| |
| |
|
|
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. Section 1355.002, Insurance Code, is amended by |
|
|
adding Subsection (c) to read as follows: |
|
|
(c) Notwithstanding any other law, Section 1355.016 applies |
|
|
to the state Medicaid program, including the Medicaid managed care |
|
|
program operated under Chapter 533, Government Code. |
|
|
SECTION 3. 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, 2029, 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 4. (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, 2024, the work group shall |
|
|
make recommendations to the department based on its findings. |
|
|
(c) Not later than March 30, 2024, 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 5. 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 6. 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, 2024. A |
|
|
health benefit plan delivered, issued for delivery, or renewed |
|
|
before March 30, 2024, is governed by the law as it existed |
|
|
immediately before that date, and that law is continued in effect |
|
|
for that purpose. |
|
|
SECTION 7. This Act takes effect September 1, 2023. |