SRC-JBJ H.B. 3016 76(R)   BILL ANALYSIS


Senate Research Center   H.B. 3016
By: Smithee (Sibley)
Economic Development
5/14/1999
Engrossed


DIGEST 


Enacted by the 75th Legislature, Article 20A.12, Insurance Code, requires
health maintenance organizations (HMOs) to establish a system for
complaints and appeals brought by enrollees and health care providers.  The
system must include a provision to notify an enrollee of the enrollee's
right to appeal an adverse determination to an independent review
organization (IRO).  Some HMOs have concluded that an enrollee's
disagreement with an adverse determination constitutes a complaint and not
an appeal within the meaning of Article 20A.12.  H.B. 3016 amends
regulations regarding health care utilization review agents. 

PURPOSE

As proposed, H.B. 3016 amends regulations regarding health care utilization
review agents. 

RULEMAKING AUTHORITY

This bill does not grant any additional rulemaking authority to a state
officer, institution, or agency. 

SECTION BY SECTION ANALYSIS

SECTION 1.  Amends Sections 5(a) and (c), Article 21.58A, Insurance Code,
to require a utilization review agent (agent) to notify the enrollee or a
person acting on behalf of the enrollee and the enrollee's provider of
record, of a determination made in a utilization review, rather than
notifying the enrollee, a person acting on behalf of the enrollee, or the
enrollee's provider of record.  Requires the agent to include certain
descriptions of the procedure for a complaint and appeal process, including
an enrollee's right to appeal, the procedures for appealing an adverse
determination to an independent review organization (organization), and
notification to an enrollee who has a life-threatening condition of the
enrollee's right to an immediate review by the organization and procedures
to obtain the review. 

SECTION 2.  Amends Section 6(a), Article 21.58A, Insurance Code, to specify
that a filed complaint with an agent that concerns dissatisfaction or
disagreement with an adverse determination constitutes an appeal of that
adverse determination, for purposes of this section. 

SECTION 3.  Amends Section 6(b), Article 21.58A, Insurance Code, to require
the letter the agent is required to send to the appealing party
acknowledging the agent's receipt of the appeal to include, among other
provisions, a list of the documents, rather than reasonable documents, that
the appealing party must submit for review by the utilization review agent.
Sets forth other procedures for appeals. Deletes requirements that a
notification include certain denials of health care insurance, a statement
of medical decisions, and notification of an appeal to the other party.
Makes conforming changes. 

SECTION 4.  Amends Section 6(c), Article 21.58A, Insurance Code, to provide
that notwithstanding this article or any other law, the enrollee is
entitled to certain appeals.   Deletes the definition for "lifethreatening
condition." 

SECTION 5.  Effective date: September 1, 1999.

SECTION 6.  Emergency clause.