By: Johnson of Dallas H.B. No. 2035
A BILL TO BE ENTITLED
AN ACT
relating to utilization review of emergency care claims under
health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 533.005, Government Code, is amended by
adding Subsection (e) to read as follows:
(e) In addition to the requirements under Subsection (a), a
contract described by that subsection must require the managed care
organization to comply with Section 541.062, Insurance Code.
SECTION 2. Subchapter B, Chapter 541, Insurance Code, is
amended by adding Section 541.062 to read as follows:
Sec. 541.062. EMERGENCY CARE. (a) In this section,
"emergency care" has the meanings assigned by Sections 1301.155 and
4201.002 as applicable.
(b) It is an unfair method of competition or an unfair or
deceptive act or practice in the business of insurance for an
insurer or an individual or entity acting on behalf of an insurer
to:
(1) violate the requirements of Section 4201.156;
(2) deter enrollees from seeking care consistent with
the prudent layperson standard for emergency care; or
(3) engage in a pattern of wrongful denials of claims
for emergency care.
(c) A violation of this section does not create a private
cause of action under Section 541.151 or Section 541.251.
SECTION 3. Section 843.002(7), Insurance Code, is amended
to read as follows:
(7) "Emergency care" means health care services
provided in a hospital emergency facility, freestanding emergency
medical care facility, or comparable emergency facility to evaluate
and stabilize medical conditions of a recent onset and severity,
including severe pain, regardless of the final diagnosis that is
given, that would lead a prudent layperson possessing an average
knowledge of medicine and health to believe that the individual's
condition, sickness, or injury is of such a nature that failure to
get immediate medical care could:
(A) place the individual's health in serious
jeopardy;
(B) result in serious impairment to bodily
functions;
(C) result in serious dysfunction of a bodily
organ or part;
(D) result in serious disfigurement; or
(E) for a pregnant woman, result in serious
jeopardy to the health of the fetus.
SECTION 4. Section 1301.155(a), Insurance Code, is amended
to read as follows:
(a) In this section, "emergency care" means health care
services provided in a hospital emergency facility, freestanding
emergency medical care facility, or comparable emergency facility
to evaluate and stabilize a medical condition of a recent onset and
severity, including severe pain, regardless of the final diagnosis
that is given, that would lead a prudent layperson possessing an
average knowledge of medicine and health to believe that the
person's condition, sickness, or injury is of such a nature that
failure to get immediate medical care could result in:
(1) placing the person's health in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of a bodily organ or part;
(4) serious disfigurement; or
(5) in the case of a pregnant woman, serious jeopardy
to the health of the fetus.
SECTION 5. Section 4201.002(2), Insurance Code, is amended
to read as follows:
(2) "Emergency care" means health care services
provided in a hospital emergency facility, freestanding emergency
medical care facility, or comparable emergency facility to evaluate
and stabilize medical conditions of a recent onset and severity,
including severe pain, regardless of the final diagnosis that is
given, that would lead a prudent layperson possessing an average
knowledge of medicine and health to believe that the individual's
condition, sickness, or injury is of such a nature that failure to
get immediate medical care could:
(A) place the individual's health in serious
jeopardy;
(B) result in serious impairment to bodily
functions;
(C) result in serious dysfunction of a bodily
organ or part;
(D) result in serious disfigurement; or
(E) for a pregnant woman, result in serious
jeopardy to the health of the fetus.
SECTION 6. Subchapter D, Chapter 4201, Insurance Code, is
amended by adding Section 4201.156 to read as follows:
Sec. 4201.156. REVIEW PROCEDURES FOR EMERGENCY CARE CLAIMS.
(a) Utilization review of an emergency care claim must be performed
by a physician:
(1) licensed to practice medicine in this state; and
(2) board certified in emergency medicine.
(b) With respect to an enrollee's medical condition that is
the basis for an emergency care claim, a utilization review agent:
(1) may not make an adverse determination for the
emergency care claim based, in whole or in part, on the final
diagnosis that is given, including the classification under a
Current Procedural Terminology or International Classification of
Diseases code; and
(2) must review the enrollee's medical record before
making an adverse determination.
(c) Nothing in this section may be construed as authorizing
utilization review of emergency care when otherwise prohibited by
law.
SECTION 7. Sections 541.062 and 4201.156, Insurance Code,
as added by this Act, apply only to a health benefit plan delivered,
issued for delivery, or renewed on or after January 1, 2022. A
health benefit plan delivered, issued for delivery, or renewed
before January 1, 2022, 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 8. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 9. This Act takes effect September 1, 2021.