By: Bonnen of Galveston H.B. No. 1621
A BILL TO BE ENTITLED
AN ACT
relat
ing to utilization review and notice and appeal of certain
adverse determinations by utilization review agents.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 4201.053, Insurance Code, is amended to
read as follows:
Sec. 4201.053. MEDICAID AND [CERTAIN] OTHER STATE HEALTH OR
MENTAL HEALTH PROGRAMS. (a) Except as provided by Section
4201.057, this chapter does not apply to:
(1) the state Medicaid program;
(2) the services program for children with special
health care needs under Chapter 35, Health and Safety Code;
(3) a program administered under Title 2, Human
Resources Code;
(4) a program of the Department of State Health
Services relating to mental health services;
(5) a program of the Department of Aging and
Disability Services relating to intellectual disability [mental
retardation] services; or
(6) a program of the Texas Department of Criminal
Justice.
(b) Sections 4201.304(b), 4201.3555, and 4201.404 do not
apply to:
(1) the child health program under Chapter 62, Health
and Safety Code, or the health benefits plan for children under
Chapter 63, Health and Safety Code;
(2) the Employees Retirement System of Texas or
another entity issuing or administering a coverage plan under
Chapter 1551;
(3) the Teacher Retirement System of Texas or another
entity issuing or administering a plan under Chapter 1575 or 1579;
and
(4) The Texas A&M University System or The University
of Texas System or another entity issuing or administering coverage
under Chapter 1601.
SECTION 2. Section 4201.054, Insurance Code, is amended by
adding Subsection (b) to read as follows:
(b) Sections 4201.304(b), 4201.3555, and 4201.404 do not
apply to utilization review of a health care service provided to a
person eligible for workers' compensation benefits under Title 5,
Labor Code.
SECTION 3. Section 4201.304, Insurance Code, is amended to
read as follows:
Sec. 4201.304. TIME FOR NOTICE OF ADVERSE DETERMINATION.
(a) Subject to Subsection (b), a [A] utilization review agent shall
provide notice of an adverse determination required by this
subchapter as follows:
(1) with respect to a patient who is hospitalized at
the time of the adverse determination, within one working day by
either telephone or electronic transmission to the provider of
record, followed by a letter within three working days notifying
the patient and the provider of record of the adverse
determination;
(2) with respect to a patient who is not hospitalized
at the time of the adverse determination, within three working days
in writing to the provider of record and the patient; or
(3) within the time appropriate to the circumstances
relating to the delivery of the services to the patient and to the
patient's condition, provided that when denying poststabilization
care subsequent to emergency treatment as requested by a treating
physician or other health care provider, the agent shall provide
the notice to the treating physician or other health care provider
not later than one hour after the time of the request.
(b) A utilization review agent shall provide notice of an
adverse determination for a concurrent review of the provision of
prescription drugs or intravenous infusions not later than the 30th
day before the date on which the provision of prescription drugs or
intravenous infusions will be discontinued.
SECTION 4. Subchapter H, Chapter 4201, Insurance Code, is
amended by adding Section 4201.3555 to read as follows:
Sec. 4201.3555. CONTINUATION OF CONCURRENT PROVISION OF
PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS. The procedures for
appealing an adverse determination for a concurrent review of the
provision of prescription drugs or intravenous infusions must
provide that:
(1) coverage or benefits for the contested
prescription drugs or intravenous infusions that are the basis of
the adverse determination continue under the enrollee's health
insurance policy or health benefit plan while the appeal is being
considered to the same extent and in the same manner as if there had
been no adverse determination;
(2) without regard to whether the adverse
determination is upheld on appeal, the payor shall cover the
contested prescription drugs or intravenous infusions received
during the period the appeal was considered to the same extent and
in the same manner, including the same benefit level, as if there
had been no adverse determination; and
(3) without regard to whether the adverse
determination is upheld on appeal, the payor may not recoup, based
on an adverse determination, any payment made to a physician or
health care provider for the continuation of coverage or benefits
under Subdivision (1) or (2).
SECTION 5. Subchapter I, Chapter 4201, Insurance Code, is
amended by adding Section 4201.404 to read as follows:
Sec. 4201.404. CONTINUATION OF CONCURRENT PROVISION OF
PRESCRIPTION DRUGS OR INTRAVENOUS INFUSIONS. The procedures for an
independent review of an appeal of an adverse determination for a
concurrent review of the provision of prescription drugs or
intravenous infusions must provide that:
(1) coverage or benefits for the contested
prescription drugs or intravenous infusions that are the basis of
the adverse determination continue under the enrollee's health
insurance policy or health benefit plan while the review is being
considered to the same extent and in the same manner as if there had
been no adverse determination;
(2) without regard to whether the adverse
determination is upheld on review, the payor shall cover the
contested prescription drugs or intravenous infusions received
during the period the review was considered to the same extent and
in the same manner, including the same benefit level, as if there
had been no adverse determination; and
(3) without regard to whether the adverse
determination is upheld on review, the payor may not recoup, based
on an adverse determination, any payment made to a physician or
health care provider for the continuation of coverage or benefits
under Subdivision (1) or (2).
SECTION 6. This Act applies only to an adverse
determination made in relation to coverage or benefits under a
health insurance policy or health benefit plan delivered, issued
for delivery, or renewed on or after January 1, 2016. An adverse
determination made in relation to coverage or benefits under a
policy or plan delivered, issued for delivery, or renewed before
January 1, 2016, 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 7. This Act takes effect September 1, 2015.