group plans cover serious emotional disturbance in kids

The text as introduced · 929 words

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.