Texas 2019 - 86th Regular

Texas House Bill HB4351 Compare Versions

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

Old	New	Differences
1	1	86R14017 LED-D
2	2	By: Martinez Fischer H.B. No. 4351
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to utilization review of and health benefit plan coverage
8	8	for emergency care.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
11	11	by adding Chapter 1380 to read as follows:
12	12	CHAPTER 1380. COVERAGE FOR EMERGENCY CARE
13	13	Sec. 1380.0001. DEFINITIONS. In this chapter:
14	14	(1) "Emergency care" has the meaning assigned by
15	15	Section 4201.002.
16	16	(2) "Enrollee" means an individual covered by a health
17	17	benefit plan.
18	18	(3) "Health benefit plan" means a plan to which this
19	19	chapter applies under Section 1380.0002.
20	20	(4) "Health benefit plan issuer" means an entity
21	21	authorized under this code or another insurance law of this state
22	22	that provides health insurance or health benefits in this state.
23	23	(5) "Utilization review" has the meaning assigned by
24	24	Section 4201.002.
25	25	Sec. 1380.0002. APPLICABILITY OF CHAPTER. (a) This
26	26	chapter applies only to a health benefit plan that provides
27	27	benefits for medical or surgical expenses incurred as a result of a
28	28	health condition, accident, or sickness, including an individual,
29	29	group, blanket, or franchise insurance policy or insurance
30	30	agreement, a group hospital service contract, or an individual or
31	31	group evidence of coverage or similar coverage document that is
32	32	issued by:
33	33	(1) an insurance company;
34	34	(2) a group hospital service corporation operating
35	35	under Chapter 842;
36	36	(3) a health maintenance organization operating under
37	37	Chapter 843;
38	38	(4) an approved nonprofit health corporation that
39	39	holds a certificate of authority under Chapter 844;
40	40	(5) a multiple employer welfare arrangement that holds
41	41	a certificate of authority under Chapter 846;
42	42	(6) a stipulated premium company operating under
43	43	Chapter 884;
44	44	(7) a fraternal benefit society operating under
45	45	Chapter 885;
46	46	(8) a Lloyd's plan operating under Chapter 941; or
47	47	(9) an exchange operating under Chapter 942.
48	48	(b) Notwithstanding any other law, this chapter applies to:
49	49	(1) a small employer health benefit plan subject to
50	50	Chapter 1501, including coverage provided through a health group
51	51	cooperative under Subchapter B of that chapter;
52	52	(2) a standard health benefit plan issued under
53	53	Chapter 1507;
54	54	(3) a basic coverage plan under Chapter 1551;
55	55	(4) a basic plan under Chapter 1575;
56	56	(5) a primary care coverage plan under Chapter 1579;
57	57	(6) a plan providing basic coverage under Chapter
58	58	1601;
59	59	(7) health benefits provided by or through a church
60	60	benefits board under Subchapter I, Chapter 22, Business
61	61	Organizations Code;
62	62	(8) group health coverage made available by a school
63	63	district in accordance with Section 22.004, Education Code;
64	64	(9) a managed care program under the state Medicaid
65	65	program, including the Medicaid managed care program operated under
66	66	Chapter 533, Government Code;
67	67	(10) a managed care program under the child health
68	68	plan program under Chapter 62, Health and Safety Code;
69	69	(11) a regional or local health care program operated
70	70	under Section 75.104, Health and Safety Code;
71	71	(12) a self-funded health benefit plan sponsored by a
72	72	professional employer organization under Chapter 91, Labor Code;
73	73	(13) county employee group health benefits provided
74	74	under Chapter 157, Local Government Code; and
75	75	(14) health and accident coverage provided by a risk
76	76	pool created under Chapter 172, Local Government Code.
77	77	Sec. 1380.0003. EMERGENCY CARE. (a) When prospective,
78	78	concurrent, or retrospective utilization review is being conducted
79	79	for a health benefit plan issuer or the issuer makes a benefit
80	80	determination to determine the medical necessity and
81	81	appropriateness of emergency care, the health benefit plan issuer
82	82	and any utilization review agent acting on the issuer's behalf
83	83	shall comply with this chapter.
84	84	(b) The issuer:
85	85	(1) shall provide coverage for emergency care
86	86	necessary to screen and stabilize an enrollee, as determined by the
87	87	health care provider providing the emergency care;
88	88	(2) may not require prior authorization of emergency
89	89	care; and
90	90	(3) shall comply with other applicable provisions of
91	91	this code, including Sections 843.252, 843.258, 1271.155,
92	92	1301.0053, 1301.155, 4201.304, and 4201.357, as applicable.
93	93	(c) Coverage of emergency care may be subject to applicable
94	94	copayments, coinsurance, and deductibles under the health benefit
95	95	plan.
96	96	(d) Before a health benefit plan issuer retrospectively
97	97	denies coverage for emergency care based on the determination that
98	98	it was not medically necessary or appropriate to provide the care as
99	99	emergency care, the issuer or the utilization review agent acting
100	100	on the issuer's behalf shall review the enrollee's medical record
101	101	regarding the medical condition for which the emergency care was
102	102	provided. If the issuer or agent requests a record relating to a
103	103	retrospective review of emergency care, the health care provider
104	104	who provided the emergency care shall submit the record of the
105	105	emergency care to the issuer or agent in accordance with Section
106	106	4201.305.
107	107	(e) Notwithstanding Section 4201.152, a board-certified
108	108	physician licensed in this state must complete a retrospective
109	109	review of emergency care for a health benefit plan issuer.
110	110	(f) The process for an appeal of a determination subject to
111	111	this section must comply with Section 4201.357.
112	112	SECTION 2. Section 1380.0003, Insurance Code, as added by
113	113	this Act, applies only to a health benefit plan that is delivered,
114	114	issued for delivery, or renewed on or after January 1, 2020. A
115	115	health benefit plan delivered, issued for delivery, or renewed
116	116	before January 1, 2020, is governed by the law as it existed
117	117	immediately before the effective date of this Act, and that law is
118	118	continued in effect for that purpose.
119	119	SECTION 3. This Act takes effect September 1, 2019.