Texas 2023 - 88th Regular

Texas House Bill HB4713 Compare Versions

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1	1	By: Plesa, Rose, Price, Oliverson, Perez, H.B. No. 4713
2	2	et al.
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to group health benefit plan coverage for early treatment
8	8	of first episode psychosis.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 1355.001, Insurance Code, is amended by
11	11	adding Subdivision (5) to read as follows:
12	12	(5) "First episode psychosis" means the initial onset
13	13	of psychosis or symptoms associated with psychosis, caused by:
14	14	(A) medical or neurological conditions;
15	15	(B) serious mental illness; or
16	16	(C) substance use.
17	17	SECTION 2. Section 1355.002, Insurance Code, is amended by
18	18	adding Subsection (c) to read as follows:
19	19	(c) Notwithstanding any other law, Section 1355.016 applies
20	20	to the state Medicaid program, including the Medicaid managed care
21	21	program operated under Chapter 533, Government Code.
22	22	SECTION 3. Subchapter A, Chapter 1355, Insurance Code, is
23	23	amended by adding Section 1355.016 to read as follows:
24	24	Sec. 1355.016. REQUIRED COVERAGE FOR EARLY TREATMENT OF
25	25	FIRST EPISODE PSYCHOSIS. (a) A group health benefit plan may
26	26	provide coverage, based on medical necessity, as provided by this
27	27	section to an individual who is younger than 26 years of age and who
28	28	is diagnosed with first episode psychosis.
29	29	(b) If the group health benefit plan provides coverage under
30	30	this section, the plan must provide coverage under this section to
31	31	the enrollee for all generally recognized services prescribed in
32	32	relation to first episode psychosis.
33	33	(c) For purposes of Subsection (b), "generally recognized
34	34	services" may include:
35	35	(1) coordinated specialty care for first episode
36	36	psychosis treatment, covering each element of the treatment model
37	37	included in the Recovery After an Initial Schizophrenia Episode
38	38	(RAISE) early treatment program study conducted by the National
39	39	Institute of Mental Health regarding treatment for psychosis, as
40	40	completed July 2017, including:
41	41	(A) psychotherapy;
42	42	(B) medication management;
43	43	(C) case management;
44	44	(D) family education and support; and
45	45	(E) education and employment support;
46	46	(2) assertive community treatment as described by the
47	47	Texas Health and Human Services Commission's Texas Resilience and
48	48	Recovery Utilization Management Guidelines: Adult Mental Health
49	49	Services, as updated in April 2017, or a more recently updated
50	50	version adopted by the commissioner; and
51	51	(3) peer support services, including:
52	52	(A) recovery and wellness support;
53	53	(B) mentoring; and
54	54	(C) advocacy.
55	55	(d) Only coordinated specialty care or assertive community
56	56	treatment provided by a provider that adheres to the fidelity of the
57	57	applicable treatment model and that has contracted with the Health
58	58	and Human Services Commission to provide coordinated specialty care
59	59	or assertive community treatment for first episode psychosis is
60	60	required to be covered by a group health benefit plan that provides
61	61	coverage under this section.
62	62	(e) If a group health benefit plan issuer credentials a
63	63	psychiatrist or licensed clinical leader of a treatment team to
64	64	provide generally recognized services for the treatment of first
65	65	episode psychosis, all members of the treatment team serving under
66	66	the credentialed psychiatrist or licensed clinical leader are
67	67	considered to be credentialed by the health benefit plan issuer.
68	68	(f) A group health benefit plan issuer may reimburse a
69	69	provider of coordinated specialty care or assertive community
70	70	treatment for first episode psychosis based on a bundled payment
71	71	model instead of providing reimbursement for each service provided
72	72	to the enrollee by the member of a treatment team.
73	73	(g) If requested by a group health benefit plan issuer that
74	74	provides coverage under this section on or after March 1, 2029, the
75	75	department shall contract with an independent third party with
76	76	expertise in analyzing health benefit plan premiums and costs to
77	77	perform an independent analysis of the impact of requiring coverage
78	78	of the team-based treatment models described by Subsection (c) on
79	79	health benefit plan premiums. Notwithstanding Subsection (c), if
80	80	the analysis finds that premiums increased annually by at least one
81	81	percent solely due to requiring coverage of a specific treatment
82	82	model, a group health benefit plan is not required to provide
83	83	coverage under this section for that treatment model.
84	84	SECTION 4. (a) As soon as practicable after the effective
85	85	date of this Act, the Texas Department of Insurance shall convene
86	86	and lead a work group that includes the Health and Human Services
87	87	Commission, providers of generally recognized services described
88	88	by Section 1355.016(c), Insurance Code, as added by this Act, and
89	89	group health benefit plan issuers. The work group shall:
90	90	(1) develop the criteria to be used to determine
91	91	medical necessity for purposes of coverage under Section 1355.016,
92	92	Insurance Code, as added by this Act; and
93	93	(2) determine a coding solution that allows for
94	94	coordinated specialty care and assertive community treatment to be
95	95	coded and reimbursed as a bundle of services under Section
96	96	1355.016(f), Insurance Code, as added by this Act.
97	97	(b) Not later than January 1, 2024, the work group shall
98	98	make recommendations to the department based on its findings.
99	99	(c) Not later than June 30, 2024, the department shall adopt
100	100	rules:
101	101	(1) establishing the criteria to be used to determine
102	102	medical necessity under Section 1355.016(a), Insurance Code, as
103	103	added by this Act;
104	104	(2) creating a coding solution that allows for
105	105	reimbursement based on a bundled payment model for coordinated
106	106	specialty care and assertive community treatment under Section
107	107	1355.016(f), Insurance Code, as added by this Act; and
108	108	(3) otherwise necessary to implement Section
109	109	1355.016, Insurance Code, as added by this Act.
110	110	SECTION 5. If before implementing any provision of this Act
111	111	a state agency determines that a waiver or authorization from a
112	112	federal agency is necessary for implementation of that provision,
113	113	the agency affected by the provision shall request the waiver or
114	114	authorization and may delay implementing that provision until the
115	115	waiver or authorization is granted.
116	116	SECTION 6. Section 1355.016, Insurance Code, as added by
117	117	this Act, applies only to a health benefit plan that is delivered,
118	118	issued for delivery, or renewed on or after June 30, 2024. A health
119	119	benefit plan delivered, issued for delivery, or renewed before June
120	120	30, 2024, is governed by the law as it existed immediately before
121	121	that date, and that law is continued in effect for that purpose.
122	122	SECTION 7. This Act takes effect September 1, 2023.