Texas 2019 - 86th Regular

Texas Senate Bill SB1187 Compare Versions

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

Old	New	Differences
1	1	86R6998 SCL-F
2	2	By: Buckingham, et al. S.B. No. 1187
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the regulation of utilization review and independent
8	8	review for health benefit plan coverage.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 4201.002(12), Insurance Code, is amended
11	11	to read as follows:
12	12	(12) "Provider of record" means the physician or other
13	13	health care provider with primary responsibility for the health
14	14	care[, treatment, and] services provided to or requested on behalf
15	15	of an enrollee or the physician or other health care provider that
16	16	has provided or has been requested to provide the health care
17	17	services to the enrollee. The term includes a health care facility
18	18	where the health care services are [if treatment is] provided on an
19	19	inpatient or outpatient basis.
20	20	SECTION 2. Sections 4201.151 and 4201.152, Insurance Code,
21	21	are amended to read as follows:
22	22	Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization
23	23	review agent's utilization review plan, including reconsideration
24	24	and appeal requirements, must be reviewed by a physician licensed
25	25	to practice medicine in this state and conducted in accordance with
26	26	standards developed with input from appropriate health care
27	27	providers and approved by a physician licensed to practice medicine
28	28	in this state.
29	29	Sec. 4201.152. UTILIZATION REVIEW UNDER [DIRECTION OF]
30	30	PHYSICIAN. A utilization review agent shall conduct utilization
31	31	review under the supervision and direction of a physician licensed
32	32	to practice medicine in this [by a] state [licensing agency in the
33	33	United States].
34	34	SECTION 3. Subchapter D, Chapter 4201, Insurance Code, is
35	35	amended by adding Section 4201.1525 to read as follows:
36	36	Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIAN. (a) A
37	37	utilization review agent that uses a physician to conduct
38	38	utilization review may only use a physician licensed to practice
39	39	medicine in this state.
40	40	(b) A payor that conducts utilization review on the payor's
41	41	own behalf is subject to Subsection (a) as if the payor were a
42	42	utilization review agent.
43	43	SECTION 4. Section 4201.153(d), Insurance Code, is amended
44	44	to read as follows:
45	45	(d) Screening criteria must be used to determine only
46	46	whether to approve the requested treatment. Before issuing an
47	47	adverse determination, a utilization review agent must obtain a
48	48	determination of medical necessity by referring a proposed [A]
49	49	denial of requested treatment [must be referred] to:
50	50	(1) an appropriate physician, dentist, or other health
51	51	care provider; or
52	52	(2) if the treatment is requested, ordered, or
53	53	provided by a physician, a physician licensed to practice medicine
54	54	in this state who is of the same or similar specialty as that
55	55	physician [to determine medical necessity].
56	56	SECTION 5. Sections 4201.155, 4201.206, and 4201.251,
57	57	Insurance Code, are amended to read as follows:
58	58	Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW
59	59	PROCEDURES. (a) A utilization review agent may not establish or
60	60	impose a notice requirement or other review procedure that is
61	61	contrary to the requirements of the health insurance policy or
62	62	health benefit plan.
63	63	(b) This section may not be construed to release a health
64	64	insurance policy or health benefit plan from full compliance with
65	65	this chapter or other applicable law.
66	66	Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
67	67	ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
68	68	notice requirements of Subchapter G, before an adverse
69	69	determination is issued by a utilization review agent who questions
70	70	the medical necessity, the [or] appropriateness, or the
71	71	experimental or investigational nature[,] of a health care service,
72	72	the agent shall provide the health care provider who ordered,
73	73	requested, or provided the service a reasonable opportunity to
74	74	discuss with a physician licensed to practice medicine in this
75	75	state the patient's treatment plan and the clinical basis for the
76	76	agent's determination.
77	77	(b) If the health care service described by Subsection (a)
78	78	was ordered, requested, or provided by a physician, the opportunity
79	79	described by that subsection must be with a physician licensed to
80	80	practice medicine in this state who is of the same or similar
81	81	specialty as that physician.
82	82	Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. A
83	83	utilization review agent may delegate utilization review to
84	84	qualified personnel in the hospital or other health care facility
85	85	in which the health care services to be reviewed were or are to be
86	86	provided. The delegation does not release the agent from the full
87	87	responsibility for compliance with this chapter or other applicable
88	88	law, including the conduct of those to whom utilization review has
89	89	been delegated.
90	90	SECTION 6. Sections 4201.252(a) and (b), Insurance Code,
91	91	are amended to read as follows:
92	92	(a) Personnel employed by or under contract with a
93	93	utilization review agent to perform utilization review must be
94	94	appropriately trained and qualified and meet the requirements of
95	95	this chapter and other applicable law, including licensing
96	96	requirements.
97	97	(b) Personnel, other than a physician licensed to practice
98	98	medicine in this state, who obtain oral or written information
99	99	directly from a patient's physician or other health care provider
100	100	regarding the patient's specific medical condition, diagnosis, or
101	101	treatment options or protocols must be a nurse, physician
102	102	assistant, or other health care provider qualified and licensed or
103	103	otherwise authorized by law and the appropriate licensing agency in
104	104	this state to provide the requested service.
105	105	SECTION 7. Section 4201.356, Insurance Code, is amended to
106	106	read as follows:
107	107	Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY
108	108	REVIEW. (a) The procedures for appealing an adverse determination
109	109	must provide that a physician licensed to practice medicine in this
110	110	state makes the decision on the appeal, except as provided by
111	111	Subsection (b) or (c).
112	112	(b) For a health care service ordered, requested, provided,
113	113	or to be provided by a physician, the procedures for appealing an
114	114	adverse determination must provide that a physician licensed to
115	115	practice medicine in this state who is of the same or similar
116	116	specialty as that physician makes the decision on appeal, except as
117	117	provided by Subsection (c).
118	118	(c) If not later than the 10th working day after the date an
119	119	appeal is denied the enrollee's health care provider states in
120	120	writing good cause for having a particular type of specialty
121	121	provider review the case, a health care provider who is of the same
122	122	or a similar specialty as the health care provider who would
123	123	typically manage the medical or dental condition, procedure, or
124	124	treatment under consideration for review and who is licensed or
125	125	otherwise authorized by the appropriate licensing agency in this
126	126	state to manage the medical or dental condition, procedure, or
127	127	treatment shall review the decision denying the appeal. The
128	128	specialty review must be completed within 15 working days of the
129	129	date the health care provider's request for specialty review is
130	130	received.
131	131	SECTION 8. Sections 4201.357(a), (a-1), and (a-2),
132	132	Insurance Code, are amended to read as follows:
133	133	(a) The procedures for appealing an adverse determination
134	134	must include, in addition to the written appeal, a procedure for an
135	135	expedited appeal of a denial of emergency care or a denial of
136	136	continued hospitalization. That procedure must include a review by
137	137	a health care provider who:
138	138	(1) has not previously reviewed the case; [and]
139	139	(2) is of the same or a similar specialty as the health
140	140	care provider who would typically manage the medical or dental
141	141	condition, procedure, or treatment under review in the appeal; and
142	142	(3) for a review of a health care service:
143	143	(A) ordered, requested, or provided by a health
144	144	care provider who is not a physician, is licensed or otherwise
145	145	authorized by the appropriate licensing agency in this state to
146	146	provide the service in this state; or
147	147	(B) ordered, requested, or provided by a
148	148	physician, is licensed to practice medicine in this state.
149	149	(a-1) The procedures for appealing an adverse determination
150	150	must include, in addition to the written appeal and the appeal
151	151	described by Subsection (a), a procedure for an expedited appeal of
152	152	a denial of prescription drugs or intravenous infusions for which
153	153	the patient is receiving benefits under the health insurance
154	154	policy. That procedure must include a review by a health care
155	155	provider who:
156	156	(1) has not previously reviewed the case; [and]
157	157	(2) is of the same or a similar specialty as the health
158	158	care provider who would typically manage the medical or dental
159	159	condition, procedure, or treatment under review in the appeal; and
160	160	(3) for a review of a health care service:
161	161	(A) ordered, requested, or provided by a health
162	162	care provider who is not a physician, is licensed or otherwise
163	163	authorized by the appropriate licensing agency in this state to
164	164	provide the service in this state; or
165	165	(B) ordered, requested, or provided by a
166	166	physician, is licensed to practice medicine in this state.
167	167	(a-2) An adverse determination under Section 1369.0546 is
168	168	entitled to an expedited appeal. The physician or, if appropriate,
169	169	other health care provider deciding the appeal must consider
170	170	atypical diagnoses and the needs of atypical patient populations.
171	171	The physician must be licensed to practice medicine in this state
172	172	and the health care provider must be licensed or otherwise
173	173	authorized by the appropriate licensing agency in this state.
174	174	SECTION 9. Section 4201.359, Insurance Code, is amended by
175	175	adding Subsection (c) to read as follows:
176	176	(c) A physician described by Subsection (b)(2) must comply
177	177	with this chapter and other applicable laws and be licensed to
178	178	practice medicine in this state. A health care provider described
179	179	by Subsection (b)(2) must comply with this chapter and other
180	180	applicable laws and be licensed or otherwise authorized by the
181	181	appropriate licensing agency in this state.
182	182	SECTION 10. Sections 4201.453 and 4201.454, Insurance Code,
183	183	are amended to read as follows:
184	184	Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty
185	185	utilization review agent's utilization review plan, including
186	186	reconsideration and appeal requirements, must be:
187	187	(1) reviewed by a health care provider of the
188	188	appropriate specialty who is licensed or otherwise authorized to
189	189	provide the specialty health care service in this state; and
190	190	(2) conducted in accordance with standards developed
191	191	with input from a health care provider of the appropriate specialty
192	192	who is licensed or otherwise authorized to provide the specialty
193	193	health care service in this state.
194	194	Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF
195	195	PROVIDER OF SAME SPECIALTY. A specialty utilization review agent
196	196	shall conduct utilization review under the direction of a health
197	197	care provider who is of the same specialty as the agent and who is
198	198	licensed or otherwise authorized to provide the specialty health
199	199	care service in this [by a] state [licensing agency in the United
200	200	States].
201	201	SECTION 11. Sections 4201.455(a) and (b), Insurance Code,
202	202	are amended to read as follows:
203	203	(a) Personnel who are employed by or under contract with a
204	204	specialty utilization review agent to perform utilization review
205	205	must be appropriately trained and qualified and meet the
206	206	requirements of this chapter and other applicable law of this
207	207	state, including licensing laws.
208	208	(b) Personnel who obtain oral or written information
209	209	directly from a physician or other health care provider must be a
210	210	nurse, physician assistant, or other health care provider of the
211	211	same specialty as the agent and who are licensed or otherwise
212	212	authorized to provide the specialty health care service in this [by
213	213	a] state [licensing agency in the United States].
214	214	SECTION 12. Sections 4201.456 and 4201.457, Insurance Code,
215	215	are amended to read as follows:
216	216	Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
217	217	ADVERSE DETERMINATION. Subject to the notice requirements of
218	218	Subchapter G, before an adverse determination is issued by a
219	219	specialty utilization review agent who questions the medical
220	220	necessity, the [or] appropriateness, or the experimental or
221	221	investigational nature[,] of a health care service, the agent shall
222	222	provide the health care provider who ordered, requested, or
223	223	provided the service a reasonable opportunity to discuss the
224	224	patient's treatment plan and the clinical basis for the agent's
225	225	determination with a health care provider who is:
226	226	(1) of the same specialty as the agent; and
227	227	(2) licensed or otherwise authorized to provide the
228	228	specialty health care service in this state.
229	229	Sec. 4201.457. APPEAL DECISIONS. A specialty utilization
230	230	review agent shall comply with the requirement that a physician or
231	231	other health care provider who makes the decision in an appeal of an
232	232	adverse determination must be:
233	233	(1) of the same or a similar specialty as the health
234	234	care provider who would typically manage the specialty condition,
235	235	procedure, or treatment under review in the appeal; and
236	236	(2) licensed or otherwise authorized to provide the
237	237	health care service in this state.
238	238	SECTION 13. Section 4202.002, Insurance Code, is amended by
239	239	adding Subsection (b-1) to read as follows:
240	240	(b-1) The standards adopted under Subsection (b)(3) must:
241	241	(1) ensure that personnel conducting independent
242	242	review for a health care service are licensed or otherwise
243	243	authorized to provide the same or similar health care service in
244	244	this state; and
245	245	(2) be consistent with the licensing laws of this
246	246	state.
247	247	SECTION 14. Subchapter B, Chapter 151, Occupations Code, is
248	248	amended by adding Section 151.057 to read as follows:
249	249	Sec. 151.057. APPLICATION TO UTILIZATION REVIEW. (a) In
250	250	this section:
251	251	(1) "Adverse determination" means a determination
252	252	that health care services provided or proposed to be provided to an
253	253	individual in this state by a physician or at the request or order
254	254	of a physician are not medically necessary or are experimental or
255	255	investigational.
256	256	(2) "Payor" has the meaning assigned by Section
257	257	4201.002, Insurance Code.
258	258	(3) "Utilization review" has the meaning assigned by
259	259	Section 4201.002, Insurance Code, and the term includes a review
260	260	of:
261	261	(A) a step therapy protocol exception request
262	262	under Section 1369.0546, Insurance Code; and
263	263	(B) prescription drug benefits under Section
264	264	1369.056, Insurance Code.
265	265	(4) "Utilization review agent" means:
266	266	(A) an entity that conducts utilization review
267	267	under Chapter 4201, Insurance Code;
268	268	(B) a payor that conducts utilization review on
269	269	the payor's own behalf or on behalf of another person or entity;
270	270	(C) an independent review organization certified
271	271	under Chapter 4202, Insurance Code; or
272	272	(D) a workers' compensation health care network
273	273	certified under Chapter 1305, Insurance Code.
274	274	(b) A person who does the following is considered to be
275	275	engaged in the practice of medicine in this state and is subject to
276	276	appropriate regulation by the board:
277	277	(1) makes on behalf of a utilization review agent or
278	278	directs a utilization review agent to make an adverse
279	279	determination, including:
280	280	(A) an adverse determination made on
281	281	reconsideration of a previous adverse determination;
282	282	(B) an adverse determination in an independent
283	283	review under Subchapter I, Chapter 4201, Insurance Code;
284	284	(C) a refusal to provide benefits for a
285	285	prescription drug under Section 1369.056, Insurance Code; or
286	286	(D) a denial of a step therapy protocol exception
287	287	request under Section 1369.0546, Insurance Code;
288	288	(2) serves as a medical director of an independent
289	289	review organization certified under Chapter 4202, Insurance Code;
290	290	(3) reviews or approves a utilization review plan
291	291	under Section 4201.151, Insurance Code;
292	292	(4) supervises and directs utilization review under
293	293	Section 4201.152, Insurance Code; or
294	294	(5) discusses a patient's treatment plan and the
295	295	clinical basis for an adverse determination before the adverse
296	296	determination is issued, as provided by Section 4201.206, Insurance
297	297	Code.
298	298	(c) For purposes of Subsection (b), a denial of health care
299	299	services based on the failure to request prospective or concurrent
300	300	review is not considered an adverse determination.
301	301	SECTION 15. Section 1305.351(d), Insurance Code, is amended
302	302	to read as follows:
303	303	(d) A [Notwithstanding Section 4201.152, a] utilization
304	304	review agent or an insurance carrier that uses doctors to perform
305	305	reviews of health care services provided under this chapter,
306	306	including utilization review, or peer reviews under Section
307	307	408.0231(g), Labor Code, may only use doctors licensed to practice
308	308	in this state.
309	309	SECTION 16. Section 1305.355(d), Insurance Code, is amended
310	310	to read as follows:
311	311	(d) The department shall assign the review request to an
312	312	independent review organization. An [Notwithstanding Section
313	313	4202.002, an] independent review organization that uses doctors to
314	314	perform reviews of health care services under this chapter may only
315	315	use doctors licensed to practice in this state.
316	316	SECTION 17. Section 408.023(h), Labor Code, is amended to
317	317	read as follows:
318	318	(h) A [Notwithstanding Section 4201.152, Insurance Code, a]
319	319	utilization review agent or an insurance carrier that uses doctors
320	320	to perform reviews of health care services provided under this
321	321	subtitle, including utilization review, may only use doctors
322	322	licensed to practice in this state.
323	323	SECTION 18. Section 413.031(e-2), Labor Code, is amended to
324	324	read as follows:
325	325	(e-2) An [Notwithstanding Section 4202.002, Insurance Code,
326	326	an] independent review organization that uses doctors to perform
327	327	reviews of health care services provided under this title may only
328	328	use doctors licensed to practice in this state.
329	329	SECTION 19. The change in law made by this Act applies only
330	330	to utilization or independent review that was requested on or after
331	331	the effective date of this Act. Utilization or independent review
332	332	requested before the effective date of this Act is governed by the
333	333	law as it existed immediately before the effective date of this Act,
334	334	and that law is continued in effect for that purpose.
335	335	SECTION 20. This Act takes effect September 1, 2019.