Texas 2019 - 86th Regular

Texas House Bill HB2387 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
	1	+	86R22677 SCL-F
1	2		By: Bonnen of Galveston H.B. No. 2387
	3	+	Substitute the following for H.B. No. 2387:
	4	+	By: Lucio III C.S.H.B. No. 2387
2	5
3	6
4	7		A BILL TO BE ENTITLED
5	8		AN ACT
6	9		relating to the regulation of utilization review, independent
7	10		review, and peer review for health benefit plan and workers'
8		-	compensation coverage and to preauthorization of certain medical
9		-	care and health care services by certain health benefit plan
10		-	issuers.
	11	+	compensation coverage.
11	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12		-	SECTION 1. Section 533.005, Government Code, is amended by
13		-	adding Subsection (e) to read as follows:
14		-	(e) In addition to the requirements under Subsection (a), a
15		-	contract described by that subsection must require the managed care
16		-	organization to comply with Section 4201.156, Insurance Code.
17		-	SECTION 2. Section 843.348(b), Insurance Code, is amended
18		-	to read as follows:
19		-	(b) A health maintenance organization that uses a
20		-	preauthorization process for health care services shall provide
21		-	each participating physician or provider, not later than the fifth
22		-	[10th] business day after the date a request is made, a list of
23		-	health care services that [do not] require preauthorization and
24		-	information concerning the preauthorization process.
25		-	SECTION 3. Subchapter J, Chapter 843, Insurance Code, is
26		-	amended by adding Sections 843.3481, 843.3482, 843.3483, and
27		-	843.3484 to read as follows:
28		-	Sec. 843.3481. POSTING OF PREAUTHORIZATION REQUIREMENTS.
29		-	(a) A health maintenance organization that uses a preauthorization
30		-	process for health care services shall make the requirements and
31		-	information about the preauthorization process readily accessible
32		-	to enrollees, physicians, providers, and the general public by
33		-	posting the requirements and information on the health maintenance
34		-	organization's Internet website.
35		-	(b) The preauthorization requirements and information
36		-	described by Subsection (a) must:
37		-	(1) be posted:
38		-	(A) conspicuously in a location on the Internet
39		-	website that does not require the use of a log-in or other input of
40		-	personal information to view the information; and
41		-	(B) in a format that is easily searchable and
42		-	accessible;
43		-	(2) be written in plain language that is easily
44		-	understandable by enrollees, physicians, providers, and the
45		-	general public;
46		-	(3) include a detailed description of the
47		-	preauthorization process and procedure; and
48		-	(4) include an accurate and current list of the health
49		-	care services for which the health maintenance organization
50		-	requires preauthorization that includes the following information
51		-	specific to each service:
52		-	(A) the effective date of the preauthorization
53		-	requirement;
54		-	(B) a list or description of any supporting
55		-	documentation that the health maintenance organization requires
56		-	from the physician or provider ordering or requesting the service
57		-	to approve a request for that service;
58		-	(C) the applicable screening criteria using
59		-	Current Procedural Terminology codes and International
60		-	Classification of Diseases codes; and
61		-	(D) statistics regarding preauthorization
62		-	approval and denial rates for the service in the preceding year and
63		-	for each previous year the preauthorization requirement was in
64		-	effect, including statistics in the following categories:
65		-	(i) physician or provider type and
66		-	specialty, if any;
67		-	(ii) indication offered;
68		-	(iii) reasons for request denial;
69		-	(iv) denials overturned on internal appeal;
70		-	(v) denials overturned on external appeal;
71		-	and
72		-	(vi) total annual preauthorization
73		-	requests, approvals, and denials for the service.
74		-	Sec. 843.3482. CHANGES TO PREAUTHORIZATION REQUIREMENTS.
75		-	(a) Except as provided by Subsection (b), not later than the 60th
76		-	day before the date a new or amended preauthorization requirement
77		-	takes effect, a health maintenance organization that uses a
78		-	preauthorization process for health care services shall provide
79		-	each participating physician or provider written notice of the new
80		-	or amended preauthorization requirement and disclose the new or
81		-	amended requirement in the health maintenance organization's
82		-	newsletter or network bulletin, if any.
83		-	(b) For a change in a preauthorization requirement or
84		-	process that removes a service from the list of health care services
85		-	requiring preauthorization or amends a preauthorization
86		-	requirement in a way that is less burdensome to enrollees or
87		-	participating physicians or providers, a health maintenance
88		-	organization shall provide each participating physician or
89		-	provider written notice of the change in the preauthorization
90		-	requirement and disclose the change in the health maintenance
91		-	organization's newsletter or network bulletin, if any, not later
92		-	than the fifth day before the date the change takes effect.
93		-	(c) Not later than the fifth day before the date a new or
94		-	amended preauthorization requirement takes effect, a health
95		-	maintenance organization shall update its Internet website to
96		-	disclose the change to the health maintenance organization's
97		-	preauthorization requirements or process and the date and time the
98		-	change is effective.
99		-	Sec. 843.3483. REMEDY FOR NONCOMPLIANCE; AUTOMATIC WAIVER.
100		-	In addition to any other penalty or remedy provided by law, a health
101		-	maintenance organization that uses a preauthorization process for
102		-	health care services that violates this subchapter with respect to
103		-	a required publication, notice, or response regarding its
104		-	preauthorization requirements, including by failing to comply with
105		-	any applicable deadline for the publication, notice, or response,
106		-	waives the health maintenance organization's preauthorization
107		-	requirements with respect to any health care service affected by
108		-	the violation, and any health care service affected by the
109		-	violation is considered preauthorized by the health maintenance
110		-	organization.
111		-	Sec. 843.3484. EFFECT OF PREAUTHORIZATION WAIVER. A waiver
112		-	of preauthorization requirements under Section 843.3483 may not be
113		-	construed to:
114		-	(1) authorize a physician or provider to provide
115		-	health care services outside of the physician's or provider's
116		-	applicable scope of practice as defined by state law; or
117		-	(2) require the health maintenance organization to pay
118		-	for a health care service provided outside of the physician's or
119		-	provider's applicable scope of practice as defined by state law.
120		-	SECTION 4. Section 1301.135(a), Insurance Code, is amended
121		-	to read as follows:
122		-	(a) An insurer that uses a preauthorization process for
123		-	medical care or [and] health care services shall provide to each
124		-	preferred provider, not later than the fifth [10th] business day
125		-	after the date a request is made, a list of medical care and health
126		-	care services that require preauthorization and information
127		-	concerning the preauthorization process.
128		-	SECTION 5. Subchapter C-1, Chapter 1301, Insurance Code, is
129		-	amended by adding Sections 1301.1351, 1301.1352, 1301.1353, and
130		-	1301.1354 to read as follows:
131		-	Sec. 1301.1351. POSTING OF PREAUTHORIZATION REQUIREMENTS.
132		-	(a) An insurer that uses a preauthorization process for medical
133		-	care or health care services shall make the requirements and
134		-	information about the preauthorization process readily accessible
135		-	to insureds, physicians, health care providers, and the general
136		-	public by posting the requirements and information on the insurer's
137		-	Internet website.
138		-	(b) The preauthorization requirements and information
139		-	described by Subsection (a) must:
140		-	(1) be posted:
141		-	(A) conspicuously in a location on the Internet
142		-	website that does not require the use of a log-in or other input of
143		-	personal information to view the information; and
144		-	(B) in a format that is easily searchable and
145		-	accessible;
146		-	(2) be written in plain language that is easily
147		-	understandable by insureds, physicians, health care providers, and
148		-	the general public;
149		-	(3) include a detailed description of the
150		-	preauthorization process and procedure; and
151		-	(4) include an accurate and current list of medical
152		-	care and health care services for which the insurer requires
153		-	preauthorization that includes the following information specific
154		-	to each service:
155		-	(A) the effective date of the preauthorization
156		-	requirement;
157		-	(B) a list or description of any supporting
158		-	documentation that the insurer requires from the physician or
159		-	health care provider ordering or requesting the service to approve
160		-	a request for the service;
161		-	(C) the applicable screening criteria using
162		-	Current Procedural Terminology codes and International
163		-	Classification of Diseases codes; and
164		-	(D) statistics regarding the insurer's
165		-	preauthorization approval and denial rates for the medical care or
166		-	health care service in the preceding year and for each previous year
167		-	the preauthorization requirement was in effect, including
168		-	statistics in the following categories:
169		-	(i) physician or health care provider type
170		-	and specialty, if any;
171		-	(ii) indication offered;
172		-	(iii) reasons for request denial;
173		-	(iv) denials overturned on internal appeal;
174		-	(v) denials overturned on external appeal;
175		-	and
176		-	(vi) total annual preauthorization
177		-	requests, approvals, and denials for the service.
178		-	(c) The provisions of this section may not be waived,
179		-	voided, or nullified by contract.
180		-	Sec. 1301.1352. CHANGES TO PREAUTHORIZATION REQUIREMENTS.
181		-	(a) Except as provided by Subsection (b), not later than the 60th
182		-	day before the date a new or amended preauthorization requirement
183		-	takes effect, an insurer that uses a preauthorization process for
184		-	medical care or health care services shall provide to each
185		-	preferred provider written notice of the new or amended
186		-	preauthorization requirement and disclose the new or amended
187		-	requirement in the insurer's newsletter or network bulletin, if
188		-	any.
189		-	(b) For a change in a preauthorization requirement or
190		-	process that removes a service from the list of medical care or
191		-	health care services requiring preauthorization or amends a
192		-	preauthorization requirement in a way that is less burdensome to
193		-	insureds, physicians, or health care providers, an insurer shall
194		-	provide each preferred provider written notice of the change in the
195		-	preauthorization requirement and disclose the change in the
196		-	insurer's newsletter or network bulletin, if any, not later than
197		-	the fifth day before the date the change takes effect.
198		-	(c) Not later than the fifth day before the date a new or
199		-	amended preauthorization requirement takes effect, an insurer
200		-	shall update its Internet website to disclose the change to the
201		-	insurer's preauthorization requirements or process and the date and
202		-	time the change is effective.
203		-	(d) The provisions of this section may not be waived,
204		-	voided, or nullified by contract.
205		-	Sec. 1301.1353. REMEDY FOR NONCOMPLIANCE; AUTOMATIC
206		-	WAIVER. (a) In addition to any other penalty or remedy provided by
207		-	law, an insurer that uses a preauthorization process for medical
208		-	care or health care services that violates this subchapter with
209		-	respect to a required publication, notice, or response regarding
210		-	its preauthorization requirements, including by failing to comply
211		-	with any applicable deadline for the publication, notice, or
212		-	response, waives the insurer's preauthorization requirements with
213		-	respect to any medical care or health care service affected by the
214		-	violation, and any medical care or health care service affected by
215		-	the violation is considered preauthorized by the insurer.
216		-	(b) The provisions of this section may not be waived,
217		-	voided, or nullified by contract.
218		-	Sec. 1301.1354. EFFECT OF PREAUTHORIZATION WAIVER. (a) A
219		-	waiver of preauthorization requirements under Section 1301.1353
220		-	may not be construed to:
221		-	(1) authorize a physician or health care provider to
222		-	provide medical care or health care services outside of the
223		-	physician's or health care provider's applicable scope of practice
224		-	as defined by state law; or
225		-	(2) require the insurer to pay for a medical care or
226		-	health care service provided outside of the physician's or health
227		-	care provider's applicable scope of practice as defined by state
228		-	law.
229		-	(b) The provisions of this section may not be waived,
230		-	voided, or nullified by contract.
231		-	SECTION 6. Section 4201.002(12), Insurance Code, is amended
	13	+	SECTION 1. Section 4201.002(12), Insurance Code, is amended
232	14		to read as follows:
233	15		(12) "Provider of record" means the physician or other
234	16		health care provider with primary responsibility for the health
235	17		care[, treatment, and] services provided to or requested on behalf
236	18		of an enrollee or the physician or other health care provider that
237	19		has provided or has been requested to provide the health care
238	20		services to the enrollee. The term includes a health care facility
239	21		where the health care services are [if treatment is] provided on an
240	22		inpatient or outpatient basis.
241		-	SECTION 7. Sections 4201.151 and 4201.152, Insurance Code,
	23	+	SECTION 2. Sections 4201.151 and 4201.152, Insurance Code,
242	24		are amended to read as follows:
243	25		Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization
244	26		review agent's utilization review plan, including reconsideration
245	27		and appeal requirements, must be reviewed by a physician licensed
246	28		to practice medicine in this state and conducted in accordance with
247	29		standards developed with input from appropriate health care
248	30		providers and approved by a physician licensed to practice medicine
249	31		in this state.
250	32		Sec. 4201.152. UTILIZATION REVIEW UNDER [DIRECTION OF]
251	33		PHYSICIAN. A utilization review agent shall conduct utilization
252	34		review under the supervision and direction of a physician licensed
253	35		to practice medicine in this [by a] state [licensing agency in the
254	36		United States].
255		-	SECTION 8. Subchapter D, Chapter 4201, Insurance Code, is
	37	+	SECTION 3. Subchapter D, Chapter 4201, Insurance Code, is
256	38		amended by adding Section 4201.1525 to read as follows:
257	39		Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIAN. (a) A
258	40		utilization review agent that uses a physician to conduct
259	41		utilization review may only use a physician licensed to practice
260	42		medicine in this state.
261	43		(b) A payor that conducts utilization review on the payor's
262	44		own behalf is subject to Subsection (a) as if the payor were a
263	45		utilization review agent.
264		-	SECTION 9. Section 4201.153(d), Insurance Code, is amended
	46	+	SECTION 4. Section 4201.153(d), Insurance Code, is amended
265	47		to read as follows:
266	48		(d) Screening criteria must be used to determine only
267	49		whether to approve the requested treatment. Before issuing an
268	50		adverse determination, a utilization review agent must obtain a
269	51		determination of medical necessity by referring a proposed [A]
270	52		denial of requested treatment [must be referred] to:
271	53		(1) an appropriate physician, dentist, or other health
272	54		care provider; or
273	55		(2) if the treatment is requested, ordered, provided,
274	56		or to be provided by a physician, a physician licensed to practice
275	57		medicine in this state who is of the same or a similar specialty as
276	58		that physician [to determine medical necessity].
277		-	SECTION 10. Sections 4201.155, 4201.206, and 4201.251,
	59	+	SECTION 5. Sections 4201.155, 4201.206, and 4201.251,
278	60		Insurance Code, are amended to read as follows:
279	61		Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW
280	62		PROCEDURES. (a) A utilization review agent may not establish or
281	63		impose a notice requirement or other review procedure that is
282	64		contrary to the requirements of the health insurance policy or
283	65		health benefit plan.
284	66		(b) This section may not be construed to release a health
285	67		insurance policy or health benefit plan from full compliance with
286	68		this chapter or other applicable law.
287	69		Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
288	70		ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
289	71		notice requirements of Subchapter G, before an adverse
290	72		determination is issued by a utilization review agent who questions
291	73		the medical necessity, the [or] appropriateness, or the
292	74		experimental or investigational nature[,] of a health care service,
293	75		the agent shall provide the health care provider who ordered,
294	76		requested, provided, or is to provide the service a reasonable
295	77		opportunity to discuss with a physician licensed to practice
296	78		medicine in this state the patient's treatment plan and the
297	79		clinical basis for the agent's determination.
298	80		(b) If the health care service described by Subsection (a)
299	81		was ordered, requested, or provided, or is to be provided by a
300	82		physician, the opportunity described by that subsection must be
301	83		with a physician licensed to practice medicine in this state who is
302	84		of the same or a similar specialty as that physician.
303	85		Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. A
304	86		utilization review agent may delegate utilization review to
305	87		qualified personnel in the hospital or other health care facility
306	88		in which the health care services to be reviewed were or are to be
307	89		provided. The delegation does not release the agent from the full
308	90		responsibility for compliance with this chapter or other applicable
309	91		law, including the conduct of those to whom utilization review has
310	92		been delegated.
311		-	SECTION 11. Subchapter D, Chapter 4201, Insurance Code, is
312		-	amended by adding Section 4201.156 to read as follows:
313		-	Sec. 4201.156. REVIEW PROCEDURES FOR EMERGENCY CARE CLAIMS.
314		-	(a) Utilization review of an emergency care claim must be made by a
315		-	utilization review agent who is a physician licensed under Subtitle
316		-	B, Title 3, Occupations Code.
317		-	(b) With respect to an enrollee's emergency medical
318		-	condition that is the basis for an emergency care claim, a
319		-	utilization review agent:
320		-	(1) may not make an adverse determination for the
321		-	emergency care claim predominantly based on the condition's
322		-	classification under a Current Procedural Terminology or
323		-	International Classification of Diseases code; and
324		-	(2) must review the enrollee's medical records.
325		-	SECTION 12. Sections 4201.252(a) and (b), Insurance Code,
	93	+	SECTION 6. Sections 4201.252(a) and (b), Insurance Code,
326	94		are amended to read as follows:
327	95		(a) Personnel employed by or under contract with a
328	96		utilization review agent to perform utilization review must be
329	97		appropriately trained and qualified and meet the requirements of
330	98		this chapter and other applicable law, including licensing
331	99		requirements.
332	100		(b) Personnel, other than a physician licensed to practice
333	101		medicine in this state, who obtain oral or written information
334	102		directly from a patient's physician or other health care provider
335	103		regarding the patient's specific medical condition, diagnosis, or
336	104		treatment options or protocols must be a nurse, physician
337	105		assistant, or other health care provider qualified and licensed or
338	106		otherwise authorized by law and the appropriate licensing agency in
339	107		this state to provide the requested service.
340		-	SECTION 13. Section 4201.356, Insurance Code, is amended to
	108	+	SECTION 7. Section 4201.356, Insurance Code, is amended to
341	109		read as follows:
342	110		Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY
343	111		REVIEW. (a) The procedures for appealing an adverse determination
344	112		must provide that a physician licensed to practice medicine in this
345	113		state makes the decision on the appeal, except as provided by
346	114		Subsection (b) or (c).
347	115		(b) For a health care service ordered, requested, provided,
348	116		or to be provided by a physician, the procedures for appealing an
349	117		adverse determination must provide that a physician licensed to
350	118		practice medicine in this state who is of the same or a similar
351	119		specialty as that physician makes the decision on appeal, except as
352	120		provided by Subsection (c).
353	121		(c) If not later than the 10th working day after the date an
354	122		appeal is denied the enrollee's health care provider states in
355	123		writing good cause for having a particular type of specialty
356	124		provider review the case, a health care provider who is of the same
357	125		or a similar specialty as the health care provider who would
358	126		typically manage the medical or dental condition, procedure, or
359	127		treatment under consideration for review and who is licensed or
360	128		otherwise authorized by the appropriate licensing agency in this
361	129		state to manage the medical or dental condition, procedure, or
362	130		treatment shall review the decision denying the appeal. The
363	131		specialty review must be completed within 15 working days of the
364	132		date the health care provider's request for specialty review is
365	133		received.
366		-	SECTION 14. Sections 4201.357(a), (a-1), and (a-2),
	134	+	SECTION 8. Sections 4201.357(a), (a-1), and (a-2),
367	135		Insurance Code, are amended to read as follows:
368	136		(a) The procedures for appealing an adverse determination
369	137		must include, in addition to the written appeal, a procedure for an
370	138		expedited appeal of a denial of emergency care or a denial of
371	139		continued hospitalization. That procedure must include a review by
372	140		a health care provider who:
373	141		(1) has not previously reviewed the case; [and]
374	142		(2) is of the same or a similar specialty as the health
375	143		care provider who would typically manage the medical or dental
376	144		condition, procedure, or treatment under review in the appeal; and
377	145		(3) for a review of a health care service:
378	146		(A) ordered, requested, provided, or to be
379	147		provided by a health care provider who is not a physician, is
380	148		licensed or otherwise authorized by the appropriate licensing
381	149		agency in this state to provide the service in this state; or
382	150		(B) ordered, requested, provided, or to be
383	151		provided by a physician, is licensed to practice medicine in this
384	152		state.
385	153		(a-1) The procedures for appealing an adverse determination
386	154		must include, in addition to the written appeal and the appeal
387	155		described by Subsection (a), a procedure for an expedited appeal of
388	156		a denial of prescription drugs or intravenous infusions for which
389	157		the patient is receiving benefits under the health insurance
390	158		policy. That procedure must include a review by a health care
391	159		provider who:
392	160		(1) has not previously reviewed the case; [and]
393	161		(2) is of the same or a similar specialty as the health
394	162		care provider who would typically manage the medical or dental
395	163		condition, procedure, or treatment under review in the appeal; and
396	164		(3) for a review of a health care service:
397	165		(A) ordered, requested, provided, or to be
398	166		provided by a health care provider who is not a physician, is
399	167		licensed or otherwise authorized by the appropriate licensing
400	168		agency in this state to provide the service in this state; or
401	169		(B) ordered, requested, provided, or to be
402	170		provided by a physician, is licensed to practice medicine in this
403	171		state.
404	172		(a-2) An adverse determination under Section 1369.0546 is
405	173		entitled to an expedited appeal. The physician or, if appropriate,
406	174		other health care provider deciding the appeal must consider
407	175		atypical diagnoses and the needs of atypical patient populations.
408	176		The physician must be licensed to practice medicine in this state
409	177		and the health care provider must be licensed or otherwise
410	178		authorized by the appropriate licensing agency in this state.
411		-	SECTION 15. Section 4201.359, Insurance Code, is amended by
	179	+	SECTION 9. Section 4201.359, Insurance Code, is amended by
412	180		adding Subsection (c) to read as follows:
413	181		(c) A physician described by Subsection (b)(2) must comply
414	182		with this chapter and other applicable laws and be licensed to
415	183		practice medicine in this state. A health care provider described
416	184		by Subsection (b)(2) must comply with this chapter and other
417	185		applicable laws and be licensed or otherwise authorized by the
418	186		appropriate licensing agency in this state.
419		-	SECTION 16. Sections 4201.453 and 4201.454, Insurance Code,
	187	+	SECTION 10. Sections 4201.453 and 4201.454, Insurance Code,
420	188		are amended to read as follows:
421	189		Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty
422	190		utilization review agent's utilization review plan, including
423	191		reconsideration and appeal requirements, must be:
424	192		(1) reviewed by a health care provider of the
425	193		appropriate specialty who is licensed or otherwise authorized to
426	194		provide the specialty health care service in this state; and
427	195		(2) conducted in accordance with standards developed
428	196		with input from a health care provider of the appropriate specialty
429	197		who is licensed or otherwise authorized to provide the specialty
430	198		health care service in this state.
431	199		Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF
432	200		PROVIDER OF SAME SPECIALTY. A specialty utilization review agent
433	201		shall conduct utilization review under the direction of a health
434	202		care provider who is of the same specialty as the agent and who is
435	203		licensed or otherwise authorized to provide the specialty health
436	204		care service in this [by a] state [licensing agency in the United
437	205		States].
438		-	SECTION 17. Sections 4201.455(a) and (b), Insurance Code,
	206	+	SECTION 11. Sections 4201.455(a) and (b), Insurance Code,
439	207		are amended to read as follows:
440	208		(a) Personnel who are employed by or under contract with a
441	209		specialty utilization review agent to perform utilization review
442	210		must be appropriately trained and qualified and meet the
443	211		requirements of this chapter and other applicable law of this
444	212		state, including licensing laws.
445	213		(b) Personnel who obtain oral or written information
446	214		directly from a physician or other health care provider must be a
447	215		nurse, physician assistant, or other health care provider of the
448	216		same specialty as the agent and who are licensed or otherwise
449	217		authorized to provide the specialty health care service in this [by
450	218		a] state [licensing agency in the United States].
451		-	SECTION 18. Sections 4201.456 and 4201.457, Insurance Code,
	219	+	SECTION 12. Sections 4201.456 and 4201.457, Insurance Code,
452	220		are amended to read as follows:
453	221		Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
454	222		ADVERSE DETERMINATION. Subject to the notice requirements of
455	223		Subchapter G, before an adverse determination is issued by a
456	224		specialty utilization review agent who questions the medical
457	225		necessity, the [or] appropriateness, or the experimental or
458	226		investigational nature[,] of a health care service, the agent shall
459	227		provide the health care provider who ordered, requested, provided,
460	228		or is to provide the service a reasonable opportunity to discuss the
461	229		patient's treatment plan and the clinical basis for the agent's
462	230		determination with a health care provider who is:
463	231		(1) of the same specialty as the agent; and
464	232		(2) licensed or otherwise authorized to provide the
465	233		specialty health care service in this state.
466	234		Sec. 4201.457. APPEAL DECISIONS. A specialty utilization
467	235		review agent shall comply with the requirement that a physician or
468	236		other health care provider who makes the decision in an appeal of an
469	237		adverse determination must be:
470	238		(1) of the same or a similar specialty as the health
471	239		care provider who would typically manage the specialty condition,
472	240		procedure, or treatment under review in the appeal; and
473	241		(2) licensed or otherwise authorized to provide the
474	242		health care service in this state.
475		-	SECTION 19. Section 4202.002, Insurance Code, is amended by
	243	+	SECTION 13. Section 4202.002, Insurance Code, is amended by
476	244		adding Subsection (b-1) to read as follows:
477	245		(b-1) The standards adopted under Subsection (b)(3) must:
478	246		(1) ensure that personnel conducting independent
479	247		review for a health care service are licensed or otherwise
480	248		authorized to provide the same or a similar health care service in
481	249		this state; and
482	250		(2) be consistent with the licensing laws of this
483	251		state.
484		-	SECTION 20. Section 408.0043, Labor Code, is amended by
	252	+	SECTION 14. Section 408.0043, Labor Code, is amended by
485	253		adding Subsection (c) to read as follows:
486	254		(c) Notwithstanding Subsection (b), if a health care
487	255		service is requested, ordered, provided, or to be provided by a
488	256		physician, a person described by Subsection (a)(1), (2), or (3) who
489	257		reviews the service with respect to a specific workers'
490	258		compensation case must be of the same or a similar specialty as that
491	259		physician.
492		-	SECTION 21. Subchapter B, Chapter 151, Occupations Code, is
	260	+	SECTION 15. Subchapter B, Chapter 151, Occupations Code, is
493	261		amended by adding Section 151.057 to read as follows:
494	262		Sec. 151.057. APPLICATION TO UTILIZATION REVIEW. (a) In
495	263		this section:
496	264		(1) "Adverse determination" means a determination
497	265		that health care services provided or proposed to be provided to an
498	266		individual in this state by a physician or at the request or order
499	267		of a physician are not medically necessary or are experimental or
500	268		investigational.
501	269		(2) "Payor" has the meaning assigned by Section
502	270		4201.002, Insurance Code.
503	271		(3) "Utilization review" has the meaning assigned by
504	272		Section 4201.002, Insurance Code, and the term includes a review
505	273		of:
506	274		(A) a step therapy protocol exception request
507	275		under Section 1369.0546, Insurance Code; and
508	276		(B) prescription drug benefits under Section
509	277		1369.056, Insurance Code.
510	278		(4) "Utilization review agent" means:
511	279		(A) an entity that conducts utilization review
512	280		under Chapter 4201, Insurance Code;
513	281		(B) a payor that conducts utilization review on
514	282		the payor's own behalf or on behalf of another person or entity;
515	283		(C) an independent review organization certified
516	284		under Chapter 4202, Insurance Code; or
517	285		(D) a workers' compensation health care network
518	286		certified under Chapter 1305, Insurance Code.
519	287		(b) A person who does the following is considered to be
520	288		engaged in the practice of medicine in this state and is subject to
521	289		appropriate regulation by the board:
522	290		(1) makes on behalf of a utilization review agent or
523	291		directs a utilization review agent to make an adverse
524	292		determination, including:
525	293		(A) an adverse determination made on
526	294		reconsideration of a previous adverse determination;
527	295		(B) an adverse determination in an independent
528	296		review under Subchapter I, Chapter 4201, Insurance Code;
529	297		(C) a refusal to provide benefits for a
530	298		prescription drug under Section 1369.056, Insurance Code; or
531	299		(D) a denial of a step therapy protocol exception
532	300		request under Section 1369.0546, Insurance Code;
533	301		(2) serves as a medical director of an independent
534	302		review organization certified under Chapter 4202, Insurance Code;
535	303		(3) reviews or approves a utilization review plan
536	304		under Section 4201.151, Insurance Code;
537	305		(4) supervises and directs utilization review under
538	306		Section 4201.152, Insurance Code; or
539	307		(5) discusses a patient's treatment plan and the
540	308		clinical basis for an adverse determination before the adverse
541	309		determination is issued, as provided by Section 4201.206, Insurance
542	310		Code.
543	311		(c) For purposes of Subsection (b), a denial of health care
544	312		services based on the failure to request prospective or concurrent
545	313		review is not considered an adverse determination.
546		-	SECTION 22. Section 1305.351(d), Insurance Code, is amended
	314	+	SECTION 16. Section 1305.351(d), Insurance Code, is amended
547	315		to read as follows:
548	316		(d) A [Notwithstanding Section 4201.152, a] utilization
549	317		review agent or an insurance carrier that uses doctors to perform
550	318		reviews of health care services provided under this chapter,
551	319		including utilization review, or peer reviews under Section
552	320		408.0231(g), Labor Code, may only use doctors licensed to practice
553	321		in this state.
554		-	SECTION 23. Section 1305.355(d), Insurance Code, is amended
	322	+	SECTION 17. Section 1305.355(d), Insurance Code, is amended
555	323		to read as follows:
556	324		(d) The department shall assign the review request to an
557	325		independent review organization. An [Notwithstanding Section
558	326		4202.002, an] independent review organization that uses doctors to
559	327		perform reviews of health care services under this chapter may only
560	328		use doctors licensed to practice in this state.
561		-	SECTION 24. Section 408.023(h), Labor Code, is amended to
	329	+	SECTION 18. Section 408.023(h), Labor Code, is amended to
562	330		read as follows:
563	331		(h) A [Notwithstanding Section 4201.152, Insurance Code, a]
564	332		utilization review agent or an insurance carrier that uses doctors
565	333		to perform reviews of health care services provided under this
566	334		subtitle, including utilization review, may only use doctors
567	335		licensed to practice in this state.
568		-	SECTION 25. Section 413.031(e-2), Labor Code, is amended to
	336	+	SECTION 19. Section 413.031(e-2), Labor Code, is amended to
569	337		read as follows:
570	338		(e-2) An [Notwithstanding Section 4202.002, Insurance Code,
571	339		an] independent review organization that uses doctors to perform
572	340		reviews of health care services provided under this title may only
573	341		use doctors licensed to practice in this state.
574		-	SECTION 26. The changes in law made by this Act to Chapters
575		-	843 and 1301, Insurance Code, apply only to a request for
576		-	preauthorization of medical care or health care services made on or
577		-	after January 1, 2020, under a health benefit plan delivered,
578		-	issued for delivery, or renewed on or after that date. A request
579		-	for preauthorization of medical care or health care services made
580		-	before January 1, 2020, or on or after January 1, 2020, under a
581		-	health benefit plan delivered, issued for delivery, or renewed
582		-	before that date is governed by the law as it existed immediately
583		-	before the effective date of this Act, and that law is continued in
584		-	effect for that purpose.
585		-	SECTION 27. The changes in law made by this Act to Chapters
586		-	1305, 4201, and 4202, Insurance Code, Chapters 408 and 413, Labor
587		-	Code, and Chapter 151, Occupations Code, apply only to utilization,
588		-	independent, or peer review that was requested on or after the
589		-	effective date of this Act. Utilization, independent, or peer
590		-	review requested before the effective date of this Act is governed
591		-	by the law as it existed immediately before the effective date of
592		-	this Act, and that law is continued in effect for that purpose.
593		-	SECTION 28. Section 4201.156, Insurance Code, as added by
594		-	this Act, applies only to a health benefit plan delivered, issued
595		-	for delivery, or renewed on or after January 1, 2020. A health
596		-	benefit plan delivered, issued for delivery, or renewed before
597		-	January 1, 2020, is governed by the law as it existed immediately
598		-	before the effective date of this Act, and that law is continued in
599		-	effect for that purpose.
600		-	SECTION 29. If before implementing any provision of this
601		-	Act a state agency determines that a waiver or authorization from a
602		-	federal agency is necessary for implementation of that provision,
603		-	the agency affected by the provision shall request the waiver or
604		-	authorization and may delay implementing that provision until
605		-	the
606		-	waiver or authorization is granted.
607		-	SECTION 30. This Act takes effect September 1, 2019.
	342	+	SECTION 20. The change in law made by this Act applies only
	343	+	to utilization, independent, or peer review that was requested on
	344	+	or after the effective date of this Act. Utilization, independent,
	345	+	or peer review requested before the effective date of this Act is
	346	+	governed by the law as it existed immediately before the effective
	347	+	date of this Act, and that law is continued in effect for that
	348	+	purpose.
	349	+	SECTION 21. This Act takes effect September 1, 2019.