By Naishtat H.B. No. 1371
75R5192 PB-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage of benefits for mental health services by
1-3 certain managed care plans.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.52G to read as follows:
1-7 Art. 21.52G. PROVISION OF MENTAL HEALTH SERVICES BY MANAGED
1-8 CARE PLAN
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Covered person" means a person entitled to
1-11 benefits under a managed care plan.
1-12 (2) "Managed care plan" means:
1-13 (A) a health maintenance organization that holds
1-14 a certificate of authority issued under the Texas Health
1-15 Maintenance Organization Act (Article 20A.01 et seq., Vernon's
1-16 Texas Insurance Code);
1-17 (B) a preferred provider organization;
1-18 (C) an approved nonprofit health corporation
1-19 that is certified under Section 5.01(a), Medical Practice Act
1-20 (Article 4495b, Vernon's Texas Civil Statutes), and that holds a
1-21 certificate of authority issued by the commissioner under Article
1-22 21.52F of this code; or
1-23 (D) any other organization that provides or
1-24 arranges for health care benefits to covered persons and requires
2-1 or encourages covered persons to use health care practitioners
2-2 designated by the organization.
2-3 (3) "Practitioner" means a physician, a psychologist,
2-4 or another individual who holds a license or other credential
2-5 issued by this state to provide mental health services.
2-6 Sec. 2. PROVISION OF SERVICES. Each managed care plan that
2-7 provides benefits for mental health services shall comply with this
2-8 article and the rules adopted under this article.
2-9 Sec. 3. APPEAL OF ADVERSE DETERMINATION. (a) Each managed
2-10 care plan shall adopt procedures under which a covered person may
2-11 appeal an adverse determination regarding coverage of a particular
2-12 mental health service to a panel of independent practitioners, a
2-13 majority of whom hold the same license as the treating mental
2-14 health care practitioner.
2-15 (b) The decision of the panel is the final decision of the
2-16 managed care entity as to all issues involving coverage of the
2-17 mental health service.
2-18 Sec. 4. UTILIZATION REVIEW. A managed care plan shall
2-19 require that the utilization review criterion for mental health
2-20 benefits be that of "clinical necessity" rather than that of
2-21 "medical necessity."
2-22 Sec. 5. COMPARABLE BENEFITS. A managed care plan shall
2-23 provide comparable reimbursement or benefits for each
2-24 scientifically recognized diagnosis related to mental health, as
2-25 listed in publications of nationally recognized mental health care
2-26 authorities.
2-27 Sec. 6. ACCESS TO FEMALE PRACTITIONERS. Each managed care
3-1 plan must include among the practitioners who provide mental health
3-2 services through the plan a number of female practitioners
3-3 sufficient to afford female covered persons the opportunity to
3-4 receive covered services from a female practitioner.
3-5 Sec. 7. PROHIBITED ACTS. A managed care plan may not:
3-6 (1) require, as a condition of coverage or for any
3-7 other reason, the observation of a psychotherapy session relating
3-8 to or involving a covered person;
3-9 (2) require or request, as a condition of coverage or
3-10 for any other reason, that a practitioner's process or progress
3-11 notes be submitted to the plan for review;
3-12 (3) deny benefits for:
3-13 (A) psychotherapy or mental health related
3-14 hospitalization on the ground that the patient refuses medication;
3-15 or
3-16 (B) mental health therapy based on the context
3-17 or setting of that therapy, whether individual, group, family,
3-18 marital, or another similar therapy; or
3-19 (4) prohibit practitioners from informing covered
3-20 persons regarding:
3-21 (A) the procedures necessary to obtain covered
3-22 services from the plan; or
3-23 (B) conduct on the part of the plan that, in the
3-24 opinion of the practitioner, impedes proper treatment.
3-25 Sec. 8. RULES; SAFEGUARDS. The commissioner by rule shall:
3-26 (1) enforce this article;
3-27 (2) prohibit mandatory reporting of confidential
4-1 patient mental health information to data banks; and
4-2 (3) implement safeguards under which:
4-3 (A) confidential patient mental health treatment
4-4 information is protected from disclosure based on standards
4-5 developed and recommended by consumers and clinicians independent
4-6 of managed care plans; and
4-7 (B) the traditional managed care gatekeeper
4-8 system is not a barrier that denies covered persons access to
4-9 mental health services.
4-10 SECTION 2. Article 21.52G, Insurance Code, as added by this
4-11 Act, applies only to a contract or evidence of coverage that is
4-12 delivered, issued for delivery, or renewed on or after January 1,
4-13 1998. A contract or evidence of coverage that is delivered, issued
4-14 for delivery, or renewed before January 1, 1998, is governed by the
4-15 law as it existed immediately before the effective date of this
4-16 Act, and that law is continued in effect for that purpose.
4-17 SECTION 3. The importance of this legislation and the
4-18 crowded condition of the calendars in both houses create an
4-19 emergency and an imperative public necessity that the
4-20 constitutional rule requiring bills to be read on three several
4-21 days in each house be suspended, and this rule is hereby suspended.