87R3326 RDS-F
By: Zaffirini S.B. No. 1141
A BILL TO BE ENTITLED
AN ACT
relating to group health benefit plan coverage for early treatment
of first episode psychosis.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1355.001, Insurance Code, is amended by
adding Subdivision (5) to read as follows:
(5) "First episode psychosis" means the initial onset
of psychosis or symptoms associated with psychosis, caused by:
(A) medical or neurological conditions;
(B) serious mental illness; or
(C) substance use.
SECTION 2. Subchapter A, Chapter 1355, Insurance Code, is
amended by adding Section 1355.016 to read as follows:
Sec. 1355.016. REQUIRED COVERAGE FOR EARLY TREATMENT OF
FIRST EPISODE PSYCHOSIS. (a) A group health benefit plan must
provide coverage, based on medical necessity, as provided by this
section to an individual who is younger than 26 years of age and who
is diagnosed with first episode psychosis.
(b) The group health benefit plan must provide coverage
under this section to the enrollee for all generally recognized
services prescribed in relation to first episode psychosis.
(c) For purposes of Subsection (b), "generally recognized
services" include:
(1) coordinated specialty care for first episode
psychosis treatment, covering each element of the treatment model
included in the Recovery After an Initial Schizophrenia Episode
(RAISE) early treatment program study conducted by the National
Institute of Mental Health regarding treatment for psychosis, as
completed July 2017, including:
(A) psychotherapy;
(B) medication management;
(C) case management;
(D) family education and support; and
(E) education and employment support;
(2) assertive community treatment as described by the
Texas Health and Human Services Commission's Texas Resilience and
Recovery Utilization Management Guidelines: Adult Mental Health
Services, as updated in April 2017, or a more recently updated
version adopted by the commissioner; and
(3) peer support services, including:
(A) recovery and wellness support;
(B) mentoring; and
(C) advocacy.
(d) Only coordinated specialty care or assertive community
treatment provided by a provider that adheres to the fidelity of the
applicable treatment model and that has contracted with the Health
and Human Services Commission to provide coordinated specialty care
or assertive community treatment for first episode psychosis is
required to be covered under this section.
(e) If a group health benefit plan issuer credentials a
psychiatrist or licensed clinical leader of a treatment team to
provide generally recognized services for the treatment of first
episode psychosis, all members of the treatment team serving under
the credentialed psychiatrist or licensed clinical leader are
considered to be credentialed by the health benefit plan issuer.
(f) A group health benefit plan issuer shall reimburse a
provider of coordinated specialty care or assertive community
treatment for first episode psychosis based on a bundled payment
model instead of providing reimbursement for each service provided
to the enrollee by the member of a treatment team.
(g) If requested by a group health benefit plan issuer on or
after March 1, 2027, the department shall contract with an
independent third party with expertise in analyzing health benefit
plan premiums and costs to perform an independent analysis of the
impact of requiring coverage of the team-based treatment models
described by Subsection (c) on health benefit plan premiums.
Notwithstanding Subsection (c), if the analysis finds that premiums
increased annually by more than one percent solely due to requiring
coverage of a specific treatment model, a group health benefit plan
is not required to provide coverage under this section for that
treatment model.
SECTION 3. (a) As soon as practicable after the effective
date of this Act, the Texas Department of Insurance shall convene
and lead a work group that includes the Health and Human Services
Commission, providers of generally recognized services described
by Section 1355.016(c), Insurance Code, as added by this Act, and
group health benefit plan issuers. The work group shall:
(1) develop the criteria to be used to determine
medical necessity for purposes of coverage under Section 1355.016,
Insurance Code, as added by this Act; and
(2) determine a coding solution that allows for
coordinated specialty care and assertive community treatment to be
coded and reimbursed as a bundle of services as required under
Section 1355.016(f), Insurance Code, as added by this Act.
(b) Not later than January 1, 2022, the work group shall
make recommendations to the department based on its findings.
(c) Not later than March 30, 2022, the department shall
adopt rules:
(1) establishing the criteria to be used to determine
medical necessity under Section 1355.016(a), Insurance Code, as
added by this Act;
(2) creating a coding solution that allows for
reimbursement based on a bundled payment model for coordinated
specialty care and assertive community treatment as required by
Section 1355.016(f), Insurance Code, as added by this Act; and
(3) otherwise necessary to implement Section
1355.016, Insurance Code, as added by this Act.
SECTION 4. Section 1355.016, 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 March 30, 2022. A
health benefit plan delivered, issued for delivery, or renewed
before March 30, 2022, is governed by the law as it existed
immediately before that date, and that law is continued in effect
for that purpose.
SECTION 5. This Act takes effect September 1, 2021.