Texas 2017 - 85th Regular

Texas House Bill HB2605 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	85R13597 MEW-D
2	2	By: Muñoz, Jr. H.B. No. 2605
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to benefits for mental health conditions and substance use
8	8	disorders.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1355, Insurance Code, is amended by
11	11	adding Subchapter F to read as follows:
12	12	SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE
13	13	USE DISORDERS
14	14	Sec. 1355.251. DEFINITIONS. In this subchapter:
15	15	(1) "Financial requirement" includes a requirement
16	16	relating to a deductible, copayment, coinsurance, or other
17	17	out-of-pocket expense or an annual or lifetime limit.
18	18	(2) "Mental health benefit" means a benefit relating
19	19	to an item or service for a mental health condition, as defined
20	20	under the terms of a health benefit plan and in accordance with
21	21	applicable federal and state law.
22	22	(3) "Nonquantitative treatment limitation" includes:
23	23	(A) a medical management standard limiting or
24	24	excluding benefits based on medical necessity or medical
25	25	appropriateness or based on whether a treatment is experimental or
26	26	investigational;
27	27	(B) formulary design for prescription drugs;
28	28	(C) network tier design;
29	29	(D) a standard for provider participation in a
30	30	network, including reimbursement rates;
31	31	(E) a method used by a health benefit plan to
32	32	determine usual, customary, and reasonable charges;
33	33	(F) a step therapy protocol;
34	34	(G) an exclusion based on failure to complete a
35	35	course of treatment; and
36	36	(H) a restriction based on geographic location,
37	37	facility type, provider specialty, and other criteria that limit
38	38	the scope or duration of a benefit.
39	39	(4) "Substance use disorder benefit" means a benefit
40	40	relating to an item or service for a substance use disorder, as
41	41	defined under the terms of a health benefit plan and in accordance
42	42	with applicable federal and state law.
43	43	(5) "Treatment limitation" includes a limit on the
44	44	frequency of treatment, number of visits, days of coverage, or
45	45	other similar limit on the scope or duration of treatment. The term
46	46	includes a nonquantitative treatment limitation.
47	47	Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
48	48	subchapter applies only to a health benefit plan that provides
49	49	benefits for medical or surgical expenses incurred as a result of a
50	50	health condition, accident, or sickness, including an individual,
51	51	group, blanket, or franchise insurance policy or insurance
52	52	agreement, a group hospital service contract, an individual or
53	53	group evidence of coverage, or a similar coverage document, that is
54	54	offered by:
55	55	(1) an insurance company;
56	56	(2) a group hospital service corporation operating
57	57	under Chapter 842;
58	58	(3) a fraternal benefit society operating under
59	59	Chapter 885;
60	60	(4) a stipulated premium company operating under
61	61	Chapter 884;
62	62	(5) a health maintenance organization operating under
63	63	Chapter 843;
64	64	(6) a reciprocal exchange operating under Chapter 942;
65	65	(7) a Lloyd's plan operating under Chapter 941;
66	66	(8) an approved nonprofit health corporation that
67	67	holds a certificate of authority under Chapter 844; or
68	68	(9) a multiple employer welfare arrangement that holds
69	69	a certificate of authority under Chapter 846.
70	70	(b) Notwithstanding Section 1501.251 or any other law, this
71	71	subchapter applies to coverage under a small employer health
72	72	benefit plan subject to Chapter 1501.
73	73	(c) This subchapter applies to a standard health benefit
74	74	plan issued under Chapter 1507.
75	75	Sec. 1355.253. EXCEPTIONS. (a) This subchapter does not
76	76	apply to:
77	77	(1) a plan that provides coverage:
78	78	(A) for wages or payments in lieu of wages for a
79	79	period during which an employee is absent from work because of
80	80	sickness or injury;
81	81	(B) as a supplement to a liability insurance
82	82	policy;
83	83	(C) for credit insurance;
84	84	(D) only for dental or vision care;
85	85	(E) only for hospital expenses; or
86	86	(F) only for indemnity for hospital confinement;
87	87	(2) a Medicare supplemental policy as defined by
88	88	Section 1882(g)(1), Social Security Act (42 U.S.C. Section
89	89	1395ss(g)(1));
90	90	(3) a workers' compensation insurance policy;
91	91	(4) medical payment insurance coverage provided under
92	92	a motor vehicle insurance policy; or
93	93	(5) a long-term care policy, including a nursing home
94	94	fixed indemnity policy, unless the commissioner determines that the
95	95	policy provides benefit coverage so comprehensive that the policy
96	96	is a health benefit plan as described by Section 1355.252.
97	97	(b) To the extent that this section would otherwise require
98	98	this state to make a payment under 42 U.S.C. Section
99	99	18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
100	100	C.F.R. Section 155.20, is not required to provide a benefit under
101	101	this subchapter that exceeds the specified essential health
102	102	benefits required under 42 U.S.C. Section 18022(b).
103	103	Sec. 1355.254. REQUIRED COVERAGE FOR MENTAL HEALTH
104	104	CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health benefit plan
105	105	must provide benefits for mental health conditions and substance
106	106	use disorders under the same terms and conditions applicable to
107	107	benefits for medical or surgical expenses.
108	108	(b) Coverage under Subsection (a) may not impose treatment
109	109	limitations or financial requirements on benefits for a mental
110	110	health condition or substance use disorder that are generally more
111	111	restrictive than treatment limitations or financial requirements
112	112	imposed on coverage of benefits for medical or surgical expenses.
113	113	Sec. 1355.255. DEFINITIONS UNDER PLAN. (a) A health
114	114	benefit plan must define a condition to be a mental health condition
115	115	or not a mental health condition in a manner consistent with
116	116	generally recognized independent standards of medical practice.
117	117	(b) A health benefit plan must define a condition to be a
118	118	substance use disorder or not a substance use disorder in a manner
119	119	consistent with generally recognized independent standards of
120	120	medical practice.
121	121	Sec. 1355.256. COORDINATION WITH OTHER LAW; INTENT OF
122	122	LEGISLATURE. This subchapter supplements Subchapters A and B of
123	123	this chapter and Chapter 1368 and the department rules adopted
124	124	under those statutes. It is the intent of the legislature that
125	125	Subchapter A or B of this chapter or Chapter 1368 or the department
126	126	rules adopted under those statutes controls in any circumstance in
127	127	which that other law requires:
128	128	(1) a benefit that is not required by this subchapter;
129	129	or
130	130	(2) a more extensive benefit than is required by this
131	131	subchapter.
132	132	Sec. 1355.257. RULES. The commissioner shall adopt rules
133	133	necessary to implement this subchapter.
134	134	SECTION 2. (a) The Texas Department of Insurance shall
135	135	conduct a study and prepare a report on benefits for medical or
136	136	surgical expenses and for mental health conditions and substance
137	137	use disorders.
138	138	(b) In conducting the study, the department must collect and
139	139	compare data from health benefit plan issuers subject to Subchapter
140	140	F, Chapter 1355, Insurance Code, as added by this Act, on medical or
141	141	surgical benefits and mental health condition or substance use
142	142	disorder benefits that are:
143	143	(1) subject to prior authorization or utilization
144	144	review;
145	145	(2) denied as not medically necessary or experimental
146	146	or investigational;
147	147	(3) internally appealed, including data that
148	148	indicates whether the appeal was denied; or
149	149	(4) subject to an independent external review,
150	150	including data that indicates whether the denial was upheld.
151	151	(c) Not later than September 1, 2018, the department shall
152	152	report the results of the study and the department's findings.
153	153	SECTION 3. (a) The Health and Human Services Commission
154	154	shall conduct a study and prepare a report on benefits for medical
155	155	or surgical expenses and for mental health conditions and substance
156	156	use disorders provided by Medicaid managed care organizations.
157	157	(b) In conducting the study, the commission must collect and
158	158	compare data from Medicaid managed care organizations on medical or
159	159	surgical benefits and mental health condition or substance use
160	160	disorder benefits that are:
161	161	(1) subject to prior authorization or utilization
162	162	review;
163	163	(2) denied as not medically necessary or experimental
164	164	or investigational;
165	165	(3) internally appealed, including data that
166	166	indicates whether the appeal was denied; or
167	167	(4) subject to an independent external review,
168	168	including data that indicates whether the denial was upheld.
169	169	(c) Not later than September 1, 2018, the commission shall
170	170	report the results of the study and the commission's findings.
171	171	SECTION 4. Subchapter F, Chapter 1355, Insurance Code, as
172	172	added by this Act, applies only to a health benefit plan delivered,
173	173	issued for delivery, or renewed on or after January 1, 2018. A
174	174	health benefit plan delivered, issued for delivery, or renewed
175	175	before January 1, 2018, is governed by the law as it existed
176	176	immediately before the effective date of this Act, and that law is
177	177	continued in effect for that purpose.
178	178	SECTION 5. This Act takes effect September 1, 2017.