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.