86R14017 LED-D
By: Martinez Fischer H.B. No. 4351
A BILL TO BE ENTITLED
AN ACT
relating to utilization review of and health benefit plan coverage
for emergency care.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
by adding Chapter 1380 to read as follows:
CHAPTER 1380. COVERAGE FOR EMERGENCY CARE
Sec. 1380.0001. DEFINITIONS. In this chapter:
(1) "Emergency care" has the meaning assigned by
Section 4201.002.
(2) "Enrollee" means an individual covered by a health
benefit plan.
(3) "Health benefit plan" means a plan to which this
chapter applies under Section 1380.0002.
(4) "Health benefit plan issuer" means an entity
authorized under this code or another insurance law of this state
that provides health insurance or health benefits in this state.
(5) "Utilization review" has the meaning assigned by
Section 4201.002.
Sec. 1380.0002. APPLICABILITY OF CHAPTER. (a) This
chapter applies only to a health benefit plan that provides
benefits for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness, including an individual,
group, blanket, or franchise insurance policy or insurance
agreement, a group hospital service contract, or an individual or
group evidence of coverage or similar coverage document that is
issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) health benefits provided by or through a church
benefits board under Subchapter I, Chapter 22, Business
Organizations Code;
(8) group health coverage made available by a school
district in accordance with Section 22.004, Education Code;
(9) a managed care program under the state Medicaid
program, including the Medicaid managed care program operated under
Chapter 533, Government Code;
(10) a managed care program under the child health
plan program under Chapter 62, Health and Safety Code;
(11) a regional or local health care program operated
under Section 75.104, Health and Safety Code;
(12) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code;
(13) county employee group health benefits provided
under Chapter 157, Local Government Code; and
(14) health and accident coverage provided by a risk
pool created under Chapter 172, Local Government Code.
Sec. 1380.0003. EMERGENCY CARE. (a) When prospective,
concurrent, or retrospective utilization review is being conducted
for a health benefit plan issuer or the issuer makes a benefit
determination to determine the medical necessity and
appropriateness of emergency care, the health benefit plan issuer
and any utilization review agent acting on the issuer's behalf
shall comply with this chapter.
(b) The issuer:
(1) shall provide coverage for emergency care
necessary to screen and stabilize an enrollee, as determined by the
health care provider providing the emergency care;
(2) may not require prior authorization of emergency
care; and
(3) shall comply with other applicable provisions of
this code, including Sections 843.252, 843.258, 1271.155,
1301.0053, 1301.155, 4201.304, and 4201.357, as applicable.
(c) Coverage of emergency care may be subject to applicable
copayments, coinsurance, and deductibles under the health benefit
plan.
(d) Before a health benefit plan issuer retrospectively
denies coverage for emergency care based on the determination that
it was not medically necessary or appropriate to provide the care as
emergency care, the issuer or the utilization review agent acting
on the issuer's behalf shall review the enrollee's medical record
regarding the medical condition for which the emergency care was
provided. If the issuer or agent requests a record relating to a
retrospective review of emergency care, the health care provider
who provided the emergency care shall submit the record of the
emergency care to the issuer or agent in accordance with Section
4201.305.
(e) Notwithstanding Section 4201.152, a board-certified
physician licensed in this state must complete a retrospective
review of emergency care for a health benefit plan issuer.
(f) The process for an appeal of a determination subject to
this section must comply with Section 4201.357.
SECTION 2. Section 1380.0003, Insurance Code, as added by
this Act, applies only to a health benefit plan that is delivered,
issued for delivery, or renewed on or after January 1, 2020. A
health benefit plan delivered, issued for delivery, or renewed
before January 1, 2020, is governed by the law as it existed
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2019.