By Davila H.B. No. 3123
75R7351 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to coverage for certain treatments under managed care
1-3 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 Section 21.52I to read as follows:
1-7 Art. 21.52I. BENEFITS FOR EXPERIMENTAL TREATMENTS
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Managed care entity" means an entity described by
1-10 Section 2 of this article.
1-11 (2) "Managed care plan" means a health benefit plan:
1-12 (A) under which health care services are
1-13 provided to enrollees through contracts with health care
1-14 professionals or health care facilities; and
1-15 (B) that provides financial incentives to
1-16 enrollees in the plan to use the participating practitioners,
1-17 participating health care facilities, and procedures covered by the
1-18 plan.
1-19 Sec. 2. SCOPE OF ARTICLE. This article applies to a health
1-20 maintenance organization, a preferred provider organization, an
1-21 approved nonprofit health corporation that holds a certificate of
1-22 authority issued by the commissioner under Article 21.52F of this
1-23 code, and any other entity that offers a managed care plan,
1-24 including:
2-1 (1) an insurance company;
2-2 (2) a group hospital service corporation operating
2-3 under Chapter 20 of this code;
2-4 (3) a fraternal benefit society operating under
2-5 Chapter 10 of this code;
2-6 (4) a stipulated premium insurance company operating
2-7 under Chapter 22 of this code; or
2-8 (5) to the extent permitted by the Employee Retirement
2-9 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.):
2-10 (A) a multiple employer welfare arrangement as
2-11 defined by Section 3, Employee Retirement Income Security Act of
2-12 1974 (29 U.S.C. Section 1002), or another analogous benefit
2-13 arrangement; or
2-14 (B) any other entity not licensed under this
2-15 code or another insurance law of this state that contracts directly
2-16 for health care services on a risk-sharing basis, including an
2-17 entity that contracts for health care services under a capitation
2-18 method.
2-19 Sec. 3. COVERAGE FOR EXPERIMENTAL TREATMENT. A managed care
2-20 plan may not exclude benefits for a treatment for a particular
2-21 condition or illness solely because the treatment is experimental
2-22 for that condition or illness if:
2-23 (1) benefits for treatment of the illness or condition
2-24 are provided under the managed care plan;
2-25 (2) the treatment is recognized for treatment of the
2-26 particular illness or condition; and
2-27 (3) there is not a clearly superior commonly used
3-1 treatment alternative for the illness or condition available to the
3-2 enrollee.
3-3 Sec. 4. NOTICE; REVIEW. (a) A managed care entity that
3-4 denies benefits for a treatment for an enrollee that has been
3-5 prescribed or recommended by a physician treating the enrollee
3-6 under the managed care plan on the grounds that the treatment is
3-7 experimental for the enrollee's illness or condition shall notify
3-8 the enrollee in writing of:
3-9 (1) the reason for the denial of benefits; and
3-10 (2) the enrollee's right to a review of the
3-11 determination under this section.
3-12 (b) An enrollee may request a review of the managed care
3-13 entity's denial of benefits. The review must be conducted by a
3-14 physician in the same area of specialty as the physician who
3-15 prescribed or recommended the treatment for which benefits have
3-16 been denied. The physician conducting the review shall determine
3-17 whether the treatment is appropriate and medically necessary for
3-18 the enrollee and whether coverage for the treatment is required
3-19 under this article.
3-20 (c) The commissioner may adopt rules governing the review
3-21 required by this section, including rules governing the time within
3-22 which the review must be completed.
3-23 SECTION 2. This Act takes effect September 1, 1997, and
3-24 applies only to an insurance policy that is delivered, issued for
3-25 delivery, or renewed on or after January 1, 1998. A policy that is
3-26 delivered, issued for delivery, or renewed before January 1, 1998,
3-27 is governed by the law as it existed immediately before the
4-1 effective date of this Act, and that law is continued in effect for
4-2 that purpose.
4-3 SECTION 3. The importance of this legislation and the
4-4 crowded condition of the calendars in both houses create an
4-5 emergency and an imperative public necessity that the
4-6 constitutional rule requiring bills to be read on three several
4-7 days in each house be suspended, and this rule is hereby suspended.