Texas 2017 - 85th Regular

Texas House Bill HB10 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	By: Price, et al. (Senate Sponsor - Zaffirini) H.B. No. 10
2		-	(In the Senate - Received from the House April 6, 2017;
3		-	April 12, 2017, read first time and referred to Committee on Health
4		-	and Human Services; April 18, 2017, rereferred to Committee on
5		-	Business & Commerce; May 17, 2017, reported favorably by the
6		-	following vote: Yeas 9, Nays 0; May 17, 2017, sent to printer.)
7		-	Click here to see the committee vote
	1	+	H.B. No. 10
8	2
9	3
10		-	A BILL TO BE ENTITLED
11	4		AN ACT
12	5		relating to access to and benefits for mental health conditions and
13	6		substance use disorders.
14	7		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
15	8		SECTION 1. Subchapter B, Chapter 531, Government Code, is
16	9		amended by adding Sections 531.02251 and 531.02252 to read as
17	10		follows:
18	11		Sec. 531.02251. OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO
19	12		CARE. (a) In this section, "ombudsman" means the individual
20	13		designated as the ombudsman for behavioral health access to care.
21	14		(b) The executive commissioner shall designate an ombudsman
22	15		for behavioral health access to care.
23	16		(c) The ombudsman is administratively attached to the
24	17		office of the ombudsman for the commission.
25	18		(d) The commission may use an alternate title for the
26	19		ombudsman in consumer-facing materials if the commission
27	20		determines that an alternate title would be beneficial to consumer
28	21		understanding or access.
29	22		(e) The ombudsman serves as a neutral party to help
30	23		consumers, including consumers who are uninsured or have public or
31	24		private health benefit coverage, and behavioral health care
32	25		providers navigate and resolve issues related to consumer access to
33	26		behavioral health care, including care for mental health conditions
34	27		and substance use disorders.
35	28		(f) The ombudsman shall:
36	29		(1) interact with consumers and behavioral health care
37	30		providers with concerns or complaints to help the consumers and
38	31		providers resolve behavioral health care access issues;
39	32		(2) identify, track, and help report potential
40	33		violations of state or federal rules, regulations, or statutes
41	34		concerning the availability of, and terms and conditions of,
42	35		benefits for mental health conditions or substance use disorders,
43	36		including potential violations related to quantitative and
44	37		nonquantitative treatment limitations;
45	38		(3) report concerns, complaints, and potential
46	39		violations described by Subdivision (2) to the appropriate
47	40		regulatory or oversight agency;
48	41		(4) receive and report concerns and complaints
49	42		relating to inappropriate care or mental health commitment;
50	43		(5) provide appropriate information to help consumers
51	44		obtain behavioral health care;
52	45		(6) develop appropriate points of contact for
53	46		referrals to other state and federal agencies; and
54	47		(7) provide appropriate information to help consumers
55	48		or providers file appeals or complaints with the appropriate
56	49		entities, including insurers and other state and federal agencies.
57	50		(g) The ombudsman shall participate in the mental health
58	51		condition and substance use disorder parity work group established
59	52		under Section 531.02252 and provide summary reports of concerns,
60	53		complaints, and potential violations described by Subsection
61	54		(f)(2) to the work group. This subsection expires September 1,
62	55		2021.
63	56		(h) The Texas Department of Insurance shall appoint a
64	57		liaison to the ombudsman to receive reports of concerns,
65	58		complaints, and potential violations described by Subsection
66	59		(f)(2) from the ombudsman, consumers, or behavioral health care
67	60		providers.
68	61		Sec. 531.02252. MENTAL HEALTH CONDITION AND SUBSTANCE USE
69	62		DISORDER PARITY WORK GROUP. (a) The commission shall establish and
70	63		facilitate a mental health condition and substance use disorder
71	64		parity work group at the office of mental health coordination to
72	65		increase understanding of and compliance with state and federal
73	66		rules, regulations, and statutes concerning the availability of,
74	67		and terms and conditions of, benefits for mental health conditions
75	68		and substance use disorders.
76	69		(b) The work group may be a part of or a subcommittee of the
77	70		behavioral health advisory committee.
78	71		(c) The work group is composed of:
79	72		(1) a representative of:
80	73		(A) Medicaid and the child health plan program;
81	74		(B) the office of mental health coordination;
82	75		(C) the Texas Department of Insurance;
83	76		(D) a Medicaid managed care organization;
84	77		(E) a commercial health benefit plan;
85	78		(F) a mental health provider organization;
86	79		(G) physicians;
87	80		(H) hospitals;
88	81		(I) children's mental health providers;
89	82		(J) utilization review agents; and
90	83		(K) independent review organizations;
91	84		(2) a substance use disorder provider or a
92	85		professional with co-occurring mental health and substance use
93	86		disorder expertise;
94	87		(3) a mental health consumer;
95	88		(4) a mental health consumer advocate;
96	89		(5) a substance use disorder treatment consumer;
97	90		(6) a substance use disorder treatment consumer
98	91		advocate;
99	92		(7) a family member of a mental health or substance use
100	93		disorder treatment consumer; and
101	94		(8) the ombudsman for behavioral health access to
102	95		care.
103	96		(d) The work group shall meet at least quarterly.
104	97		(e) The work group shall study and make recommendations on:
105	98		(1) increasing compliance with the rules,
106	99		regulations, and statutes described by Subsection (a);
107	100		(2) strengthening enforcement and oversight of these
108	101		laws at state and federal agencies;
109	102		(3) improving the complaint processes relating to
110	103		potential violations of these laws for consumers and providers;
111	104		(4) ensuring the commission and the Texas Department
112	105		of Insurance can accept information on concerns relating to these
113	106		laws and investigate potential violations based on de-identified
114	107		information and data submitted to providers in addition to
115	108		individual complaints; and
116	109		(5) increasing public and provider education on these
117	110		laws.
118	111		(f) The work group shall develop a strategic plan with
119	112		metrics to serve as a roadmap to increase compliance with the rules,
120	113		regulations, and statutes described by Subsection (a) in this state
121	114		and to increase education and outreach relating to these laws.
122	115		(g) Not later than September 1 of each even-numbered year,
123	116		the work group shall submit a report to the appropriate committees
124	117		of the legislature and the appropriate state agencies on the
125	118		findings, recommendations, and strategic plan required by
126	119		Subsections (e) and (f).
127	120		(h) The work group is abolished and this section expires
128	121		September 1, 2021.
129	122		SECTION 2. Chapter 1355, Insurance Code, is amended by
130	123		adding Subchapter F to read as follows:
131	124		SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE
132	125		USE DISORDERS
133	126		Sec. 1355.251. DEFINITIONS. In this subchapter:
134	127		(1) "Mental health benefit" means a benefit relating
135	128		to an item or service for a mental health condition, as defined
136	129		under the terms of a health benefit plan and in accordance with
137	130		applicable federal and state law.
138	131		(2) "Nonquantitative treatment limitation" means a
139	132		limit on the scope or duration of treatment that is not expressed
140	133		numerically. The term includes:
141	134		(A) a medical management standard limiting or
142	135		excluding benefits based on medical necessity or medical
143	136		appropriateness or based on whether a treatment is experimental or
144	137		investigational;
145	138		(B) formulary design for prescription drugs;
146	139		(C) network tier design;
147	140		(D) a standard for provider participation in a
148	141		network, including reimbursement rates;
149	142		(E) a method used by a health benefit plan to
150	143		determine usual, customary, and reasonable charges;
151	144		(F) a step therapy protocol;
152	145		(G) an exclusion based on failure to complete a
153	146		course of treatment; and
154	147		(H) a restriction based on geographic location,
155	148		facility type, provider specialty, and other criteria that limit
156	149		the scope or duration of a benefit.
157	150		(3) "Quantitative treatment limitation" means a
158	151		treatment limitation that determines whether, or to what extent,
159	152		benefits are provided based on an accumulated amount such as an
160	153		annual or lifetime limit on days of coverage or number of visits.
161	154		The term includes a deductible, a copayment, coinsurance, or
162	155		another out-of-pocket expense or annual or lifetime limit, or
163	156		another financial requirement.
164	157		(4) "Substance use disorder benefit" means a benefit
165	158		relating to an item or service for a substance use disorder, as
166	159		defined under the terms of a health benefit plan and in accordance
167	160		with applicable federal and state law.
168	161		Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
169	162		subchapter applies only to a health benefit plan that provides
170	163		benefits or coverage for medical or surgical expenses incurred as a
171	164		result of a health condition, accident, or sickness and for
172	165		treatment expenses incurred as a result of a mental health
173	166		condition or substance use disorder, including an individual,
174	167		group, blanket, or franchise insurance policy or insurance
175	168		agreement, a group hospital service contract, an individual or
176	169		group evidence of coverage, or a similar coverage document, that is
177	170		offered by:
178	171		(1) an insurance company;
179	172		(2) a group hospital service corporation operating
180	173		under Chapter 842;
181	174		(3) a fraternal benefit society operating under
182	175		Chapter 885;
183	176		(4) a stipulated premium company operating under
184	177		Chapter 884;
185	178		(5) a health maintenance organization operating under
186	179		Chapter 843;
187	180		(6) a reciprocal exchange operating under Chapter 942;
188	181		(7) a Lloyd's plan operating under Chapter 941;
189	182		(8) an approved nonprofit health corporation that
190	183		holds a certificate of authority under Chapter 844; or
191	184		(9) a multiple employer welfare arrangement that holds
192	185		a certificate of authority under Chapter 846.
193	186		(b) Notwithstanding Section 1501.251 or any other law, this
194	187		subchapter applies to coverage under a small employer health
195	188		benefit plan subject to Chapter 1501.
196	189		(c) This subchapter applies to a standard health benefit
197	190		plan issued under Chapter 1507.
198	191		Sec. 1355.253. EXCEPTIONS. (a) This subchapter does not
199	192		apply to:
200	193		(1) a plan that provides coverage:
201	194		(A) for wages or payments in lieu of wages for a
202	195		period during which an employee is absent from work because of
203	196		sickness or injury;
204	197		(B) as a supplement to a liability insurance
205	198		policy;
206	199		(C) for credit insurance;
207	200		(D) only for dental or vision care;
208	201		(E) only for hospital expenses;
209	202		(F) only for indemnity for hospital confinement;
210	203		or
211	204		(G) only for accidents;
212	205		(2) a Medicare supplemental policy as defined by
213	206		Section 1882(g)(1), Social Security Act (42 U.S.C. Section
214	207		1395ss(g)(1));
215	208		(3) a workers' compensation insurance policy;
216	209		(4) medical payment insurance coverage provided under
217	210		a motor vehicle insurance policy; or
218	211		(5) a long-term care policy, including a nursing home
219	212		fixed indemnity policy, unless the commissioner determines that the
220	213		policy provides benefit coverage so comprehensive that the policy
221	214		is a health benefit plan as described by Section 1355.252.
222	215		(b) To the extent that this section would otherwise require
223	216		this state to make a payment under 42 U.S.C. Section
224	217		18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
225	218		C.F.R. Section 155.20, is not required to provide a benefit under
226	219		this subchapter that exceeds the specified essential health
227	220		benefits required under 42 U.S.C. Section 18022(b).
228	221		Sec. 1355.254. COVERAGE FOR MENTAL HEALTH CONDITIONS AND
229	222		SUBSTANCE USE DISORDERS. (a) A health benefit plan must provide
230	223		benefits and coverage for mental health conditions and substance
231	224		use disorders under the same terms and conditions applicable to the
232	225		plan's medical and surgical benefits and coverage.
233	226		(b) Coverage under Subsection (a) may not impose
234	227		quantitative or nonquantitative treatment limitations on benefits
235	228		for a mental health condition or substance use disorder that are
236	229		generally more restrictive than quantitative or nonquantitative
237	230		treatment limitations imposed on coverage of benefits for medical
238	231		or surgical expenses.
239	232		Sec. 1355.255. COMPLIANCE. The commissioner shall enforce
240	233		compliance with Section 1355.254 by evaluating the benefits and
241	234		coverage offered by a health benefit plan for quantitative and
242	235		nonquantitative treatment limitations in the following categories:
243	236		(1) in-network and out-of-network inpatient care;
244	237		(2) in-network and out-of-network outpatient care;
245	238		(3) emergency care; and
246	239		(4) prescription drugs.
247	240		Sec. 1355.256. DEFINITIONS UNDER PLAN. (a) A health
248	241		benefit plan must define a condition to be a mental health condition
249	242		or not a mental health condition in a manner consistent with
250	243		generally recognized independent standards of medical practice.
251	244		(b) A health benefit plan must define a condition to be a
252	245		substance use disorder or not a substance use disorder in a manner
253	246		consistent with generally recognized independent standards of
254	247		medical practice.
255	248		Sec. 1355.257. COORDINATION WITH OTHER LAW; INTENT OF
256	249		LEGISLATURE. This subchapter supplements Subchapters A and B of
257	250		this chapter and Chapter 1368 and the department rules adopted
258	251		under those statutes. It is the intent of the legislature that
259	252		Subchapter A or B of this chapter or Chapter 1368 or a department
260	253		rule adopted under those statutes controls in any circumstance in
261	254		which that other law requires:
262	255		(1) a benefit that is not required by this subchapter;
263	256		or
264	257		(2) a more extensive benefit than is required by this
265	258		subchapter.
266	259		Sec. 1355.258. RULES. The commissioner shall adopt rules
267	260		necessary to implement this subchapter.
268	261		SECTION 3. (a) The Texas Department of Insurance shall
269	262		conduct a study and prepare a report on benefits for medical or
270	263		surgical expenses and for mental health conditions and substance
271	264		use disorders.
272	265		(b) In conducting the study, the department must collect and
273	266		compare data from health benefit plan issuers subject to Subchapter
274	267		F, Chapter 1355, Insurance Code, as added by this Act, on medical or
275	268		surgical benefits and mental health condition or substance use
276	269		disorder benefits that are:
277	270		(1) subject to prior authorization or utilization
278	271		review;
279	272		(2) denied as not medically necessary or experimental
280	273		or investigational;
281	274		(3) internally appealed, including data that
282	275		indicates whether the appeal was denied; or
283	276		(4) subject to an independent external review,
284	277		including data that indicates whether the denial was upheld.
285	278		(c) Not later than September 1, 2018, the department shall
286	279		report the results of the study and the department's findings.
287	280		SECTION 4. (a) The Health and Human Services Commission
288	281		shall conduct a study and prepare a report on benefits for medical
289	282		or surgical expenses and for mental health conditions and substance
290	283		use disorders provided by Medicaid managed care organizations.
291	284		(b) In conducting the study, the commission must collect and
292	285		compare data from Medicaid managed care organizations on medical or
293	286		surgical benefits and mental health condition or substance use
294	287		disorder benefits that are:
295	288		(1) subject to prior authorization or utilization
296	289		review;
297	290		(2) denied as not medically necessary or experimental
298	291		or investigational;
299	292		(3) internally appealed, including data that
300	293		indicates whether the appeal was denied; or
301	294		(4) subject to an independent external review,
302	295		including data that indicates whether the denial was upheld.
303	296		(c) Not later than September 1, 2018, the commission shall
304	297		report the results of the study and the commission's findings.
305	298		SECTION 5. Subchapter F, Chapter 1355, Insurance Code, as
306	299		added by this Act, applies only to a health benefit plan delivered,
307	300		issued for delivery, or renewed on or after January 1, 2018. A
308	301		health benefit plan delivered, issued for delivery, or renewed
309	302		before January 1, 2018, is governed by the law as it existed
310	303		immediately before the effective date of this Act, and that law is
311	304		continued in effect for that purpose.
312	305		SECTION 6. This Act takes effect September 1, 2017.
313		-	* * * * *
	306	+	______________________________ ______________________________
	307	+	President of the Senate Speaker of the House
	308	+	I certify that H.B. No. 10 was passed by the House on April 5,
	309	+	2017, by the following vote: Yeas 130, Nays 13, 1 present, not
	310	+	voting.
	311	+	______________________________
	312	+	Chief Clerk of the House
	313	+	I certify that H.B. No. 10 was passed by the Senate on May 22,
	314	+	2017, by the following vote: Yeas 30, Nays 1.
	315	+	______________________________
	316	+	Secretary of the Senate
	317	+	APPROVED: _____________________
	318	+	Date
	319	+	_____________________
	320	+	Governor