CHAPTER 1366. BENEFITS RELATED TO FERTILITY AND CHILDBIRTH
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1366. BENEFITS RELATED TO FERTILITY AND CHILDBIRTH
SUBCHAPTER A. COVERAGE FOR IN VITRO FERTILIZATION PROCEDURES
Sec. 1366.001. APPLICABILITY OF SUBCHAPTER. This subchapter
applies only to a group health benefit plan that provides
benefits for hospital, medical, or surgical expenses incurred as
a result of accident or sickness, including a group health
insurance policy, health care service contract or plan, or other
provision of group health benefits, coverage, or services in this
state that is issued, entered into, or provided by:
(1) an insurer;
(2) a group hospital service corporation operating under Chapter
842;
(3) a health maintenance organization operating under Chapter
843; or
(4) an employer, multiple employer, union, association, trustee,
or other self-funded or self-insured welfare or benefit plan,
program, or arrangement.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.002. EXCEPTION. This subchapter does not apply to:
(1) a credit accident and health insurance policy subject to
Chapter 1153;
(2) any group specifically provided for or authorized by law in
existence and covered under a policy filed with the State Board
of Insurance before April 1, 1975;
(3) accident and health coverages that are incidental to any
form of a group automobile, casualty, property, workers'
compensation, or employers' liability policy approved by the
commissioner; or
(4) any policy or contract of insurance with a state agency,
department, or board providing health services:
(A) to eligible individuals under Chapter 32, Human Resources
Code; or
(B) under a state plan adopted in accordance with 42 U.S.C.
Sections 1396-1396g, as amended, or 42 U.S.C. Section 1397aa et
seq., as amended.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.003. OFFER OF COVERAGE REQUIRED. (a) Subject to this
subchapter, an issuer of a group health benefit plan that
provides pregnancy-related benefits for individuals covered under
the plan shall offer and make available to each holder or sponsor
of the plan coverage for services and benefits on an expense
incurred, service, or prepaid basis for outpatient expenses that
arise from in vitro fertilization procedures.
(b) Benefits for in vitro fertilization procedures required
under this section must be provided to the same extent as
benefits provided for other pregnancy-related procedures under
the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.004. REJECTION OF OFFER. A rejection of an offer
under Section 1366.003 to provide coverage for in vitro
fertilization procedures must be in writing.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.005. CONDITIONS APPLICABLE TO COVERAGE. The coverage
offered under Section 1366.003 is required only if:
(1) the patient for the in vitro fertilization procedure is an
individual covered under the group health benefit plan;
(2) the fertilization or attempted fertilization of the
patient's oocytes is made only with the sperm of the patient's
spouse;
(3) the patient and the patient's spouse have a history of
infertility of at least five continuous years' duration or the
infertility is associated with:
(A) endometriosis;
(B) exposure in utero to diethylstilbestrol (DES);
(C) blockage of or surgical removal of one or both fallopian
tubes; or
(D) oligospermia;
(4) the patient has been unable to attain a successful pregnancy
through any less costly applicable infertility treatments for
which coverage is available under the group health benefit plan;
and
(5) the in vitro fertilization procedures are performed at a
medical facility that conforms to the minimal standards for
programs of in vitro fertilization adopted by the American
Society for Reproductive Medicine.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.006. CERTAIN ISSUERS OF HEALTH BENEFIT PLANS NOT
REQUIRED TO OFFER COVERAGE. An insurer, health maintenance
organization, or self-insuring employer that is owned by or that
is part of an entity, group, or order that is directly affiliated
with a bona fide religious denomination that includes as an
integral part of its beliefs and practices that in vitro
fertilization is contrary to moral principles that the religious
denomination considers to be an essential part of its beliefs is
not required to offer coverage for in vitro fertilization under
Section 1366.003.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.007. RULES. The commissioner may adopt rules
necessary to administer this subchapter. A rule adopted under
this section is subject to notice and hearing as provided by
Section 1201.007 for a rule adopted under Chapter 1201.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER B. MINIMUM INPATIENT STAY FOLLOWING BIRTH OF CHILD AND
POSTDELIVERY CARE
Sec. 1366.051. SHORT TITLE. This subchapter may be cited as the
Lee Alexandria Hanley Act.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.052. DEFINITIONS. In this subchapter:
(1) "Attending physician" means an obstetrician, pediatrician,
or other physician who attends a woman who has given birth to a
child or who attends a newborn child.
(2) "Postdelivery care" means postpartum health care services
provided in accordance with accepted maternal and neonatal
physical assessments. The term includes parent education,
assistance and training in breast-feeding and bottle-feeding, and
the performance of any necessary and appropriate clinical tests.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.053. APPLICABILITY OF SUBCHAPTER. This subchapter
applies only to a health benefit plan that:
(1) provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including:
(A) an individual, group, blanket, or franchise insurance policy
or insurance agreement, a group hospital service contract, or an
individual or group evidence of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation operating under
Chapter 842;
(iii) a fraternal benefit society operating under Chapter 885;
(iv) a stipulated premium company operating under Chapter 884;
or
(v) a health maintenance organization operating under Chapter
843; and
(B) to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health
benefit plan that is offered by:
(i) a multiple employer welfare arrangement as defined by
Section 3 of that Act;
(ii) an entity not authorized under this code or another
insurance law of this state that contracts directly for health
care services on a risk-sharing basis, including a capitation
basis; or
(iii) another analogous benefit arrangement; or
(2) is offered by an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.054. EXCEPTION. This subchapter does not apply to:
(1) a 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; or
(G) 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 1366.053.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.055. COVERAGE FOR INPATIENT CARE REQUIRED. (a)
Except as provided by Subsection (b), a health benefit plan that
provides maternity benefits, including benefits for childbirth,
must provide to a woman who has given birth to a child and the
newborn child coverage for inpatient care in a health care
facility for not less than:
(1) 48 hours after an uncomplicated vaginal delivery; and
(2) 96 hours after an uncomplicated delivery by cesarean
section.
(b) A health benefit plan that provides to a woman who has given
birth to a child and the newborn child coverage for in-home
postdelivery care is not required to provide the coverage
required under Subsection (a) unless:
(1) the attending physician determines that inpatient care is
medically necessary; or
(2) the woman requests inpatient care.
(c) For purposes of Subsection (a), the attending physician
shall determine whether a delivery is complicated.
(d) This section does not require a woman who is eligible for
coverage under a health benefit plan to:
(1) give birth to a child in a hospital or other health care
facility; or
(2) remain under inpatient care in a hospital or other health
care facility for any fixed term following the birth of a child.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.056. COVERAGE FOR POSTDELIVERY CARE REQUIRED. (a) If
a decision is made to discharge a woman who has given birth to a
child or the newborn child from inpatient care before the
expiration of the minimum hours of coverage required under
Section 1366.055(a), a health benefit plan must provide to the
woman and child coverage for timely postdelivery care.
(b) The timeliness of the postdelivery care shall be determined
in accordance with recognized medical standards for that care.
(c) The postdelivery care may be provided by a physician,
registered nurse, or other appropriate licensed health care
provider.
(d) Subject to Subsection (e), the postdelivery care may be
provided at:
(1) the woman's home;
(2) a health care provider's office;
(3) a health care facility; or
(4) another location determined to be appropriate under rules
adopted by the commissioner.
(e) The coverage required under this section must give the woman
the option to have the care provided in the woman's home.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.057. PROHIBITED CONDUCT. An issuer of a health
benefit plan may not:
(1) modify the terms and conditions of coverage based on a
request by an enrollee for less than the minimum coverage
required under Section 1366.055(a);
(2) offer to a woman who has given birth to a child a financial
incentive or other compensation the receipt of which is
contingent on the waiver by the woman of the minimum coverage
required under Section 1366.055(a);
(3) refuse to accept a physician's recommendation for inpatient
care made in consultation with the woman who has given birth to a
child if the period of inpatient care recommended by the
physician does not exceed the minimum periods recommended in
guidelines for perinatal care developed by:
(A) the American College of Obstetricians and Gynecologists;
(B) the American Academy of Pediatrics; or
(C) another nationally recognized professional association of
obstetricians and gynecologists or of pediatricians;
(4) reduce payments or other forms of reimbursement for
inpatient care below the usual and customary rate of
reimbursement for that care; or
(5) penalize a physician for recommending inpatient care for a
woman or the woman's newborn child by:
(A) refusing to permit the physician to participate as a
provider in the health benefit plan;
(B) reducing payments made to the physician;
(C) requiring the physician to:
(i) provide additional documentation; or
(ii) undergo additional utilization review; or
(D) imposing other analogous sanctions or disincentives.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.058. NOTICE OF COVERAGE. (a) An issuer of a health
benefit plan shall provide to each individual enrolled in the
plan written notice of the coverage required under this
subchapter.
(b) The notice must be provided in accordance with rules adopted
by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1366.059. RULES. The commissioner shall adopt rules
necessary to administer this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.