By: Bonnen of Galveston H.B. No. 1621
COMMITTEE SUBSTITUTE FOR H.B. No. 1621By: Seliger By: Seliger
(In the Senate - Received from the House May 6, 2015;
May 11, 2015, read first time and referred to Committee on Business
and Commerce; May 22, 2015, reported adversely, with favorable
Committee Substitute by the following vote: Yeas 8, Nays 0;
May 22, 2015, sent to printer.)
Click here to see the committee vote
A BILL TO BE ENTITLED
AN ACT
relating 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 4201.303(c), 4201.304(b), 4201.357(a-1), and
4201.3601 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;
(4) The Texas A&M University System or The University
of Texas System or another entity issuing or administering coverage
under Chapter 1601; and
(5) a managed care organization providing a Medicaid
managed care plan under Chapter 533, Government Code.
SECTION 2. Section 4201.054, Insurance Code, is amended by
adding Subsection (b) to read as follows:
(b) Sections 4201.303(c), 4201.304(b), 4201.357(a-1), and
4201.3601 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 4201.303, Insurance Code, is amended by
adding Subsection (c) to read as follows:
(c) For an enrollee who is denied the provision of
prescription drugs or intravenous infusions for which the patient
is receiving benefits under the health insurance policy, the notice
required by Subsection (a)(4) must include a description of the
enrollee's right to an immediate review by an independent review
organization and of the procedures to obtain that review.
SECTION 4. 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 a
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 for which the patient
is receiving health benefits under the health insurance policy not
later than the 30th day before the date on which the provision of
prescription drugs or intravenous infusions will be discontinued.
SECTION 5. The heading to Section 4201.357, Insurance Code,
is amended to read as follows:
Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY
CARE, [OR] CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR
INTRAVENOUS INFUSIONS.
SECTION 6. Section 4201.357, Insurance Code, is amended by
adding Subsection (a-1) to read as follows:
(a-1) The procedures for appealing an adverse determination
must include, in addition to the written appeal and the appeal
described by Subsection (a), a procedure for an expedited appeal of
a denial of prescription drugs or intravenous infusions for which
the patient is receiving benefits under the health insurance
policy. That procedure must include a review by a health care
provider who:
(1) has not previously reviewed the case; and
(2) is of the same or a similar specialty as the health
care provider who would typically manage the medical or dental
condition, procedure, or treatment under review in the appeal.
SECTION 7. Subchapter H, Chapter 4201, Insurance Code, is
amended by adding Section 4201.3601 to read as follows:
Sec. 4201.3601. IMMEDIATE APPEAL TO INDEPENDENT REVIEW
ORGANIZATION FOR DENIAL OF PRESCRIPTION DRUGS OR INTRAVENOUS
INFUSIONS. Notwithstanding any other law, in a circumstance
involving the provision of prescription drugs or intravenous
infusions for which the patient is receiving benefits under the
health insurance policy, the enrollee is:
(1) entitled to an immediate appeal to an independent
review organization as provided by Subchapter I; and
(2) not required to comply with procedures for an
internal review of the utilization review agent's adverse
determination.
SECTION 8. Section 4202.003, Insurance Code, is amended to
read as follows:
Sec. 4202.003. REQUIREMENTS REGARDING TIMELINESS OF
DETERMINATION. The standards adopted under Section 4202.002 must
require each independent review organization to make the
organization's determination:
(1) for a life-threatening condition as defined by
Section 4201.002 or the provision of prescription drugs or
intravenous infusions for which the patient is receiving benefits
under the health insurance policy, not later than the earlier of the
third day after the date the organization receives the information
necessary to make the determination or, with respect to:
(A) a review of a health care service provided to
a person with a life-threatening condition eligible for workers'
compensation medical benefits, the eighth day after the date the
organization receives the request that the determination be made;
or
(B) a review of a health care service other than a
service described by Paragraph (A), the third day after the date the
organization receives the request that the determination be made;
or
(2) for a situation [condition] other than a situation
described by Subdivision (1) [life-threatening condition], not
later than the earlier of:
(A) the 15th day after the date the organization
receives the information necessary to make the determination; or
(B) the 20th day after the date the organization
receives the request that the determination be made.
SECTION 9. 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 10. This Act takes effect September 1, 2015.
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