Texas 2021 - 87th Regular

Texas House Bill HB2035 Compare Versions

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

Old	New	Differences
1	1	By: Johnson of Dallas H.B. No. 2035
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to utilization review of emergency care claims under
7	7	health benefit plans.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Section 533.005, Government Code, is amended by
10	10	adding Subsection (e) to read as follows:
11	11	(e) In addition to the requirements under Subsection (a), a
12	12	contract described by that subsection must require the managed care
13	13	organization to comply with Section 541.062, Insurance Code.
14	14	SECTION 2. Subchapter B, Chapter 541, Insurance Code, is
15	15	amended by adding Section 541.062 to read as follows:
16	16	Sec. 541.062. EMERGENCY CARE. (a) In this section,
17	17	"emergency care" has the meanings assigned by Sections 1301.155 and
18	18	4201.002 as applicable.
19	19	(b) It is an unfair method of competition or an unfair or
20	20	deceptive act or practice in the business of insurance for an
21	21	insurer or an individual or entity acting on behalf of an insurer
22	22	to:
23	23	(1) violate the requirements of Section 4201.156;
24	24	(2) deter enrollees from seeking care consistent with
25	25	the prudent layperson standard for emergency care; or
26	26	(3) engage in a pattern of wrongful denials of claims
27	27	for emergency care.
28	28	(c) A violation of this section does not create a private
29	29	cause of action under Section 541.151 or Section 541.251.
30	30	SECTION 3. Section 843.002(7), Insurance Code, is amended
31	31	to read as follows:
32	32	(7) "Emergency care" means health care services
33	33	provided in a hospital emergency facility, freestanding emergency
34	34	medical care facility, or comparable emergency facility to evaluate
35	35	and stabilize medical conditions of a recent onset and severity,
36	36	including severe pain, regardless of the final diagnosis that is
37	37	given, that would lead a prudent layperson possessing an average
38	38	knowledge of medicine and health to believe that the individual's
39	39	condition, sickness, or injury is of such a nature that failure to
40	40	get immediate medical care could:
41	41	(A) place the individual's health in serious
42	42	jeopardy;
43	43	(B) result in serious impairment to bodily
44	44	functions;
45	45	(C) result in serious dysfunction of a bodily
46	46	organ or part;
47	47	(D) result in serious disfigurement; or
48	48	(E) for a pregnant woman, result in serious
49	49	jeopardy to the health of the fetus.
50	50	SECTION 4. Section 1301.155(a), Insurance Code, is amended
51	51	to read as follows:
52	52	(a) In this section, "emergency care" means health care
53	53	services provided in a hospital emergency facility, freestanding
54	54	emergency medical care facility, or comparable emergency facility
55	55	to evaluate and stabilize a medical condition of a recent onset and
56	56	severity, including severe pain, regardless of the final diagnosis
57	57	that is given, that would lead a prudent layperson possessing an
58	58	average knowledge of medicine and health to believe that the
59	59	person's condition, sickness, or injury is of such a nature that
60	60	failure to get immediate medical care could result in:
61	61	(1) placing the person's health in serious jeopardy;
62	62	(2) serious impairment to bodily functions;
63	63	(3) serious dysfunction of a bodily organ or part;
64	64	(4) serious disfigurement; or
65	65	(5) in the case of a pregnant woman, serious jeopardy
66	66	to the health of the fetus.
67	67	SECTION 5. Section 4201.002(2), Insurance Code, is amended
68	68	to read as follows:
69	69	(2) "Emergency care" means health care services
70	70	provided in a hospital emergency facility, freestanding emergency
71	71	medical care facility, or comparable emergency facility to evaluate
72	72	and stabilize medical conditions of a recent onset and severity,
73	73	including severe pain, regardless of the final diagnosis that is
74	74	given, that would lead a prudent layperson possessing an average
75	75	knowledge of medicine and health to believe that the individual's
76	76	condition, sickness, or injury is of such a nature that failure to
77	77	get immediate medical care could:
78	78	(A) place the individual's health in serious
79	79	jeopardy;
80	80	(B) result in serious impairment to bodily
81	81	functions;
82	82	(C) result in serious dysfunction of a bodily
83	83	organ or part;
84	84	(D) result in serious disfigurement; or
85	85	(E) for a pregnant woman, result in serious
86	86	jeopardy to the health of the fetus.
87	87	SECTION 6. Subchapter D, Chapter 4201, Insurance Code, is
88	88	amended by adding Section 4201.156 to read as follows:
89	89	Sec. 4201.156. REVIEW PROCEDURES FOR EMERGENCY CARE CLAIMS.
90	90	(a) Utilization review of an emergency care claim must be performed
91	91	by a physician:
92	92	(1) licensed to practice medicine in this state; and
93	93	(2) board certified in emergency medicine.
94	94	(b) With respect to an enrollee's medical condition that is
95	95	the basis for an emergency care claim, a utilization review agent:
96	96	(1) may not make an adverse determination for the
97	97	emergency care claim based, in whole or in part, on the final
98	98	diagnosis that is given, including the classification under a
99	99	Current Procedural Terminology or International Classification of
100	100	Diseases code; and
101	101	(2) must review the enrollee's medical record before
102	102	making an adverse determination.
103	103	(c) Nothing in this section may be construed as authorizing
104	104	utilization review of emergency care when otherwise prohibited by
105	105	law.
106	106	SECTION 7. Sections 541.062 and 4201.156, Insurance Code,
107	107	as added by this Act, apply only to a health benefit plan delivered,
108	108	issued for delivery, or renewed on or after January 1, 2022. A
109	109	health benefit plan delivered, issued for delivery, or renewed
110	110	before January 1, 2022, is governed by the law as it existed
111	111	immediately before the effective date of this Act, and that law is
112	112	continued in effect for that purpose.
113	113	SECTION 8. If before implementing any provision of this Act
114	114	a state agency determines that a waiver or authorization from a
115	115	federal agency is necessary for implementation of that provision,
116	116	the agency affected by the provision shall request the waiver or
117	117	authorization and may delay implementing that provision until the
118	118	waiver or authorization is granted.
119	119	SECTION 9. This Act takes effect September 1, 2021.