicing within the scope of the applicable license; and                       (B)  meets at least one of the following criteria:                             (i)     the disorder substantially impairs the   person's ability in at least two of the following activities or   tasks:                                   (a)  self-care;                                   (b)  engaging in family relationships;                                   (c)  functioning in school; or                                   (d)  functioning in the community;                             (ii)     the disorder creates a risk that the   person will be removed from the person's home and placed in a more   restrictive environment, including in a facility or program   operated by the Department of Family and Protective Services or an   agency that is part of the juvenile justice system;                             (iii)  the disorder causes the person to:                                   (a)     display psychotic features or   violent behavior; or                                   (b)     pose a danger to the person's self   or others; or                             (iv)     the disorder results in the person   meeting state special education eligibility requirements for   emotional disturbance.          SECTION 2.  Subchapter A, Chapter 1355, Insurance Code, is   amended by adding Section 1355.0041 to read as follows:           Sec.   1355.0041.     REQUIRED COVERAGE FOR SERIOUS EMOTIONAL   DISTURBANCE OF A CHILD. (a)   A group health benefit plan:                 (1)     must provide coverage for serious emotional   disturbance of a child, based on medical necessity, for not less   than the following treatments in each calendar year:                       (A)  45 days of inpatient treatment; and                       (B)     60 visits for outpatient treatment,   including group and individual outpatient treatment;                 (2)     may not include a lifetime limitation on the   number of days of inpatient treatment or the number of visits for   outpatient treatment covered under the plan; and                 (3)     must include the same amount limitations,   deductibles, copayments, and coinsurance factors for serious   emotional disturbance of a child as the plan includes for physical   illness.           (b)  A group health benefit plan issuer:                 (1)     may not count an outpatient visit for medication   management against the number of outpatient visits required to be   covered under Subsection (a)(1)(B); and                 (2)     must provide coverage for an outpatient visit   described by Subsection (a)(1)(B) under the same terms as the   coverage the issuer provides for an outpatient visit for the   treatment of physical illness.           (c)     The department shall conduct a study to determine and   evaluate the extent to which enrollees are making claims under   coverage for serious emotional disturbance of a child and the   impact, if any, the coverage for serious emotional disturbance of a   child and the claims have on the cost of the coverage for group   health benefit plans.           (d)     Not later than December 1, 2026, the department shall   submit to the governor, the lieutenant governor, the speaker of the   house of representatives, and the appropriate standing committees   of the legislature a report regarding the results of the study   required by Subsection (c), together with any recommendations for   legislation.           (e)     This subsection and Subsections (c) and (d) expire   September 1, 2027.          SECTION 3.  Sections 1355.005 and 1355.007, Insurance Code,   are amended to read as follows:          Sec. 1355.005.  MANAGED CARE PLAN AUTHORIZED. A group   health benefit plan issuer may provide or offer coverage required   by Section 1355.004 or 1355.0041 through a managed care plan.          Sec. 1355.007.  SMALL EMPLOYER COVERAGE. An issuer of a   group health benefit plan to a small employer must offer the   coverage described by Section 1355.004 or 1355.0041 to the employer   but is not required to provide the coverage if the employer rejects   the coverage.          SECTION 4.  Section 1355.054(a), Insurance Code, is amended   to read as follows:          (a)  Benefits of coverage provided under this subchapter may   be used only in a situation in which:                (1)  the covered individual has a serious mental   illness or serious emotional disturbance of a child as defined by   Section 1355.001 that requires confinement of the individual in a   hospital unless treatment is available through a residential   treatment center for children and adolescents or a crisis   stabilization unit; and                (2)  the covered individual's mental illness or   emotional disturbance :                      (A)  substantially impairs the individual's   thought, perception of reality, emotional process, or judgment; or                      (B)  as manifested by the individual's recent   disturbed behavior, grossly impairs the individual's behavior.          SECTION 5.  The change in law made by this Act applies only   to a group health benefit plan that is delivered, issued for   delivery, or renewed on or after January 1, 2026. A group health   benefit plan that is 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 6.  This Act takes effect September 1, 2025.