The Texas Legislature has enacted a new law that requires coverage under a health benefit plan for prescription contraceptive drugs, devices and related services. The new law took effect on September 1, 2001.
Since 1978, health insurance plans in Texas were prohibited from excluding from prescription drug benefits oral contraceptives when all other prescription drugs were covered. However, many women who used non-oral forms of contraceptives discovered that they were not covered by their health plans. Under the new law, all types of prescriptive contraceptive drugs, devices and related services must be covered under a health benefit plan.
A health benefit plan that provides benefits for prescription drugs or devices may not exclude or limit benefits to any person who is entitled to benefits under a health benefit plan for a prescription contraceptive drug or device approved by the FDA or out-patient contraceptive services.
A "health benefit plan" is a plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness. A health benefit plan does not include a plan that provides coverage only for benefits for specified disease or for another limited benefit other than for cancer; for accidental death or dismemberment; for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury; as a supplement to a liability insurance policy; for credit insurance; for dental or vision care; or for indemnity for hospital confinement.
The new law, however, does not prohibit a limitation that applies to all prescription drugs or devices or all services for which benefits are provided under a health benefit plan. It further does not provide coverage for abortifacients or any other drug or device that terminates a pregnancy.
In addition, a health benefit plan may not impose any deductible, co-payment, co-insurance, or other cost-sharing provision applicable to benefits for prescription contraceptive drugs or devices unless the amount of the required cost-sharing does not exceed the amount of the required cost-sharing applicable to benefits for other prescription drugs or devices or other out-patient services under the plan. Moreover, a health benefit plan may not impose any waiting period applicable to benefits for prescription contraceptive drugs or devices or for outpatient contraceptive services unless the waiting period is not longer than any waiting period applicable to benefits for other prescription drugs or devices or for other out-patient services under the plan.
The statute also prohibits the issuer of a health benefit plan from denying an applicant for enrollment or an enrollee eligibility or continued eligibility under the plan, or deny renewal of a plan to an enrollee, solely because of the applicant's or enrollee's use or potential use of a prescription contraceptive drug or device or an out-patient contraceptive service; provide a monetary incentive to an applicant for enrollment or an enrollee to induce the applicant or enrollee to accept coverage that does not satisfy the requirements of this new law; or reduce or limit a payment to a health care professional, or otherwise penalize the professional, because the professional prescribed a contraceptive drug or device or provides an out-patient contraceptive service.
The applicability of the new contraceptive equity law is not without certain exceptions. Health benefit plans that are issued by an entity associated with a religious organization or any physician or health care provider providing medical or health care services under the health benefit plan are not required to offer, recommend, offer advice concerning, pay for, provide, assist in, or form, arrange, or participate in providing or performing a medical or health care service that violates the religious convictions of the organization, except if the prescription contraceptive coverage is necessary to preserve the life or health of the insured individual. In the event an insurer of a health benefit plan limits or excludes coverage for these types of medical or healthcare services, the issuer must state the limitation or exclusion in the coverage document, the plan's statement of benefits, brochures, and other informational materials for the health benefit plan.
Studies show less than half of U.S. health plans provide birth control services. Congress in 1998 required that health plans for federal employees cover prescription contraceptives. Sixteen states, in addition to Texas, have approved "contraceptive equity laws." They are California, Connecticut, Delaware, Georgia, Hawaii Iowa, Maine, Maryland, Nevada, New Hampshire, New Mexico, North Carolina, Rhode Island, Vermont and Washington.
The new statute took effect September 1, 2001 and applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2002. For a complete copy of the new law, please see our website.