Texas 2019 - 86th Regular

Texas House Bill HB2327 Compare Versions

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1	1		By: Bonnen of Galveston, Guillen H.B. No. 2327
2		-	(Senate Sponsor - Buckingham, Schwertner)
3		-	(In the Senate - Received from the House April 24, 2019;
4		-	April 25, 2019, read first time and referred to Committee on
5		-	Business & Commerce; May 20, 2019, reported adversely, with
6		-	favorable Committee Substitute by the following vote: Yeas 9,
7		-	Nays 0; May 20, 2019, sent to printer.)
8		-	Click here to see the committee vote
9		-	COMMITTEE SUBSTITUTE FOR H.B. No. 2327 By: Nichols
10	2
11	3
12	4		A BILL TO BE ENTITLED
13	5		AN ACT
14	6		relating to preauthorization of certain medical care and health
15	7		care services by certain health benefit plan issuers and to the
16	8		regulation of utilization review, independent review, and peer
17	9		review for health benefit plan and workers' compensation coverage.
18	10		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
19	11		ARTICLE 1. PREAUTHORIZATION
20	12		SECTION 1.01. Section 843.348(b), Insurance Code, is
21	13		amended to read as follows:
22	14		(b) A health maintenance organization that uses a
23	15		preauthorization process for health care services shall provide
24	16		each participating physician or provider, not later than the fifth
25	17		[10th] business day after the date a request is made, a list of
26	18		health care services that [do not] require preauthorization and
27	19		information concerning the preauthorization process.
28	20		SECTION 1.02. Subchapter J, Chapter 843, Insurance Code, is
29		-	amended by adding Sections 843.3481, 843.3482, ~~and~~ 843.3483 ~~to read~~
30		-	as follows:
	21	+	amended by adding Sections 843.3481, 843.3482, 843.3483, and
	22	+	843.3484 to read as follows:
31	23		Sec. 843.3481. POSTING OF PREAUTHORIZATION REQUIREMENTS.
32		-	(a) A health maintenance organization that uses a
33		-	~~preauthorization~~ process for health care services shall make the
34		-	~~requirements and~~ information about the preauthorization process
35		-	~~readily accessible~~ to enrollees, physicians, providers, and the
36		-	~~general public by~~ posting the requirements and information on the
37		-	~~health maintenance~~ organization's Internet website.
	24	+	(a) A health maintenance organization that uses a preauthorization
	25	+	process for health care services shall make the requirements and
	26	+	information about the preauthorization process readily accessible
	27	+	to enrollees, physicians, providers, and the general public by
	28	+	posting the requirements and information on the health maintenance
	29	+	organization's Internet website.
38	30		(b) The preauthorization requirements and information
39	31		described by Subsection (a) must:
40	32		(1) be posted:
41		-	(A) except as provided by Subsection (c) or (d),
42		-	conspicuously in a location on the Internet website that does not
43		-	require the use of a log-in or other input of personal information
44		-	to view the information; and
	33	+	(A) conspicuously in a location on the Internet
	34	+	website that does not require the use of a log-in or other input of
	35	+	personal information to view the information; and
45	36		(B) in a format that is easily searchable and
46	37		accessible;
47		-	(2) ~~except for the screening criteria under Paragraph~~
48		-	~~(4)(C)~~, ~~be written in plain language that is easily understandable~~
49		-	~~by enrollees, physicians, providers, and the~~ general public;
	38	+	(2) be written in plain language that is easily
	39	+	understandable by enrollees, physicians, providers, and the
	40	+	general public;
50	41		(3) include a detailed description of the
51	42		preauthorization process and procedure; and
52	43		(4) include an accurate and current list of the health
53	44		care services for which the health maintenance organization
54	45		requires preauthorization that includes the following information
55	46		specific to each service:
56	47		(A) the effective date of the preauthorization
57	48		requirement;
58	49		(B) a list or description of any supporting
59	50		documentation that the health maintenance organization requires
60	51		from the physician or provider ordering or requesting the service
61	52		to approve a request for that service;
62		-	(C) the applicable screening criteria~~, which may~~
63		-	~~include~~ Current Procedural Terminology codes and International
	53	+	(C) the applicable screening criteria using
	54	+	Current Procedural Terminology codes and International
64	55		Classification of Diseases codes; and
65	56		(D) statistics regarding preauthorization
66		-	approval and denial rates for the service in the preceding year,
67		-	including statistics in the following categories:
	57	+	approval and denial rates for the service in the preceding year and
	58	+	for each previous year the preauthorization requirement was in
	59	+	effect, including statistics in the following categories:
68	60		(i) physician or provider type and
69	61		specialty, if any;
70	62		(ii) indication offered;
71	63		(iii) reasons for request denial;
72		-	(iv) denials overturned on appeal; and
73		-	(v) total annual preauthorization
	64	+	(iv) denials overturned on internal appeal;
	65	+	(v) denials overturned on external appeal;
	66	+	and
	67	+	(vi) total annual preauthorization
74	68		requests, approvals, and denials for the service.
75		-	(c) This section may not be construed to require a health
76		-	maintenance organization to provide specific information that
77		-	would violate any applicable copyright law or licensing agreement.
78		-	A health maintenance organization is required to supply, in lieu of
79		-	any information withheld on the basis of copyright law or a
80		-	licensing agreement, a summary of the withheld information
81		-	sufficient to allow a licensed physician or provider, as applicable
82		-	for the specific service, who has sufficient training and
83		-	experience related to the service to understand the basis for the
84		-	health maintenance organization's medical necessity or
85		-	appropriateness determinations.
86		-	(d) If a requirement or information described by Subsection
87		-	(a) is licensed, proprietary, or copyrighted material that the
88		-	health maintenance organization has received from a third party
89		-	with which the health maintenance organization has contracted, the
90		-	health maintenance organization may, instead of making that
91		-	information publicly available on the health maintenance
92		-	organization's Internet website, provide the material to a
93		-	physician or provider who submits a preauthorization request using
94		-	a nonpublic secured Internet website link or other protected,
95		-	nonpublic electronic means.
96	69		Sec. 843.3482. CHANGES TO PREAUTHORIZATION REQUIREMENTS.
97	70		(a) Except as provided by Subsection (b), not later than the 60th
98	71		day before the date a new or amended preauthorization requirement
99	72		takes effect, a health maintenance organization that uses a
100	73		preauthorization process for health care services shall provide
101		-	notice of the new ~~or amended preauthorization requirement in the~~
102		-	~~health maintenance organization's newsletter~~ or ~~network bulletin,~~
103		-	~~if any,~~ ~~and on~~ the health maintenance organization's ~~Internet~~
104		-	~~website~~.
	74	+	each participating physician or provider written notice of the new
	75	+	or amended preauthorization requirement and disclose the new or
	76	+	amended requirement in the health maintenance organization's
	77	+	newsletter or network bulletin, if any.
105	78		(b) For a change in a preauthorization requirement or
106	79		process that removes a service from the list of health care services
107	80		requiring preauthorization or amends a preauthorization
108	81		requirement in a way that is less burdensome to enrollees or
109	82		participating physicians or providers, a health maintenance
110		-	organization shall provide ~~notice of the change in the~~
111		-	~~preauthorization requirement~~ in the ~~health maintenance~~
112		-	~~organization's newsletter or network bulletin, if any,~~ and on the
113		-	~~health maintenance~~ organization's ~~Internet website~~ not later ~~than~~
114		-	the fifth day before the date the change takes effect.
	83	+	organization shall provide each participating physician or
	84	+	provider written notice of the change in the preauthorization
	85	+	requirement and disclose the change in the health maintenance
	86	+	organization's newsletter or network bulletin, if any, not later
	87	+	than the fifth day before the date the change takes effect.
115	88		(c) Not later than the fifth day before the date a new or
116	89		amended preauthorization requirement takes effect, a health
117	90		maintenance organization shall update its Internet website to
118	91		disclose the change to the health maintenance organization's
119	92		preauthorization requirements or process and the date and time the
120	93		change is effective.
121		-	Sec. 843.3483. REMEDY FOR NONCOMPLIANCE. In addition to
122		-	any other penalty or remedy provided by law, a health maintenance
123		-	organization that uses a preauthorization process for health care
124		-	services that violates this subchapter with respect to a required
125		-	publication, notice, or response regarding its preauthorization
126		-	requirements, including by failing to comply with any applicable
127		-	deadline for the publication, notice, or response, must provide an
128		-	expedited appeal under Section 4201.357 for any health care service
129		-	affected by the violation.
	94	+	Sec. 843.3483. REMEDY FOR NONCOMPLIANCE; AUTOMATIC WAIVER.
	95	+	In addition to any other penalty or remedy provided by law, a health
	96	+	maintenance organization that uses a preauthorization process for
	97	+	health care services that violates this subchapter with respect to
	98	+	a required publication, notice, or response regarding its
	99	+	preauthorization requirements, including by failing to comply with
	100	+	any applicable deadline for the publication, notice, or response,
	101	+	waives the health maintenance organization's preauthorization
	102	+	requirements with respect to any health care service affected by
	103	+	the violation, and any health care service affected by the
	104	+	violation is considered preauthorized by the health maintenance
	105	+	organization.
	106	+	Sec. 843.3484. EFFECT OF PREAUTHORIZATION WAIVER. A waiver
	107	+	of preauthorization requirements under Section 843.3483 may not be
	108	+	construed to:
	109	+	(1) authorize a physician or provider to provide
	110	+	health care services outside of the physician's or provider's
	111	+	applicable scope of practice as defined by state law; or
	112	+	(2) require the health maintenance organization to pay
	113	+	for a health care service provided outside of the physician's or
	114	+	provider's applicable scope of practice as defined by state law.
130	115		SECTION 1.03. Section 1301.135(a), Insurance Code, is
131	116		amended to read as follows:
132	117		(a) An insurer that uses a preauthorization process for
133	118		medical care or [and] health care services shall provide to each
134	119		preferred provider, not later than the fifth [10th] business day
135	120		after the date a request is made, a list of medical care and health
136	121		care services that require preauthorization and information
137	122		concerning the preauthorization process.
138	123		SECTION 1.04. Subchapter C-1, Chapter 1301, Insurance Code,
139		-	is amended by adding Sections 1301.1351, 1301.1352, ~~and~~ 1301.1353
140		-	to read as follows:
	124	+	is amended by adding Sections 1301.1351, 1301.1352, 1301.1353, and
	125	+	1301.1354 to read as follows:
141	126		Sec. 1301.1351. POSTING OF PREAUTHORIZATION REQUIREMENTS.
142	127		(a) An insurer that uses a preauthorization process for medical
143	128		care or health care services shall make the requirements and
144	129		information about the preauthorization process readily accessible
145	130		to insureds, physicians, health care providers, and the general
146	131		public by posting the requirements and information on the insurer's
147	132		Internet website.
148	133		(b) The preauthorization requirements and information
149	134		described by Subsection (a) must:
150	135		(1) be posted:
151		-	(A) except as provided by Subsection (c) or (d),
152		-	conspicuously in a location on the Internet website that does not
153		-	require the use of a log-in or other input of personal information
154		-	to view the information; and
	136	+	(A) conspicuously in a location on the Internet
	137	+	website that does not require the use of a log-in or other input of
	138	+	personal information to view the information; and
155	139		(B) in a format that is easily searchable and
156	140		accessible;
157		-	(2) except for the screening criteria under Paragraph
158		-	(4)(C), be written in plain language that is easily understandable
159		-	by insureds, physicians, health care providers, and the general
160		-	public;
	141	+	(2) be written in plain language that is easily
	142	+	understandable by insureds, physicians, health care providers, and
	143	+	the general public;
161	144		(3) include a detailed description of the
162	145		preauthorization process and procedure; and
163	146		(4) include an accurate and current list of medical
164	147		care and health care services for which the insurer requires
165	148		preauthorization that includes the following information specific
166	149		to each service:
167	150		(A) the effective date of the preauthorization
168	151		requirement;
169	152		(B) a list or description of any supporting
170	153		documentation that the insurer requires from the physician or
171	154		health care provider ordering or requesting the service to approve
172	155		a request for the service;
173		-	(C) the applicable screening criteria~~, which may~~
174		-	~~include~~ Current Procedural Terminology codes and International
	156	+	(C) the applicable screening criteria using
	157	+	Current Procedural Terminology codes and International
175	158		Classification of Diseases codes; and
176	159		(D) statistics regarding the insurer's
177	160		preauthorization approval and denial rates for the medical care or
178		-	health care service in the preceding year, including statistics in
179		-	the following categories:
	161	+	health care service in the preceding year and for each previous year
	162	+	the preauthorization requirement was in effect, including
	163	+	statistics in the following categories:
180	164		(i) physician or health care provider type
181	165		and specialty, if any;
182	166		(ii) indication offered;
183	167		(iii) reasons for request denial;
184		-	(iv) denials overturned on appeal; and
185		-	(v) total annual preauthorization
	168	+	(iv) denials overturned on internal appeal;
	169	+	(v) denials overturned on external appeal;
	170	+	and
	171	+	(vi) total annual preauthorization
186	172		requests, approvals, and denials for the service.
187		-	(c) This section may not be construed to require an insurer
188		-	to provide specific information that would violate any applicable
189		-	copyright law or licensing agreement. An insurer is required to
190		-	supply, in lieu of any information withheld on the basis of
191		-	copyright law or a licensing agreement, a summary of the withheld
192		-	information sufficient to allow a licensed physician or other
193		-	health care provider, as applicable for the specific service, who
194		-	has sufficient training and experience related to the service to
195		-	understand the basis for the insurer's medical necessity or
196		-	appropriateness determinations.
197		-	(d) If a requirement or information described by Subsection
198		-	(a) is licensed, proprietary, or copyrighted material that the
199		-	insurer has received from a third party with which the insurer has
200		-	contracted, the insurer may, instead of making that information
201		-	publicly available on the insurer's Internet website, provide the
202		-	material to a physician or health care provider who submits a
203		-	preauthorization request using a nonpublic secured Internet
204		-	website link or other protected, nonpublic electronic means.
205		-	(e) The provisions of this section may not be waived,
	173	+	(c) The provisions of this section may not be waived,
206	174		voided, or nullified by contract.
207	175		Sec. 1301.1352. CHANGES TO PREAUTHORIZATION REQUIREMENTS.
208	176		(a) Except as provided by Subsection (b), not later than the 60th
209	177		day before the date a new or amended preauthorization requirement
210	178		takes effect, an insurer that uses a preauthorization process for
211		-	medical care or health care services shall provide notice of the new
212		-	or amended preauthorization requirement in the insurer's
213		-	newsletter or network bulletin, if any, and on the insurer's
214		-	Internet website.
	179	+	medical care or health care services shall provide to each
	180	+	preferred provider written notice of the new or amended
	181	+	preauthorization requirement and disclose the new or amended
	182	+	requirement in the insurer's newsletter or network bulletin, if
	183	+	any.
215	184		(b) For a change in a preauthorization requirement or
216	185		process that removes a service from the list of medical care or
217	186		health care services requiring preauthorization or amends a
218	187		preauthorization requirement in a way that is less burdensome to
219	188		insureds, physicians, or health care providers, an insurer shall
220		-	provide notice of the change in the ~~preauthorization requirement in~~
221		-	the ~~insurer's newsletter or network bulletin, if any, and on~~ the
222		-	insurer's ~~Internet website~~ not later than ~~the fifth day before the~~
223		-	date the change takes effect.
	189	+	provide each preferred provider written notice of the change in the
	190	+	preauthorization requirement and disclose the change in the
	191	+	insurer's newsletter or network bulletin, if any, not later than
	192	+	the fifth day before the date the change takes effect.
224	193		(c) Not later than the fifth day before the date a new or
225	194		amended preauthorization requirement takes effect, an insurer
226	195		shall update its Internet website to disclose the change to the
227	196		insurer's preauthorization requirements or process and the date and
228	197		time the change is effective.
229	198		(d) The provisions of this section may not be waived,
230	199		voided, or nullified by contract.
231		-	Sec. 1301.1353. REMEDY FOR NONCOMPLIANCE. (a) In addition
232		-	to any other penalty or remedy provided by law, an insurer that uses
233		-	a preauthorization process for medical care or health care services
234		-	that violates this subchapter with respect to a required
235		-	publication, notice, or response regarding its preauthorization
236		-	requirements, including by failing to comply with any applicable
237		-	deadline for the publication, notice, or response, must provide an
238		-	expedited appeal under Section 4201.357 for any medical care or
239		-	health care service affected by the violation.
	200	+	Sec. 1301.1353. REMEDY FOR NONCOMPLIANCE; AUTOMATIC
	201	+	WAIVER. (a) In addition to any other penalty or remedy provided by
	202	+	law, an insurer that uses a preauthorization process for medical
	203	+	care or health care services that violates this subchapter with
	204	+	respect to a required publication, notice, or response regarding
	205	+	its preauthorization requirements, including by failing to comply
	206	+	with any applicable deadline for the publication, notice, or
	207	+	response, waives the insurer's preauthorization requirements with
	208	+	respect to any medical care or health care service affected by the
	209	+	violation, and any medical care or health care service affected by
	210	+	the violation is considered preauthorized by the insurer.
	211	+	(b) The provisions of this section may not be waived,
	212	+	voided, or nullified by contract.
	213	+	Sec. 1301.1354. EFFECT OF PREAUTHORIZATION WAIVER. (a) A
	214	+	waiver of preauthorization requirements under Section 1301.1353
	215	+	may not be construed to:
	216	+	(1) authorize a physician or health care provider to
	217	+	provide medical care or health care services outside of the
	218	+	physician's or health care provider's applicable scope of practice
	219	+	as defined by state law; or
	220	+	(2) require the insurer to pay for a medical care or
	221	+	health care service provided outside of the
	222	+	physician's or health
	223	+	care provider's applicable scope of practice as defined by state
	224	+	law.
240	225		(b) The provisions of this section may not be waived,
241	226		voided, or nullified by contract.
242	227		ARTICLE 2. UTILIZATION, INDEPENDENT, AND PEER REVIEW
243	228		SECTION 2.01. Section 4201.002(12), Insurance Code, is
244	229		amended to read as follows:
245	230		(12) "Provider of record" means the physician or other
246	231		health care provider with primary responsibility for the health
247	232		care[, treatment, and] services provided to or requested on behalf
248	233		of an enrollee or the physician or other health care provider that
249	234		has provided or has been requested to provide the health care
250	235		services to the enrollee. The term includes a health care facility
251	236		where the health care services are [if treatment is] provided on an
252	237		inpatient or outpatient basis.
253	238		SECTION 2.02. Sections 4201.151 and 4201.152, Insurance
254	239		Code, are amended to read as follows:
255	240		Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization
256	241		review agent's utilization review plan, including reconsideration
257	242		and appeal requirements, must be reviewed by a physician licensed
258	243		to practice medicine in this state and conducted in accordance with
259	244		standards developed with input from appropriate health care
260	245		providers and approved by a physician licensed to practice medicine
261	246		in this state.
262	247		Sec. 4201.152. UTILIZATION REVIEW UNDER [DIRECTION OF]
263	248		PHYSICIAN. A utilization review agent shall conduct utilization
264		-	review under the direction of a physician licensed to practice
265		-	medicine in this [by a] state [licensing agency in the United
266		-	States].
267		-	SECTION 2.03. Section 4201.153(d), Insurance Code, is
	249	+	review under the supervision and direction of a physician licensed
	250	+	to practice medicine in this [by a] state [licensing agency in the
	251	+	United States].
	252	+	SECTION 2.03. Subchapter D, Chapter 4201, Insurance Code,
	253	+	is amended by adding Section 4201.1525 to read as follows:
	254	+	Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIAN. (a) A
	255	+	utilization review agent that uses a physician to conduct
	256	+	utilization review may only use a physician licensed to practice
	257	+	medicine in this state.
	258	+	(b) A payor that conducts utilization review on the payor's
	259	+	own behalf is subject to Subsection (a) as if the payor were a
	260	+	utilization review agent.
	261	+	SECTION 2.04. Section 4201.153(d), Insurance Code, is
268	262		amended to read as follows:
269	263		(d) Screening criteria must be used to determine only
270	264		whether to approve the requested treatment. Before issuing an
271	265		adverse determination, a utilization review agent must obtain a
272		-	determination of medical necessity and appropriateness by
273		-	referring a proposed [A] denial of requested treatment [must be
274		-	referred] to:
	266	+	determination of medical necessity by referring a proposed [A]
	267	+	denial of requested treatment [must be referred] to:
275	268		(1) an appropriate physician, dentist, or other health
276	269		care provider; or
277	270		(2) if the treatment is requested, ordered, provided,
278	271		or to be provided by a physician, a physician licensed to practice
279		-	medicine who is of the same or a similar specialty as ~~that physician~~
280		-	[to determine medical necessity].
281		-	SECTION 2.04. Sections 4201.155, 4201.206, and 4201.251,
	272	+	medicine in this state who is of the same or a similar specialty as
	273	+	that physician [to determine medical necessity].
	274	+	SECTION 2.05. Sections 4201.155, 4201.206, and 4201.251,
282	275		Insurance Code, are amended to read as follows:
283	276		Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW
284	277		PROCEDURES. (a) A utilization review agent may not establish or
285	278		impose a notice requirement or other review procedure that is
286	279		contrary to the requirements of the health insurance policy or
287	280		health benefit plan.
288	281		(b) This section may not be construed to release a health
289	282		insurance policy or health benefit plan from full compliance with
290	283		this chapter or other applicable law.
291	284		Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
292	285		ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
293	286		notice requirements of Subchapter G, before an adverse
294	287		determination is issued by a utilization review agent who questions
295	288		the medical necessity, the [or] appropriateness, or the
296	289		experimental or investigational nature[,] of a health care service,
297	290		the agent shall provide the health care provider who ordered,
298	291		requested, provided, or is to provide the service a reasonable
299	292		opportunity to discuss with a physician licensed to practice
300		-	medicine the patient's treatment plan and the ~~clinical basis for~~
301		-	the agent's determination.
	293	+	medicine in this state the patient's treatment plan and the
	294	+	clinical basis for the agent's determination.
302	295		(b) If the health care service described by Subsection (a)
303	296		was ordered, requested, or provided, or is to be provided by a
304	297		physician, the opportunity described by that subsection must be
305		-	with a physician licensed to practice medicine who is ~~of the same or~~
306		-	a similar specialty as that physician.
	298	+	with a physician licensed to practice medicine in this state who is
	299	+	of the same or a similar specialty as that physician.
307	300		Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. A
308	301		utilization review agent may delegate utilization review to
309	302		qualified personnel in the hospital or other health care facility
310	303		in which the health care services to be reviewed were or are to be
311	304		provided. The delegation does not release the agent from the full
312	305		responsibility for compliance with this chapter or other applicable
313	306		law, including the conduct of those to whom utilization review has
314	307		been delegated.
315		-	SECTION 2.05. Sections 4201.252(a) and (b), Insurance Code,
	308	+	SECTION 2.06. Sections 4201.252(a) and (b), Insurance Code,
316	309		are amended to read as follows:
317	310		(a) Personnel employed by or under contract with a
318	311		utilization review agent to perform utilization review must be
319	312		appropriately trained and qualified and meet the requirements of
320		-	this chapter and other applicable law, including ~~applicable~~
321		-	~~licensing~~ requirements.
	313	+	this chapter and other applicable law, including licensing
	314	+	requirements.
322	315		(b) Personnel, other than a physician licensed to practice
323		-	medicine, who obtain oral or written information ~~directly from a~~
324		-	patient's physician or other health care provider ~~regarding the~~
325		-	patient's specific medical condition, diagnosis, or ~~treatment~~
326		-	options or protocols must be a nurse, physician ~~assistant, or other~~
327		-	health care provider qualified and licensed or ~~otherwise authorized~~
328		-	by law and an appropriate licensing agency in ~~the United States to~~
329		-	provide the requested service.
330		-	SECTION 2.06. Section 4201.356, Insurance Code, is amended
	316	+	medicine in this state, who obtain oral or written information
	317	+	directly from a patient's physician or other health care provider
	318	+	regarding the patient's specific medical condition, diagnosis, or
	319	+	treatment options or protocols must be a nurse, physician
	320	+	assistant, or other health care provider qualified and licensed or
	321	+	otherwise authorized by law and the appropriate licensing agency in
	322	+	this state to provide the requested service.
	323	+	SECTION 2.07. Section 4201.356, Insurance Code, is amended
331	324		to read as follows:
332	325		Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY
333	326		REVIEW. (a) The procedures for appealing an adverse determination
334		-	must provide that a physician licensed to practice medicine makes
335		-	the decision on the appeal, except as provided by Subsection (b).
336		-	(b) If not later than the 10th working day after the date an
337		-	appeal is requested or denied the enrollee's health care provider
338		-	requests [states in writing good cause for having] a particular
339		-	type of specialty provider review the case, a health care provider
340		-	who is of the same or a similar specialty as the health care
341		-	provider who would typically manage the medical or dental
342		-	condition, procedure, or treatment under consideration for review
343		-	and who is licensed or otherwise authorized by the appropriate
344		-	licensing agency in the United States to manage the medical or
345		-	dental condition, procedure, or treatment shall review the denial
346		-	or the decision denying the appeal. The specialty review must be
347		-	completed within 15 working days of the date the health care
348		-	provider's request for specialty review is received.
349		-	SECTION 2.07. Sections 4201.357(a), (a-1), and (a-2),
	327	+	must provide that a physician licensed to practice medicine in this
	328	+	state makes the decision on the appeal, except as provided by
	329	+	Subsection (b) or (c).
	330	+	(b) For a health care service ordered, requested, provided,
	331	+	or to be provided by a physician, the procedures for appealing an
	332	+	adverse determination must provide that a physician licensed to
	333	+	practice medicine in this state who is of the same or a similar
	334	+	specialty as that physician makes the decision on appeal, except as
	335	+	provided by Subsection (c).
	336	+	(c) If not later than the 10th working day after the date an
	337	+	appeal is denied the enrollee's health care provider states in
	338	+	writing good cause for having a particular type of specialty
	339	+	provider review the case, a health care provider who is of the same
	340	+	or a similar specialty as the health care provider who would
	341	+	typically manage the medical or dental condition, procedure, or
	342	+	treatment under consideration for review and who is licensed or
	343	+	otherwise authorized by the appropriate licensing agency in this
	344	+	state to manage the medical or dental condition, procedure, or
	345	+	treatment shall review the decision denying the appeal. The
	346	+	specialty review must be completed within 15 working days of the
	347	+	date the health care provider's request for specialty review is
	348	+	received.
	349	+	SECTION 2.08. Sections 4201.357(a), (a-1), and (a-2),
350	350		Insurance Code, are amended to read as follows:
351	351		(a) The procedures for appealing an adverse determination
352	352		must include, in addition to the written appeal, a procedure for an
353		-	expedited appeal of a denial of emergency care, [or] a denial of
354		-	continued hospitalization, or a denial of another service if the
355		-	requesting health care provider includes a written statement with
356		-	supporting documentation that the service is necessary to treat a
357		-	life-threatening condition or prevent serious harm to the patient.
358		-	That procedure must include a review by a health care provider who:
	353	+	expedited appeal of a denial of emergency care or a denial of
	354	+	continued hospitalization. That procedure must include a review by
	355	+	a health care provider who:
359	356		(1) has not previously reviewed the case; [and]
360	357		(2) is of the same or a similar specialty as the health
361	358		care provider who would typically manage the medical or dental
362	359		condition, procedure, or treatment under review in the appeal; and
363	360		(3) for a review of a health care service:
364		-	(A) ordered, requested, or to be provided by a
365		-	health care provider who is not a physician, is licensed or
366		-	otherwise authorized by an appropriate licensing agency in the
367		-	United States; or
368		-	(B) ordered, requested, or to be provided by a
369		-	physician, is licensed to practice medicine in the United States.
	361	+	(A) ordered, requested, provided, or to be
	362	+	provided by a health care provider who is not a physician, is
	363	+	licensed or otherwise authorized by the appropriate licensing
	364	+	agency in this state to provide the service in this state; or
	365	+	(B) ordered, requested, provided, or to be
	366	+	provided by a physician, is licensed to practice medicine in this
	367	+	state.
370	368		(a-1) The procedures for appealing an adverse determination
371	369		must include, in addition to the written appeal and the appeal
372	370		described by Subsection (a), a procedure for an expedited appeal of
373	371		a denial of prescription drugs or intravenous infusions for which
374	372		the patient is receiving benefits under the health insurance
375	373		policy. That procedure must include a review by a health care
376	374		provider who:
377	375		(1) has not previously reviewed the case; [and]
378	376		(2) is of the same or a similar specialty as the health
379	377		care provider who would typically manage the medical or dental
380	378		condition, procedure, or treatment under review in the appeal; and
381	379		(3) for a review of a health care service:
382		-	(A) ordered, requested, or to be provided by a
383		-	health care provider who is not a physician, is licensed or
384		-	otherwise authorized by the appropriate licensing agency in this
385		-	state to provide the service in this state; or
386		-	(B) ordered, requested, or to be provided by a
387		-	physician, is licensed to practice medicine in this state.
	380	+	(A) ordered, requested, provided, or to be
	381	+	provided by a health care provider who is not a physician, is
	382	+	licensed or otherwise authorized by the appropriate licensing
	383	+	agency in this state to provide the service in this state; or
	384	+	(B) ordered, requested, provided, or to be
	385	+	provided by a physician, is licensed to practice medicine in this
	386	+	state.
388	387		(a-2) An adverse determination under Section 1369.0546 is
389	388		entitled to an expedited appeal. The physician or, if appropriate,
390	389		other health care provider deciding the appeal must consider
391	390		atypical diagnoses and the needs of atypical patient populations.
392		-	The physician must be licensed to practice medicine in ~~the United~~
393		-	~~States~~ and the health care provider must be licensed or otherwise
394		-	authorized by an appropriate licensing agency in ~~the United States~~.
395		-	SECTION 2.08. Section 4201.359, Insurance Code, is amended
	391	+	The physician must be licensed to practice medicine in this state
	392	+	and the health care provider must be licensed or otherwise
	393	+	authorized by the appropriate licensing agency in this state.
	394	+	SECTION 2.09. Section 4201.359, Insurance Code, is amended
396	395		by adding Subsection (c) to read as follows:
397	396		(c) A physician described by Subsection (b)(2) must comply
398	397		with this chapter and other applicable laws and be licensed to
399		-	practice medicine. A health care provider described ~~by Subsection~~
400		-	(b)(2) must comply with this chapter and other ~~applicable laws and~~
401		-	be licensed or otherwise authorized by ~~an appropriate licensing~~
402		-	agency in ~~the United States~~.
403		-	SECTION 2.09. Sections 4201.453 and 4201.454, Insurance
	398	+	practice medicine in this state. A health care provider described
	399	+	by Subsection (b)(2) must comply with this chapter and other
	400	+	applicable laws and be licensed or otherwise authorized by the
	401	+	appropriate licensing agency in this state.
	402	+	SECTION 2.10. Sections 4201.453 and 4201.454, Insurance
404	403		Code, are amended to read as follows:
405	404		Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty
406	405		utilization review agent's utilization review plan, including
407	406		reconsideration and appeal requirements, must be:
408	407		(1) reviewed by a health care provider of the
409	408		appropriate specialty who is licensed or otherwise authorized to
410	409		provide the specialty health care service in this state; and
411	410		(2) conducted in accordance with standards developed
412	411		with input from a health care provider of the appropriate specialty
413	412		who is licensed or otherwise authorized to provide the specialty
414	413		health care service in this state.
415	414		Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF
416	415		PROVIDER OF SAME SPECIALTY. A specialty utilization review agent
417	416		shall conduct utilization review under the direction of a health
418	417		care provider who is of the same specialty as the agent and who is
419	418		licensed or otherwise authorized to provide the specialty health
420	419		care service in this [by a] state [licensing agency in the United
421	420		States].
422		-	SECTION 2.10. Sections 4201.455(a) and (b), Insurance Code,
	421	+	SECTION 2.11. Sections 4201.455(a) and (b), Insurance Code,
423	422		are amended to read as follows:
424	423		(a) Personnel who are employed by or under contract with a
425	424		specialty utilization review agent to perform utilization review
426	425		must be appropriately trained and qualified and meet the
427	426		requirements of this chapter and other applicable law of this
428		-	state, including ~~applicable~~ licensing laws.
	427	+	state, including licensing laws.
429	428		(b) Personnel who obtain oral or written information
430	429		directly from a physician or other health care provider must be a
431	430		nurse, physician assistant, or other health care provider of the
432	431		same specialty as the agent and who are licensed or otherwise
433		-	authorized to provide the specialty health care service by a
434		-	[~~state]~~ licensing agency in the United States.
435		-	SECTION 2.11. Sections 4201.456 and 4201.457, Insurance
	432	+	authorized to provide the specialty health care service in this [by
	433	+	a] state [licensing agency in the United States].
	434	+	SECTION 2.12. Sections 4201.456 and 4201.457, Insurance
436	435		Code, are amended to read as follows:
437	436		Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
438	437		ADVERSE DETERMINATION. Subject to the notice requirements of
439	438		Subchapter G, before an adverse determination is issued by a
440	439		specialty utilization review agent who questions the medical
441	440		necessity, the [or] appropriateness, or the experimental or
442	441		investigational nature[,] of a health care service, the agent shall
443		-	provide the health care provider who ordered, requested, ~~or is to~~
444		-	provide the service a reasonable opportunity to discuss the
	442	+	provide the health care provider who ordered, requested, provided,
	443	+	or is to provide the service a reasonable opportunity to discuss the
445	444		patient's treatment plan and the clinical basis for the agent's
446	445		determination with a health care provider who is:
447	446		(1) of the same specialty as the agent; and
448	447		(2) licensed or otherwise authorized to provide the
449		-	specialty health care service by a licensing agency in the United
450		-	States.
	448	+	specialty health care service in this state.
451	449		Sec. 4201.457. APPEAL DECISIONS. A specialty utilization
452	450		review agent shall comply with the requirement that a physician or
453	451		other health care provider who makes the decision in an appeal of an
454	452		adverse determination must be:
455	453		(1) of the same or a similar specialty as the health
456	454		care provider who would typically manage the specialty condition,
457	455		procedure, or treatment under review in the appeal; and
458	456		(2) licensed or otherwise authorized to provide the
459		-	health care service by a licensing agency in the United States.
460		-	SECTION 2.12. Section 408.0043, Labor Code, is amended by
	457	+	health care service in this state.
	458	+	SECTION 2.13. Section 4202.002, Insurance Code, is amended
	459	+	by adding Subsection (b-1) to read as follows:
	460	+	(b-1) The standards adopted under Subsection (b)(3) must:
	461	+	(1) ensure that personnel conducting independent
	462	+	review for a health care service are licensed or otherwise
	463	+	authorized to provide the same or a similar health care service in
	464	+	this state; and
	465	+	(2) be consistent with the licensing laws of this
	466	+	state.
	467	+	SECTION 2.14. Section 408.0043, Labor Code, is amended by
461	468		adding Subsection (c) to read as follows:
462	469		(c) Notwithstanding Subsection (b), if a health care
463	470		service is requested, ordered, provided, or to be provided by a
464	471		physician, a person described by Subsection (a)(1), (2), or (3) who
465	472		reviews the service with respect to a specific workers'
466	473		compensation case must be of the same or a similar specialty as that
467	474		physician.
468		-	SECTION 2.13. Section 1305.351(d), Insurance Code, is
	475	+	SECTION 2.15. Subchapter B, Chapter 151, Occupations Code,
	476	+	is amended by adding Section 151.057 to read as follows:
	477	+	Sec. 151.057. APPLICATION TO UTILIZATION REVIEW. (a) In
	478	+	this section:
	479	+	(1) "Adverse determination" means a determination
	480	+	that health care services provided or proposed to be provided to an
	481	+	individual in this state by a physician or at the request or order
	482	+	of a physician are not medically necessary or are experimental or
	483	+	investigational.
	484	+	(2) "Payor" has the meaning assigned by Section
	485	+	4201.002, Insurance Code.
	486	+	(3) "Utilization review" has the meaning assigned by
	487	+	Section 4201.002, Insurance Code, and the term includes a review
	488	+	of:
	489	+	(A) a step therapy protocol exception request
	490	+	under Section 1369.0546, Insurance Code; and
	491	+	(B) prescription drug benefits under Section
	492	+	1369.056, Insurance Code.
	493	+	(4) "Utilization review agent" means:
	494	+	(A) an entity that conducts utilization review
	495	+	under Chapter 4201, Insurance Code;
	496	+	(B) a payor that conducts utilization review on
	497	+	the payor's own behalf or on behalf of another person or entity;
	498	+	(C) an independent review organization certified
	499	+	under Chapter 4202, Insurance Code; or
	500	+	(D) a workers' compensation health care network
	501	+	certified under Chapter 1305, Insurance Code.
	502	+	(b) A person who does the following is considered to be
	503	+	engaged in the practice of medicine in this state and is subject to
	504	+	appropriate regulation by the board:
	505	+	(1) makes on behalf of a utilization review agent or
	506	+	directs a utilization review agent to make an adverse
	507	+	determination, including:
	508	+	(A) an adverse determination made on
	509	+	reconsideration of a previous adverse determination;
	510	+	(B) an adverse determination in an independent
	511	+	review under Subchapter I, Chapter 4201, Insurance Code;
	512	+	(C) a refusal to provide benefits for a
	513	+	prescription drug under Section 1369.056, Insurance Code; or
	514	+	(D) a denial of a step therapy protocol exception
	515	+	request under Section 1369.0546, Insurance Code;
	516	+	(2) serves as a medical director of an independent
	517	+	review organization certified under Chapter 4202, Insurance Code;
	518	+	(3) reviews or approves a utilization review plan
	519	+	under Section 4201.151, Insurance Code;
	520	+	(4) supervises and directs utilization review under
	521	+	Section 4201.152, Insurance Code; or
	522	+	(5) discusses a patient's treatment plan and the
	523	+	clinical basis for an adverse determination before the adverse
	524	+	determination is issued, as provided by Section 4201.206, Insurance
	525	+	Code.
	526	+	(c) For purposes of Subsection (b), a denial of health care
	527	+	services based on the failure to request prospective or concurrent
	528	+	review is not considered an adverse determination.
	529	+	SECTION 2.16. Section 1305.351(d), Insurance Code, is
469	530		amended to read as follows:
470	531		(d) A [Notwithstanding Section 4201.152, a] utilization
471	532		review agent or an insurance carrier that uses doctors to perform
472	533		reviews of health care services provided under this chapter,
473	534		including utilization review, or peer reviews under Section
474	535		408.0231(g), Labor Code, may only use doctors licensed to practice
475	536		in this state.
476		-	SECTION 2.14. Section 1305.355(d), Insurance Code, is
	537	+	SECTION 2.17. Section 1305.355(d), Insurance Code, is
477	538		amended to read as follows:
478	539		(d) The department shall assign the review request to an
479	540		independent review organization. An [Notwithstanding Section
480	541		4202.002, an] independent review organization that uses doctors to
481	542		perform reviews of health care services under this chapter may only
482	543		use doctors licensed to practice in this state.
483		-	SECTION 2.15. Section 408.023(h), Labor Code, is amended to
	544	+	SECTION 2.18. Section 408.023(h), Labor Code, is amended to
484	545		read as follows:
485	546		(h) A [Notwithstanding Section 4201.152, Insurance Code, a]
486	547		utilization review agent or an insurance carrier that uses doctors
487	548		to perform reviews of health care services provided under this
488	549		subtitle, including utilization review, may only use doctors
489	550		licensed to practice in this state.
490		-	SECTION 2.16. Section 413.031(e-2), Labor Code, is amended
	551	+	SECTION 2.19. Section 413.031(e-2), Labor Code, is amended
491	552		to read as follows:
492	553		(e-2) An [Notwithstanding Section 4202.002, Insurance Code,
493	554		an] independent review organization that uses doctors to perform
494	555		reviews of health care services provided under this title may only
495	556		use doctors licensed to practice in this state.
496		-	ARTICLE 3. JOINT INTERIM STUDY
497		-	SECTION 3.01. CREATION OF JOINT INTERIM COMMITTEE. (a) A
498		-	joint interim committee is created to study, review, and report on
499		-	the use of prior authorization and utilization review processes by
500		-	private health benefit plan issuers in this state, as provided by
501		-	Section 3.02 of this article, and propose reforms under that
502		-	section related to the transparency of and improving patient
503		-	outcomes under the prior authorization and utilization review
504		-	processes used by private health benefit plan issuers in this
505		-	state.
506		-	(b) The joint interim committee shall be composed of four
507		-	senators appointed by the lieutenant governor and four members of
508		-	the house of representatives appointed by the speaker of the house
509		-	of representatives.
510		-	(c) The lieutenant governor and speaker of the house of
511		-	representatives shall each designate a co-chair from among the
512		-	joint interim committee members.
513		-	(d) The joint interim committee shall convene at the joint
514		-	call of the co-chairs.
515		-	(e) The joint interim committee has all other powers and
516		-	duties provided to a special or select committee by the rules of the
517		-	senate and house of representatives, by Subchapter B, Chapter 301,
518		-	Government Code, and by policies of the senate and house committees
519		-	on administration.
520		-	SECTION 3.02. INTERIM STUDY REGARDING PRIOR AUTHORIZATION
521		-	AND UTILIZATION REVIEW PROCESSES. (a) The joint interim committee
522		-	created by Section 3.01 of this article shall study data and other
523		-	information available from the Texas Department of Insurance, the
524		-	office of public insurance counsel, or other sources the committee
525		-	determines relevant to examine and analyze the transparency of and
526		-	improving patient outcomes under the prior authorization and
527		-	utilization review processes used by private health benefit plan
528		-	issuers in this state.
529		-	(b) The joint interim committee shall propose reforms based
530		-	on the study required under Subsection (a) of this section to
531		-	improve the transparency of and patient outcomes under prior
532		-	authorization and utilization review processes in this state.
533		-	(c) The joint interim committee shall prepare a report of
534		-	the findings and proposed reforms.
535		-	SECTION 3.03. COMMITTEE FINDINGS AND PROPOSED REFORMS.
536		-	(a) Not later than December 1, 2020, the joint interim committee
537		-	created under Section 3.01 of this article shall submit to the
538		-	lieutenant governor, the speaker of the house of representatives,
539		-	and the governor the report prepared under Section 3.02 of this
540		-	article. The joint interim committee shall include in its report
541		-	recommendations of specific statutory and regulatory changes that
542		-	appear necessary from the committee's study under Section 3.02 of
543		-	this article.
544		-	(b) Not later than the 60th day after the effective date of
545		-	this Act, the lieutenant governor and speaker of the house of
546		-	representatives shall appoint the members of the joint interim
547		-	committee in accordance with Section 3.01 of this article.
548		-	SECTION 3.04. ABOLITION OF COMMITTEE. The joint interim
549		-	committee created under Section 3.01 of this article is abolished
550		-	and this article expires December 15, 2020.
551		-	ARTICLE 4. TRANSITIONS; EFFECTIVE DATE
552		-	SECTION 4.01. The changes in law made by Article 1 of this
	557	+	ARTICLE 3. TRANSITIONS; EFFECTIVE DATE
	558	+	SECTION 3.01. The changes in law made by Article 1 of this
553	559		Act apply only to a request for preauthorization of medical care or
554	560		health care services made on or after January 1, 2020, under a
555	561		health benefit plan delivered, issued for delivery, or renewed on
556	562		or after that date. A request for preauthorization of medical care
557	563		or health care services made before January 1, 2020, or on or after
558	564		January 1, 2020, under a health benefit plan delivered, issued for
559	565		delivery, or renewed before that date is governed by the law as it
560	566		existed immediately before the effective date of this Act, and that
561	567		law is continued in effect for that purpose.
562		-	SECTION 4.02. The changes in law made by Article 2 of this
	568	+	SECTION 3.02. The changes in law made by Article 2 of this
563	569		Act apply only to utilization, independent, or peer review
564	570		requested on or after the effective date of this Act. Utilization,
565	571		independent, or peer review requested before the effective date of
566	572		this Act is governed by the law as it existed immediately before the
567	573		effective date of this Act, and that law is continued in effect for
568	574		that purpose.
569		-	SECTION 4.03. This Act takes effect September 1, 2019.
570		-	* * * * *
	575	+	SECTION 3.03. This Act takes effect September 1, 2019.