28 TAC §21.2601, §21.2606
The Commissioner of Insurance adopts amendments to §21.2601
and §21.2606 concerning minimum standards for benefits provided to enrollees
with diabetes in health benefit plans and coverage under health benefit plans
for equipment and supplies and self-management training associated with the
treatment of diabetes. The amendments to §21.2601 are adopted with a
change to the proposed text as published in the January 10, 2003, issue of
the
Texas Register
(28 TexReg 430). The amendments
to §21.2606 are adopted without changes and will not be republished.
The amendments to §21.2602 and §21.2604 that were proposed in the
January 10, 2003, issue of the
Texas Register
(28
TexReg 430) will not be adopted at this time. That proposal for amendments
to those sections is being withdrawn. A separate new proposal for amendments
to §21.2602 and §21.2604 is being published simultaneously with
this notice of adoption of the amendments to §21.2601 and §21.2606.
The amendments are necessary to implement legislation enacted by the 76th
Legislature in Senate Bill 982, amending Article 21.53G, Coverage for Supplies
and Services Associated with Treatment of Diabetes.
The adopted amendments to §21.2601 remove unnecessary language and
add a definition for nutrition counseling. The adopted amendments to §21.2606
delete references to §21.2607, the repeal of which is being simultaneously
adopted elsewhere in this issue of the
Texas Register
. The adopted amendments to §21.2606 also identify the components
of diabetes self-management training and those individuals or entities who
may provide diabetes self-management training and the required training for
those individuals. The adoption also includes grammatical and other changes
to conform language to
Texas Register
style
guidelines.
Section 21.2604: A commenter believes that requiring a risk pool created
pursuant to Local Government Code Chapter 172 to provide coverage for diabetes
equipment and supplies and for diabetes self-management training is beyond
the department’s authority. The commenter notes that Chapter 172 risk
pools are generally exempt from Texas Insurance Code provisions but acknowledges
that art. 21.53D contains language that essentially nullifies the Chapter
172 exemption. The commenter contends that the exemption applies to mandated
benefits under article 21.53D, but not to coverage for supplies and services
associated with diabetes under article 21.53G. The standards set forth by
the commissioner pursuant to art. 21.53D, the commenter argues, "may not include
requirements regarding coverage for supplies and services associated with
the treatment of diabetes" because the legislature enacted a separate statute,
article 21.53G, that applies to those supplies and services. The commenter
requests that the rule be revised to clarify that Chapter 172 risk pools are
subject only to the requirements of art. 21.53D and not to art. 21.53G.
Agency Response: While the department disagrees with the reasoning suggested
by this commenter, the department is withdrawing the proposal to amend this
section and publishing contemporaneously with this adoption notice a revised
proposal to amend this subchapter. That proposal addresses the applicability
of this subchapter to Chapter 172 risk pools, and the commenter may wish to
submit comments that address that proposal during the comment period.
Section 21.2601(7): A commenter requests that the department amend the
definition of "health benefit plan" to exclude Tricare Supplement policies,
in the same way that Medicare supplement policies are excluded. These types
of policies cover only such things as deductibles and copayments and are not
health benefit plans.
Agency Response: The department agrees and has specifically excluded Tricare
Supplement policies from the definition of "health benefit plan."
For, with changes: Government Personnel Mutual Life Insurance Company and
TML Intergovernmental Employee Benefits Pool (TML IEGP).
The amendments are adopted under the Insurance Code Article 21.53G,
21.53D and §36.001. Article 21.53G determines and defines the component
or components of self-management training and provides that the commissioner
shall adopt rules as necessary for the implementation of the article. Article
21.53D, §3 provides that the commissioner shall by rule adopt minimum
standards for benefits to enrollees with diabetes and that each health care
benefit plan shall provide benefits for the care required by the minimum standards.
Section 36.001 provides that the Commissioner of Insurance may adopt rules
necessary and appropriate to implement the powers and duties of the Texas
Department of Insurance.
§21.2601.Definitions.
The following words and terms, when used in this subchapter, shall
have the following meanings, unless the context clearly indicates otherwise:
(1)
Basic benefit--Health care service or coverage, which is
included in the evidence of coverage, policy, or certificate, without additional
premium.
(2)
Caretaker--A family member or significant other responsible
for ensuring that an insured not able to manage his or her illness (due to
age or infirmity) is properly managed, including overseeing diet, administration
of medications, and use of equipment and supplies.
(3)
Diabetes--Diabetes mellitus. A chronic disorder of glucose
metabolism that can be characterized by an elevated blood glucose level. The
terms diabetes and diabetes mellitus are synonymous.
(4)
Diabetes equipment--The term "diabetes equipment" includes
items defined in Insurance Code Article 21.53 G §§1(1) and 5, and §21.2605
of this title (relating to Diabetes Equipment and Supplies).
(5)
Diabetes supplies--The term "diabetes supplies" includes
items defined in Insurance Code Article 21.53 G §§1(2) and 5, and §21.2605
of this title.
(6)
Diabetes self-management training--Instruction enabling
an insured and/or his or her caretaker to understand the care and management
of diabetes, including nutritional counseling and proper use of diabetes equipment
and supplies.
(7)
Health benefit plan--A health benefit plan, for purposes
of this subchapter, means:
(A)
a plan that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness, including:
(i)
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
20 of the Texas Insurance Code;
(III)
a fraternal benefit society operating under Chapter 10
of the Texas Insurance Code;
(IV)
a stipulated premium insurance company operating under
Chapter 22 of the Insurance Code;
(V)
a reciprocal exchange operating under Chapter 19 of the
Texas Insurance Code; or
(VI)
a health maintenance organization (HMO) operating under
the Texas Health Maintenance Organization Act (Chapter 20A, Texas Insurance
Code);
(ii)
to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 USC §1002), a health benefit plan that is offered
by a multiple employer welfare arrangement as defined by §3, Employee
Retirement Income Security Act of 1974 (29 USC §1002) that holds a certificate
of authority under Insurance Code Article 3.95-2; or
(iii)
notwithstanding §172.014, Local Government Code,
or any other law, health and accident coverage provided by a risk pool created
under Chapter 172, Local Government Code.
(B)
A plan offered by an approved nonprofit health corporation
that is certified under §5.01(a), Medical Practice Act, and that holds
a certificate of authority issued by the commissioner under Insurance Code
Article 21.52F.
(C)
A health benefit plan is not:
(i)
a plan that provides coverage:
(I)
only for a specified disease or other limited benefit;
(II)
only for accidental death or dismemberment;
(III)
for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or injury;
(IV)
as a supplement to liability insurance;
(V)
for credit insurance;
(VI)
dental or vision care only; or
(VII)
hospital confinement indemnity coverage only.
(ii)
a small employer plan written under Chapter 26 of the
Insurance Code;
(iii)
a Medicare supplemental policy as defined by §1882(g)(1),
Social Security Act (42 USC §1395 ss);
(iv)
a plan that is designed to supplement benefits provided
under a program established by the Department of Defense pursuant to Chapter
55 of Title 10, United States Code (10 USC Section 1071 et seq.);
(v)
workers' compensation insurance coverage;
(vi)
medical payment insurance issued as part of a motor vehicle
insurance policy; or
(vii)
a long-term care 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 subparagraph (A) of this paragraph.
(8)
Insured--A person enrolled in a health benefit plan who
has been diagnosed with:
(A)
insulin dependent or noninsulin dependent diabetes; or
(B)
elevated blood glucose levels induced by pregnancy or another
medical condition associated with elevated glucose levels.
(9)
Nutrition counseling--As defined in §701.002 of the
Texas Occupations Code.
(10)
Physician--A Doctor of Medicine or a Doctor of Osteopathy
licensed by the Texas State Board of Medical Examiners.
(11)
Practitioner--An Advanced Practice Nurse, Doctor of Dentistry,
Physician Assistant, Doctor of Podiatry, or other licensed person with prescriptive
authority.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on July 7, 2003.
TRD-200304107
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Effective date: July 27, 2003
Proposal publication date: January 10, 2003
For further information, please call: (512) 463-6327
28 TAC §21.2607
The Commissioner of Insurance adopts the repeal of §21.2607,
concerning minimum standards for benefits provided to enrollees with diabetes
in health benefit plans and coverage under health benefit plans for equipment
and supplies and self-management training associated with the treatment of
diabetes. The repeal is adopted without changes to the proposed text as published
in the January 10, 2003, issue of the
Texas Register
(28 TexReg 434) and will not be republished.
The repeal is necessary to remove language for which the statutory authority
has expired.
The repeal of the section eliminates language which is no longer necessary.
Contemporaneously with this repeal, adopted amendments to §21.2601 and §21.260
6
are published elsewhere in this issue of the
Texas
Register
.
No comments were received.
The repeal is adopted under the Insurance Code Articles 21.53D
and §36.001. Article 21.53D §3 provides that the commissioner shall
by rule adopt minimum standards for benefits to enrollees with diabetes. Section
36.001 provides that the Commissioner of Insurance may adopt rules necessary
and appropriate to execute the powers and duties of the Texas Department of
Insurance.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on July 7, 2003.
TRD-200304108
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Effective date: July 27, 2003
Proposal publication date: January 10, 2003
For further information, please call: (512) 463-6327