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6.3 Million Texans May Be In For An Unpleasant Surprise

JULY 21, 2003
AUSTIN, TX — Texas consumers may be in for a rude awakening when they start renewing their health insurance policies next January, as a result of mandated health benefits that were wiped out by the legislature this year.
SB 541, by Sen. Tommy Williams, R-The Woodlands, could affect the health insurance policies of about 6.3 million Texans, both employer-provided and individual policies. Approximately 60 percent of Texans who obtain healthcare coverage through their employers will be affected.
No longer required to be covered would be items like substance abuse treatment, HMO rehabilitation services and AIDS treatment. These and other benefits were mandated by previous legislatures over the past two decades over the objections of the insurance industry.
Insurance companies will still be required to sell policies that include all of the mandates, but also be permitted to sell stripped down plans that include only some of the benefits required by law.
Lisa McGiffert, senior policy analyst with Consumers Union’s Southwest Regional Office, said the legislature’s action does not bode well for Texas consumers and is likely to result in a general erosion of coverage for everyone.
“Another fear is that doctors and hospitals are going to start telling people to pay up front rather than wait to find out if the insurance company will cover a procedure,” she said.
The following chart shows the benefits that must be covered and those that can be ignored by health insurers:

Serious mental illness
Coverage for medically necessary treatment annually with specified diagnoses: 45 days inpatient and 60 outpatient treatments; no lifetime limits on number of treatments; limits and cost sharing must be same as for physical illness.
Diabetes services
Supplies and services (including self-management-training programs) associated with the treatment of diabetes.
Surgery to correct craniofacial abnormalities in children
Policies that provide benefits to a child under 18 years of age must define reconstructive surgery to improve the function or to attempt to create a normal appearance of an abnormality caused by congenital defects, developmental deformities, trauma, tumors, infections, or disease.
Hearing tests for children
Policies that provide benefits of family members must cover a screening test for hearing loss from birth through 30 days of age as well as diagnostic follow-up care until 2 years of age.
Policies that provide benefits for a family member of the insured must cover specified immunizations for Immunizations may not be subject to a deductible, co-payment or coinsurance requirement. Small employer plans are exempt.
Phenylketonuria (PKU) formulas
Policies that cover prescription drugs must include formulas for the treatment of PKU or other heritable diseases.
Annual mammography screening for females 35 and older must be provided on the same basis as other radiological examinations.
Prostate Testing (PSA)
Policies must include benefits for diagnostic tests used in the detection of prostate cancer, including physical exams and prostate-specific antigen (PSA) test. Small employer plans are exempt.
Colorectal cancer screening
Screening for persons over 50 years and at normal risk for colon cancer. Covers annual fecal occult blood test, sigmoidoscopy every 5 years or colonoscopy every 10 years.
Access to OB/GYN HMO policies must allow direct access to a OB-GYN provider for OB-GYN services.
HMO access to out of network providers A
ccess to an out of network provider if the HMO network must be offered if the HMO network does not have the specialist needed by a patient.
Covered services cannot differentiate in payment or access based on the healthcare provider delivering the care
Applies to the following healthcare providers: Podiatrists, optometrists, chiropractors, dentists, occupational therapists, physical therapists, audiologists, speech-language pathologists, social workers, dietitians, licensed professional counselors, marriage and family therapists, psychologists, psychological associates, chemical dependency counselors, advanced practice nurses, nurse first assistants, physician assistants, acupuncturists, hearing instrument fitter and dispensers.
Coverage for certain populations Coverage still must be included for newborns, adopted children, adult children with mental retardation or a disability or otherwise dependent, students up to age 25, children under a court medical support order.
HMO rehabilitation services
If rehab services are covered, the doctor determines length of treatment and services must include rehabilitation to maintain functioning for people with disabilities.
HMO specialist as PCP
People with chronic and life-threatening illness must be allowed to use a specialist as their primary care provider.
Cost sharing
TDI regulations limit the amount of cost sharing health plans may charge. HMOs cannot charge deductibles and are limited in the amount of co-payments to require of patients at the point of service.
Chemical Dependency
Requires the inclusion of benefits for the treatment of chemical dependency based on specific criteria established by TDI rule.
Complications of Pregnancy
Benefits for complications of pregnancy must be provided on the same basis as for other illnesses.
Policies may not exclude or deny coverage, or cancel a policy based on a diagnosis of AIDS, HIV, or HIV-related illness.
Oral Contraceptives Benefits for oral contraceptives must be provided when all other prescription drugs are covered.
Osteoporosis Detection and Prevention
Policies must provide benefits for medically accepted bone mass measurement to determine risk of osteoporosis when indicated for certain qualified individuals.
Acquired Brain Injury Rehabilitation Policies that cover rehabilitation services must also include rehabilitation services needed as a result of an acquired brain injury.
Emergency Care
Policies that include preferred provider benefits must reimburse certain emergency care services at the preferred provider level if an insured cannot reasonably reach a preferred provider.
Temporomandibular Joint Benefits for TMJ must be provided when treatment of skeletal joints is covered.
NOTE: FEDERAL mandated benefits offer minimal protections and don’t necessarily cover all group or individual health plans. While this should not be considered a comprehensive list, the federal law does require the following:
 The federal Mental Health Parity Act does not require coverage for mental health services, but requires parity with physical health coverage IF a health plan includes mental health coverage. For example, the plan could not set a $100,000 limit on mental health coverage and a $1 million cap for physical health coverage.
 The federal Omnibus consolidated and Emergency Supplemental Appropriations Act requires plans to provide coverage for reconstructive surgery after mastectomies.
 The federal Newborns and Mothers Health Protection Plan requires plans that provide coverage for maternity benefits to provide for minimum 48-hour (for normal vaginal birth) and 96-hour (for cesarean delivery) inpatient stay for a mother and her newborn following delivery.
 The federal Health Insurance Portability and Accountability Act (HIPAA) prohibits pregnancy to be treated as a pre-existing condition; HIPAA also prohibits any pre-existing conditions for newborn and adopted children enrolled within 30 days.
 Health plans must comply with other federal laws like the Americans with Disabilities Act and federal labor laws.
 COBRA – requires employers with 20 or more employees to offer continued health coverage to terminated employees and dependents for a specified period.
For more information contact Lisa McGiffert, Consumers Union, 512-477-4431 ext. 115.