I haven't had time to properly interlink these pages; to
navigate, use back browser or return (go to if not initially
there) the main index page of this section of mmy site.
Text of the Texas Mental Health Parity Law
I'm finding that hardly anyone either who is involved in
mental health advocacy or who is immediate affected by this
law in this town has ever read it, so I decided I'd better make
it more available for people to read. I guess not even most
people with manic depression visit law libraries. So here it
is.
The Texas Mental Health Parity law consists of two parts,
a section that covers state, county and city workers that was
passed in 1991, and a section that covers all other employee
health plans provided by companies that employ more than
50 people (and who don't both self-insure and have branches in
other states, and claim exemption under a section of the federal
Employee Retirement and Insurance Security Act), which was
passed in 1997, effective 9/97. Both laws
were amended in 1999, to make the definitions of the two laws
consistent and to improve the 1997 law by banning different
co-pays for mental health conditions than other mental
health conditions. The Texas laws only cover certain specified
serious biologically based disorders.
Art. 3.51-14, Insurance Code. (Vernon's)
This section of the law, which is the one that applies to
private sector employees - was actually passed as part of the
1991 bill, but not given any teeth until 1997. As it was
passed in 1997, it was worrisomely similar to Beth Mitchell's
of Advocacy Inc.'s understanding of the law; insurance
companies had to make it available to people but the
employer did not have to include it. According to the
1997 hearings, insurance companies were interpreting that as
anything from tell the employer if asked it can't be done to
tell the employer only if begged that it will cost a large
sum! (Beth Mitchell thought they have to make it available
to EMPLOYEES to purchase extra if they want it!) Beth Mitchell
said she had never read the law, it looks as if she failed to
comprehend that the situation she has paid no attention to
since her agency was trying to get the law passed changed with
the passage of the law!
I also talked to consumers at Austin DMDA who said things like
their policy provides 20 visits a year - who have no idea that
that is illegal.
Definitions
Sec. 1. For purposes of this article:
(1) "Serious mental illness" means the following psychiatric
illnesses as defined by the American Psychiatric Association in the
Diagnostic and Statistical Manual (DSM):
(A) schizophrenia;
(B) paranoid and other psychotic disorders
(C) bipolar disorders (hypomanic, manic, depressive, and mixed);
(D) major depressive disorders (single episode or recurrent);
(E) schizo-affective disorders (bipolar or depressive);
(F) pervasive developmental disorders
(G) obsessive-compulsive disorders
(H) depression in childhood and adolescence
(2) "Group health benefit plan" means a plan described by
Section 2 of this article.
(3) "Small Employer" has the meaning assigned by Article 26.02
of this code.
Scope of article
Sec. 2. (a) This article applies only to a group health benefit
that provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including:
(1) a group insurance policy or insurance agreement, a group
hospital service contract, or a group evidence of coverage that
is offered by:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
20 of this code;
(C) a health maintenance organization operating under the Texas
Health Maintenance Organization Act (Chapter 20A, Vernon's
Texas Insurance Code);
(D) a fraternal benefit society operating under Chapter 10 of this
code; or
(E) a stipulated premium insurance company operating under Chapter
22 of this code; and
(2) to the extenet permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1002); or
(B) another analogous benefit arrangement.
(b) This article does not apply to coverage under:
(1) a blanket accident and health insurance policy as that term
is defined under Section 2, Article 3.51-6 of this code;
(2) a short-term travel policy;
(3) an accident-only policy;
(4) a limited or specified-disease policy, other than a plan that
provides benefits for mental health care or similar services;
The following two provisions were added in 1999, and I
do not understand what they mean.
(5) with the exception of Section 1 of this article which shall
apply, a plan offered under the Texas Employees Uniform
Group Insurance Benefits Act (Article 3.50-2, Vernon's Texas
Insurance Code) or the Texas State College and University
Employees Uniform Insurance Benefits Act (Article 3.50-3,
Vernon's Texas Insurance Code);
(6) a plan offered under or in accordance with Article 3.51-5A of
this code; or
(7) a medicare supplement policy, as that term is defined under
Section 1(b)(3), Article 3.74, of this code.
Required coverage for serious mental illnesses
Sec. 3. (a) Except as provided by Section 4 of this article,
a group health benefit plan:
(1) must provide coverage, based on medical necessity, for the
following treatment of serious mental illness 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 limit on the number of days of
inpatient treatment or the number of outpatient visits covered
under the plan; and
(3) must include the same amount limits, deductibles, copayments,
and coinsurance factors for serious mental illness as for physical
illness.
(b) An issuer of a group health benefit plan may not count toward
the number of outpatient visits required to be covered under
Subsection (a)(1) of this section an outpatient visit for the
purpose of medication management and must cover that outpatient
visit under the same terms and conditions as it covers outpatient
visits for treatment of physical illness.
(c) An issuer of a group health benefit plan may provide or
offer coverage required under this section through a managed
care plan.
Small employer coverage
Sec. 4. An issuer of a group health benefit plan to a small
employer must offer the coverage described in Section 3 of
this article but is not required to provide the coverage if
the small employer rejects the coverage.
Certain benefits prohibited
Sec. 5. (a) This article may not be interpreted to require a
group health benefit plan to provide coverage for treatment of:
(1) addiction to a controlled substance or marihuana that is
used in violation of law; or
(2) mental illness resulting from the use of a controlled
substance or marihuana in violation of law.
(b) In this section, "controlled substance" and "marihuana" have
the meanings assigned by Section 481.002, Health and Safety Code.
Article 3/50-2, Vernon's Texas Insurance Code
Art. 3.50-2, -3, -4, -5. Texas Employees Uniform Group
Inurance Benefits Act, and provisions relating to local
governments, school teachers, etc.
The 1991 law added nearly identical provisions to each of
these sections of law. The 1999 amendment changed the smaller
lists of specific disorders meant by mental illness to the
definition provided in section 3.14.
Sec 3. (a). Unless a different meaning is plainly required by
the context, the following words and phrases as used in this
Act shall have the following meanings:....
(23) "Serious mental illness" has teh meaning assigned by
Section 1, Article 3.51-14, Insurance Code.
(c)
Sec. 5. (j) The trustee may not contract for or provide a plan
of coverage that (2) provides coverage for serious mental
illness that is less extensive than the coverage provided
for any physical illness.
Vernon's law code (1999 pocket part) appears to have this
wrong; the chapter sessions law reads that section 16 was
redesignated section 19 and then amended; Vernon's includes
section 16 unamended and then the new section 19 as amended.
(19) Serious mental illness" has teh meaning assigned by
Section 1, Article 3.51-14, Insurance Code.
Sec. 4. peterinas to Texas STate College and University
Employees Uniform Insurance Benefits Program.
Sec. 4C. An institution, in contracting for group or health
maintenance organzation coverage or in self-insuring its
own coverage, may not contract for or provide in that coverage;
(2) provides coverage for serious mental illnes that is less
extensive than the coverage provided for any other physical
illness.
3.51-5A. Local Governments Prohibited From Excluding or
Limiting Certain Coverages
(a) A municpality, county, school district, district created
underARticle III, Section 52, or Article XVI, SEction 59, of the
Texas Constitution, or other politcial subdivision of the
state that provides group health insurance coverage, health
maintenance organization coverage, or self-insured health
coverage to its officers or employees or to both its officers
and employees may not contract for or provide coverage that:
(2) is less extensive for serious mental illness than the coverage
provided for any other physical illness.
(b) For purposes of this article, "serious mental illness"
has the meaning assigned by Sectin 1, Article 3.51-14, of this
code.
This law is a very strong law that very effectively provides
full parity for many biologically based mental illnesses - for
the plans the state law applies to. Insurance companies and
HMO's really have little in the way of ways to effectively
wiggle around it- within the law itself. One problem is taht
the failure to include mild and moderate depression, which
is often disruptive and always interferes with quality of life
and in addition is often actually the more serious bipolar
disorder that hasn't been diagnosed yet, is that it opens the
door for "not sick enough" findings for people with depression
and with anxiety disorders that often mask depression and also often appear to mask depression and actually mask manic
depression. That happened to me - and of course, partly because
I reacted to all tricyclic antidepressants in a way that people
with manic depression often do, the eventual decision was I had
"generalized anxiety disorder" as a result of malfunctional
learned ways of handling things! Noone with manic depression
doesn't have anxiety disorders, the two problems share common
neurochemistry.
Another problem is that the law exempts companies that hire
fewer than 50 employees. These are the only weaknesses of this
law.
The very substantial problem that the state parity law faces is
not its own fault. ERISA, which is the Employee Retirment Income
Security Act of 1974, effectively protects many health plans
from all state level reform laws, by exemptiong broad categories
of health plans from basically state regulation.
There is unfortunately considerable confusion about what plans
ERISA exempts, and unfortunately both most mental health
advocates, and the courts, share the confusion. Most mental
health advocacy pamphlets on state mental
health parity laws, including NAMI's, wrongly state that
employers who provide any sort of group health insurance to
their employees AND have branches in other states claim exemption
from the state law under ERISA. ERISA actually exempts two much
larger groups of employers; all who SELF-INSURE, that is, cover
their employees' medical bills themselves, often using a major
insurance provider to do the billing and paperwork, and all multi-employer plans that are set up and negotiated by unions
under the Taft Harley act, as part of collective bargaining (as
I understand it). These exemptions are set up
by different sections of ERISA on differing terms.
ERISA's exemptions were intended by Congress to allow large
employers to run their employee benefit plans without havning
to deal with conflicting regulations in different states. ERISA
is in several ways effectively providing free license to
HMO's and insurance companies to get away with murder - quite
literally. Another problem with ERISA of cataclysmic proportions
is that currently, people usually can't sue or in any way
hold accountable HMO's whose negligent or deliberately wrong
decisions result in serious damages and death. The courts
have tangled with ERISA preemptions in a massive body of very
confused case law. The courts are basically very confused about
ERISA preemptions. Congress has preferred to deal with ERISA's
problems by passing insurance and managed care reform laws to
correct the most glaring problems at the Federal level. No
attempt to tighten the ERISA preemptions has been able to get
off the ground, I've been told it's a "sacred cow" in Washington.
One thing the courts are almost in agreement on; when employers
provide some policies taht they self-insure, and others taht
are traditional indemnity plans and HMO's, the parts of their
plans that are NOT self-insured ARE subject to state regulation.
So if a company has both self-insured plans, and HMO's, then
the HMO plans have to conform to the state mental health law -
as I currently understand the situation.
I have the most important including important current cases
on ERISA preemptions on my Congressional hearings page.
Email me at dorasmith24@hotmail.com
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