TX
Texas Senate Bill SB860

Texas 2017 - 85th Regular

Texas Senate Bill SB860 Compare Versions

OldNewDifferences
11 By: Zaffirini S.B. No. 860
22 (In the Senate - Filed February 14, 2017; February 27, 2017,
33 read first time and referred to Committee on Business & Commerce;
44 April 12, 2017, reported adversely, with favorable Committee
55 Substitute by the following vote: Yeas 9, Nays 0; April 12, 2017,
66 sent to printer.)
77 Click here to see the committee vote
88 COMMITTEE SUBSTITUTE FOR S.B. No. 860 By: Zaffirini
99
1010
1111 A BILL TO BE ENTITLED
1212 AN ACT
1313 relating to access to and benefits for mental health conditions and
1414 substance use disorders.
1515 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1616 SECTION 1. Subchapter B, Chapter 531, Government Code, is
1717 amended by adding Sections 531.02251 and 531.02252 to read as
1818 follows:
1919 Sec. 531.02251. OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO
2020 CARE. (a) In this section, "ombudsman" means the individual
2121 designated as the ombudsman for behavioral health access to care.
2222 (b) The executive commissioner shall designate an ombudsman
2323 for behavioral health access to care.
2424 (c) The ombudsman is administratively attached to the
2525 office of the ombudsman for the commission.
2626 (d) The commission may use an alternate title for the
2727 ombudsman in consumer-facing materials if the commission
2828 determines that an alternate title would be beneficial to consumer
2929 understanding or access.
3030 (e) The ombudsman serves as a neutral party to help
3131 consumers, including consumers who are uninsured or have public or
3232 private health benefit coverage, and behavioral health care
3333 providers navigate and resolve issues related to consumer access to
3434 behavioral health care, including care for mental health conditions
3535 and substance use disorders.
3636 (f) The ombudsman shall:
3737 (1) interact with consumers and behavioral health care
3838 providers with concerns or complaints to help the consumers and
3939 providers resolve behavioral health care access issues;
4040 (2) identify, track, and help report potential
4141 violations of state or federal rules, regulations, or statutes
4242 concerning the availability of, and terms and conditions of,
4343 benefits for mental health conditions or substance use disorders,
4444 including potential violations related to quantitative and
4545 nonquantitative treatment limitations;
4646 (3) report concerns, complaints, and potential
4747 violations described by Subdivision (2) to the appropriate
4848 regulatory or oversight agency;
4949 (4) receive and report concerns and complaints
5050 relating to inappropriate care or mental health commitment;
5151 (5) provide appropriate information to help consumers
5252 obtain behavioral health care;
5353 (6) develop appropriate points of contact for
5454 referrals to other state and federal agencies; and
5555 (7) provide appropriate information to help consumers
5656 or providers file appeals or complaints with the appropriate
5757 entities, including insurers and other state and federal agencies.
5858 (g) The ombudsman shall participate in the mental health
5959 condition and substance use disorder parity work group established
6060 under Section 531.02252 and provide summary reports of concerns,
6161 complaints, and potential violations described by Subsection
6262 (f)(2) to the work group. This subsection expires September 1,
6363 2021.
6464 (h) The Texas Department of Insurance shall appoint a
6565 liaison to the ombudsman to receive reports of concerns,
6666 complaints, and potential violations described by Subsection
6767 (f)(2) from the ombudsman, consumers, or behavioral health care
6868 providers.
6969 Sec. 531.02252. MENTAL HEALTH CONDITION AND SUBSTANCE USE
7070 DISORDER PARITY WORK GROUP. (a) The commission shall establish
7171 and facilitate a mental health condition and substance use disorder
7272 parity work group at the office of mental health coordination to
7373 increase understanding of and compliance with state and federal
7474 rules, regulations, and statutes concerning the availability of,
7575 and terms and conditions of, benefits for mental health conditions
7676 and substance use disorders.
7777 (b) The work group may be a part of or a subcommittee of the
7878 behavioral health advisory committee.
7979 (c) The work group is composed of:
8080 (1) a representative of:
8181 (A) Medicaid and the child health plan program;
8282 (B) the office of mental health coordination;
8383 (C) the Texas Department of Insurance;
8484 (D) a Medicaid managed care organization;
8585 (E) a commercial health benefit plan;
8686 (F) a mental health provider organization;
8787 (G) physicians;
8888 (H) hospitals;
8989 (I) children's mental health providers;
9090 (J) utilization review agents; and
9191 (K) independent review organizations;
9292 (2) a substance use disorder provider or a
9393 professional with co-occurring mental health and substance use
9494 disorder expertise;
9595 (3) a mental health consumer;
9696 (4) a mental health consumer advocate;
9797 (5) a substance use disorder treatment consumer;
9898 (6) a substance use disorder treatment consumer
9999 advocate;
100100 (7) a family member of a mental health or substance use
101101 disorder treatment consumer; and
102102 (8) the ombudsman for behavioral health access to
103103 care.
104104 (d) The work group shall meet at least quarterly.
105105 (e) The work group shall study and make recommendations on:
106106 (1) increasing compliance with the rules,
107107 regulations, and statutes described by Subsection (a);
108108 (2) strengthening enforcement and oversight of these
109109 laws at state and federal agencies;
110110 (3) improving the complaint processes relating to
111111 potential violations of these laws for consumers and providers;
112112 (4) ensuring the commission and the Texas Department
113113 of Insurance can accept information on concerns relating to these
114114 laws and investigate potential violations based on de-identified
115115 information and data submitted to providers in addition to
116116 individual complaints; and
117117 (5) increasing public and provider education on these
118118 laws.
119119 (f) The work group shall develop a strategic plan with
120120 metrics to serve as a roadmap to increase compliance with the rules,
121121 regulations, and statutes described by Subsection (a) in this state
122122 and to increase education and outreach relating to these laws.
123123 (g) Not later than September 1 of each even-numbered year,
124124 the work group shall submit a report to the appropriate committees
125125 of the legislature and the appropriate state agencies on the
126126 findings, recommendations, and strategic plan required by
127127 Subsections (e) and (f).
128128 (h) The work group is abolished and this section expires
129129 September 1, 2021.
130130 SECTION 2. Chapter 1355, Insurance Code, is amended by
131131 adding Subchapter F to read as follows:
132132 SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE
133133 USE DISORDERS
134134 Sec. 1355.251. DEFINITIONS. In this subchapter:
135135 (1) "Mental health benefit" means a benefit relating
136136 to an item or service for a mental health condition, as defined
137137 under the terms of a health benefit plan and in accordance with
138138 applicable federal and state law.
139139 (2) "Nonquantitative treatment limitation" means a
140140 limit on the scope or duration of treatment that is not expressed
141141 numerically. The term includes:
142142 (A) a medical management standard limiting or
143143 excluding benefits based on medical necessity or medical
144144 appropriateness or based on whether a treatment is experimental or
145145 investigational;
146146 (B) formulary design for prescription drugs;
147147 (C) network tier design;
148148 (D) a standard for provider participation in a
149149 network, including reimbursement rates;
150150 (E) a method used by a health benefit plan to
151151 determine usual, customary, and reasonable charges;
152152 (F) a step therapy protocol;
153153 (G) an exclusion based on failure to complete a
154154 course of treatment; and
155155 (H) a restriction based on geographic location,
156156 facility type, provider specialty, and other criteria that limit
157157 the scope or duration of a benefit.
158158 (3) "Quantitative treatment limitation" means a
159159 treatment limitation that determines whether, or to what extent,
160160 benefits are provided based on an accumulated amount such as an
161161 annual or lifetime limit on days of coverage or number of visits.
162162 The term includes a deductible, a copayment, coinsurance, or
163163 another out-of-pocket expense or annual or lifetime limit, or
164164 another financial requirement.
165165 (4) "Substance use disorder benefit" means a benefit
166166 relating to an item or service for a substance use disorder, as
167167 defined under the terms of a health benefit plan and in accordance
168168 with applicable federal and state law.
169169 Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This
170170 subchapter applies only to a health benefit plan that provides
171171 benefits or coverage for medical or surgical expenses incurred as a
172172 result of a health condition, accident, or sickness and for
173173 treatment expenses incurred as a result of a mental health
174174 condition or substance use disorder, including an individual,
175175 group, blanket, or franchise insurance policy or insurance
176176 agreement, a group hospital service contract, an individual or
177177 group evidence of coverage, or a similar coverage document, that is
178178 offered by:
179179 (1) an insurance company;
180180 (2) a group hospital service corporation operating
181181 under Chapter 842;
182182 (3) a fraternal benefit society operating under
183183 Chapter 885;
184184 (4) a stipulated premium company operating under
185185 Chapter 884;
186186 (5) a health maintenance organization operating under
187187 Chapter 843;
188188 (6) a reciprocal exchange operating under Chapter 942;
189189 (7) a Lloyd's plan operating under Chapter 941;
190190 (8) an approved nonprofit health corporation that
191191 holds a certificate of authority under Chapter 844; or
192192 (9) a multiple employer welfare arrangement that holds
193193 a certificate of authority under Chapter 846.
194194 (b) Notwithstanding Section 1501.251 or any other law, this
195195 subchapter applies to coverage under a small employer health
196196 benefit plan subject to Chapter 1501.
197197 (c) This subchapter applies to a standard health benefit
198198 plan issued under Chapter 1507.
199199 Sec. 1355.253. EXCEPTIONS. (a) This subchapter does not
200200 apply to:
201201 (1) a plan that provides coverage:
202202 (A) for wages or payments in lieu of wages for a
203203 period during which an employee is absent from work because of
204204 sickness or injury;
205205 (B) as a supplement to a liability insurance
206206 policy;
207207 (C) for credit insurance;
208208 (D) only for dental or vision care;
209209 (E) only for hospital expenses;
210210 (F) only for indemnity for hospital confinement;
211211 or
212212 (G) only for accidents;
213213 (2) a Medicare supplemental policy as defined by
214214 Section 1882(g)(1), Social Security Act (42 U.S.C. Section
215215 1395ss(g)(1));
216216 (3) a workers' compensation insurance policy;
217217 (4) medical payment insurance coverage provided under
218218 a motor vehicle insurance policy; or
219219 (5) a long-term care policy, including a nursing home
220220 fixed indemnity policy, unless the commissioner determines that the
221221 policy provides benefit coverage so comprehensive that the policy
222222 is a health benefit plan as described by Section 1355.252.
223223 (b) To the extent that this section would otherwise require
224224 this state to make a payment under 42 U.S.C. Section
225225 18031(d)(3)(B)(ii), a qualified health plan, as defined by 45
226226 C.F.R. Section 155.20, is not required to provide a benefit under
227227 this subchapter that exceeds the specified essential health
228228 benefits required under 42 U.S.C. Section 18022(b).
229229 Sec. 1355.254. COVERAGE FOR MENTAL HEALTH CONDITIONS AND
230230 SUBSTANCE USE DISORDERS. (a) A health benefit plan must provide
231231 benefits and coverage for mental health conditions and substance
232232 use disorders under the same terms and conditions applicable to the
233233 plan's medical and surgical benefits and coverage.
234234 (b) Coverage under Subsection (a) may not impose
235235 quantitative or nonquantitative treatment limitations on benefits
236236 for a mental health condition or substance use disorder that are
237237 generally more restrictive than quantitative or nonquantitative
238238 treatment limitations imposed on coverage of benefits for medical
239239 or surgical expenses.
240240 Sec. 1355.255. COMPLIANCE. The commissioner shall enforce
241241 compliance with Section 1355.254 by evaluating the benefits and
242242 coverage offered by a health benefit plan for quantitative and
243243 nonquantitative treatment limitations in the following categories:
244244 (1) in-network and out-of-network inpatient care;
245245 (2) in-network and out-of-network outpatient care;
246246 (3) emergency care; and
247247 (4) prescription drugs.
248248 Sec. 1355.256. DEFINITIONS UNDER PLAN. (a) A health
249249 benefit plan must define a condition to be a mental health condition
250250 or not a mental health condition in a manner consistent with
251251 generally recognized independent standards of medical practice.
252252 (b) A health benefit plan must define a condition to be a
253253 substance use disorder or not a substance use disorder in a manner
254254 consistent with generally recognized independent standards of
255255 medical practice.
256256 Sec. 1355.257. COORDINATION WITH OTHER LAW; INTENT OF
257257 LEGISLATURE. This subchapter supplements Subchapters A and B of
258258 this chapter and Chapter 1368 and the department rules adopted
259259 under those statutes. It is the intent of the legislature that
260260 Subchapter A or B of this chapter or Chapter 1368 or a department
261261 rule adopted under those statutes controls in any circumstance in
262262 which that other law requires:
263263 (1) a benefit that is not required by this subchapter;
264264 or
265265 (2) a more extensive benefit than is required by this
266266 subchapter.
267267 Sec. 1355.258. RULES. The commissioner shall adopt rules
268268 necessary to implement this subchapter.
269269 SECTION 3. (a) The Texas Department of Insurance shall
270270 conduct a study and prepare a report on benefits for medical or
271271 surgical expenses and for mental health conditions and substance
272272 use disorders.
273273 (b) In conducting the study, the department must collect and
274274 compare data from health benefit plan issuers subject to Subchapter
275275 F, Chapter 1355, Insurance Code, as added by this Act, on medical or
276276 surgical benefits and mental health condition or substance use
277277 disorder benefits that are:
278278 (1) subject to prior authorization or utilization
279279 review;
280280 (2) denied as not medically necessary or experimental
281281 or investigational;
282282 (3) internally appealed, including data that
283283 indicates whether the appeal was denied; or
284284 (4) subject to an independent external review,
285285 including data that indicates whether the denial was upheld.
286286 (c) Not later than September 1, 2018, the department shall
287287 report the results of the study and the department's findings.
288288 SECTION 4. (a) The Health and Human Services Commission
289289 shall conduct a study and prepare a report on benefits for medical
290290 or surgical expenses and for mental health conditions and substance
291291 use disorders provided by Medicaid managed care organizations.
292292 (b) In conducting the study, the commission must collect and
293293 compare data from Medicaid managed care organizations on medical or
294294 surgical benefits and mental health condition or substance use
295295 disorder benefits that are:
296296 (1) subject to prior authorization or utilization
297297 review;
298298 (2) denied as not medically necessary or experimental
299299 or investigational;
300300 (3) internally appealed, including data that
301301 indicates whether the appeal was denied; or
302302 (4) subject to an independent external review,
303303 including data that indicates whether the denial was upheld.
304304 (c) Not later than September 1, 2018, the commission shall
305305 report the results of the study and the commission's findings.
306306 SECTION 5. Subchapter F, Chapter 1355, Insurance Code, as
307307 added by this Act, applies only to a health benefit plan delivered,
308308 issued for delivery, or renewed on or after January 1, 2018. A
309309 health benefit plan delivered, issued for delivery, or renewed
310310 before January 1, 2018, is governed by the law as it existed
311311 immediately before the effective date of this Act, and that law is
312312 continued in effect for that purpose.
313313 SECTION 6. This Act takes effect September 1, 2017.
314314 * * * * *