By Smithee H.B. No. 3021
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to a health maintenance organization's complaint and
1-3 appeals procedures.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 2(f), Texas Health Maintenance
1-6 Organization Act (Article 20A.02, Vernon's Texas Insurance Code),
1-7 is amended to read as follows:
1-8 (f) "Complaint" means any dissatisfaction expressed by a
1-9 complainant orally or in writing to the health maintenance
1-10 organization with any aspect of the health maintenance
1-11 organization's operation, including but not limited to
1-12 dissatisfaction with plan administration; procedures related to
1-13 review or appeal of an adverse determination, as that term is
1-14 defined by Section 12A of this Act; the denial, reduction, or
1-15 termination of a service for reasons not related to medical
1-16 necessity; the way a service is provided; or disenrollment
1-17 decisions, expressed by a complainant. The term does not include
1-18 [A complaint is not] a misunderstanding or a problem of
1-19 misinformation that is resolved promptly by clearing up the
1-20 misunderstanding or supplying the appropriate information to the
1-21 satisfaction of the enrollee and does not include a provider's or
1-22 enrollee's oral or written dissatisfaction or disagreement with an
1-23 adverse determination.
1-24 SECTION 2. Section 12, Texas Health Maintenance Organization
2-1 Act (Article 20A.12, Vernon's Texas Insurance Code), as amended by
2-2 Chapters 163 and 1026, Acts of the 75th Legislature, Regular
2-3 Session, 1997, is amended to read as follows:
2-4 Sec. 12. COMPLAINT SYSTEM. (a) Every health maintenance
2-5 organization shall implement [establish] and maintain a complaint
2-6 system to provide reasonable procedures for the resolution of oral
2-7 and written complaints initiated by enrollees or providers
2-8 concerning health care services [an internal system for the
2-9 resolution of complaints], including a process for the notice and
2-10 appeal of complaints.
2-11 (b) The commissioner may adopt reasonable rules as necessary
2-12 or proper to implement and administer this section[. Each health
2-13 maintenance organization shall implement and maintain a system for
2-14 the resolution of complaints as provided by this section].
2-15 (c) [(b)] If a complainant notifies the health maintenance
2-16 organization orally or in writing of a complaint, the health
2-17 maintenance organization, not later than the fifth business day
2-18 after the date of the receipt of the complaint, shall send to the
2-19 complainant a letter acknowledging the date of receipt of the
2-20 complaint that includes a description of the organization's
2-21 complaint procedures and time frames. If the complaint is received
2-22 orally, the health maintenance organization shall also enclose a
2-23 one-page complaint form. The one-page complaint form must
2-24 prominently and clearly state that the complaint form must be
2-25 returned to the health maintenance organization for prompt
2-26 resolution of the complaint.
2-27 (d) [(c)] The health maintenance organization shall
3-1 investigate each oral and written complaint received in accordance
3-2 with its own policies and in compliance with this Act.
3-3 (e) [(d)] The total time for acknowledgment, investigation,
3-4 and resolution of the complaint by the health maintenance
3-5 organization may not exceed 30 calendar days after the date the
3-6 health maintenance organization receives the written complaint or
3-7 one-page complaint form from the complainant.
3-8 (f) [(e)] Subsections (c) [(b)] and (e) [(d)] of this
3-9 section do not apply to complaints concerning emergencies or
3-10 denials of continued stays for hospitalization. Investigation and
3-11 resolution of complaints concerning emergencies or denials of
3-12 continued stays for hospitalization shall be concluded in
3-13 accordance with the medical or dental immediacy of the case and may
3-14 not exceed one business day from receipt of the complaint.
3-15 (g) [(f)] After the health maintenance organization has
3-16 investigated a complaint, the health maintenance organization shall
3-17 issue a response letter to the complainant explaining the health
3-18 maintenance organization's resolution of the complaint within the
3-19 time frame set forth in Subsection (e) [(d)] of this section. The
3-20 letter must include a statement of the specific medical and
3-21 contractual reasons for the resolution and the specialization of
3-22 any physician or other provider consulted. [If the resolution is
3-23 to deny services based on an adverse determination of medical
3-24 necessity, the clinical basis used to reach that decision must be
3-25 included.] The response letter must contain a full description of
3-26 the process for appeal, including the time frames for the appeals
3-27 process and the time frames for the final decision on the appeal.
4-1 (h) [(g)] If the complaint is not resolved to the
4-2 satisfaction of the complainant, the health maintenance
4-3 organization shall provide an appeals process that includes the
4-4 right of the complainant either to appear in person before a
4-5 complaint appeal panel where the enrollee normally receives health
4-6 care services, unless another site is agreed to by the complainant,
4-7 or to address a written appeal to the complaint appeal panel. The
4-8 health maintenance organization shall complete the appeals process
4-9 under this section not later than the 30th calendar day after the
4-10 date of the receipt of the written request for appeal.
4-11 (i) [(h)] The health maintenance organization shall send an
4-12 acknowledgment letter to the complainant not later than the fifth
4-13 business day after the date of receipt of the written request for
4-14 appeal.
4-15 (j) [(i)] The health maintenance organization shall appoint
4-16 members to the complaint appeal panel, which shall advise the
4-17 health maintenance organization on the resolution of the dispute.
4-18 The complaint appeal panel shall be composed of equal numbers of
4-19 health maintenance organization staff, physicians or other
4-20 providers, and enrollees. A member of the complaint appeal panel
4-21 may not have been previously involved in the disputed decision.
4-22 The physicians or other providers must have experience in the area
4-23 of care that is in dispute and must be independent of any physician
4-24 or provider who made any prior determination. If specialty care is
4-25 in dispute, the appeal panel must include a [an additional] person
4-26 who is a specialist in the field of care to which the appeal
4-27 relates. The enrollees may not be employees of the health
5-1 maintenance organization.
5-2 (k) [(j)] Not later than the fifth business day before the
5-3 scheduled meeting of the panel, unless the complainant agrees
5-4 otherwise, the health maintenance organization shall provide to the
5-5 complainant or the complainant's designated representative:
5-6 (1) any documentation to be presented to the panel by
5-7 the health maintenance organization staff;
5-8 (2) the specialization of any physicians or providers
5-9 consulted during the investigation; and
5-10 (3) the name and affiliation of each health
5-11 maintenance organization representative on the panel.
5-12 (l) [(k)] The complainant, or designated representative if
5-13 the enrollee is a minor or disabled, is entitled to:
5-14 (1) appear in person before the complaint appeal
5-15 panel;
5-16 (2) present alternative expert testimony; and
5-17 (3) request the presence of and question any person
5-18 responsible for making the prior determination that resulted in the
5-19 appeal.
5-20 (m) [(l)] Investigation and resolution of appeals relating
5-21 to ongoing emergencies or denials of continued stays for
5-22 hospitalization shall be concluded in accordance with the medical
5-23 or dental immediacy of the case but in no event to exceed one
5-24 business day after the complainant's request for appeal. Due to
5-25 the ongoing emergency or continued hospital stay, and at the
5-26 request of the complainant, the health maintenance organization
5-27 shall provide, in lieu of a complaint appeal panel, a review by a
6-1 physician or provider who has not previously reviewed the case and
6-2 is of the same or similar specialty as typically manages the
6-3 medical condition, procedure, or treatment under discussion for
6-4 review of the appeal. The physician or provider reviewing the
6-5 appeal may interview the patient or the patient's designated
6-6 representative and shall render a decision on the appeal. Initial
6-7 notice of the decision may be delivered orally if followed by
6-8 written notice of the determination within three days.
6-9 Investigation and resolution of appeals after emergency care has
6-10 been provided shall be conducted in accordance with the process
6-11 established under this section, including the right to a review by
6-12 an appeal panel.
6-13 (n) [(m)] Notice of the final decision of the health
6-14 maintenance organization on the appeal must include a statement of
6-15 the specific medical determination, clinical basis, and contractual
6-16 criteria used to reach the final decision. The notice must also
6-17 include the toll-free telephone number and the address of the Texas
6-18 Department of Insurance.
6-19 (o) [(n)] The health maintenance organization shall maintain
6-20 a record of each complaint and any complaint proceeding and any
6-21 actions taken on a complaint for three years from the date of the
6-22 receipt of the complaint. A complainant is entitled to a copy of
6-23 the record on the applicable complaint and any complaint
6-24 proceeding.
6-25 (p) [(o)] Each health maintenance organization shall
6-26 maintain a complaint and appeal log regarding each complaint.
6-27 (q) [(p)] Each health maintenance organization shall
7-1 maintain documentation on each complaint received and the action
7-2 taken on the complaint until the third anniversary of the date of
7-3 receipt of the complaint. The Texas Department of Insurance may
7-4 review documentation maintained under this subsection during any
7-5 investigation of the health maintenance organization.
7-6 (r) [(q)] The commissioner may examine the complaint system
7-7 for compliance with this Act and may require the health maintenance
7-8 organization to make corrections as considered necessary by the
7-9 commissioner.
7-10 SECTION 3. Section 12A, Texas Health Maintenance
7-11 Organization Act (Article 20A.12A, Vernon's Texas Insurance Code),
7-12 as added by Chapter 163, Acts of the 75th Legislature, Regular
7-13 Session, 1997, is amended to read as follows:
7-14 Sec. 12A. APPEAL [REVIEW] OF ADVERSE DETERMINATIONS.
7-15 (a) [The complaint system required by Section 12 of this Act must
7-16 include:]
7-17 [(1) notification to the enrollee of the enrollee's
7-18 right to appeal an adverse determination to an independent review
7-19 organization;]
7-20 [(2) notification to the enrollee of the procedures
7-21 for appealing an adverse determination to an independent review
7-22 organization; and]
7-23 [(3) notification to an enrollee who has a
7-24 life-threatening condition of the enrollee's right to immediate
7-25 review by an independent review organization and the procedures to
7-26 obtain that review.]
7-27 [(b) The provisions of Article 21.58A, Insurance Code, that
8-1 relate to independent review apply to a health maintenance
8-2 organization under this section as if the health maintenance
8-3 organization were a utilization review agent.]
8-4 [(c)] In this section:
8-5 (1) "Adverse determination" means a determination by a
8-6 health maintenance organization or a utilization review agent that
8-7 the health care services furnished or proposed to be furnished to
8-8 an enrollee are not medically necessary or are not appropriate.
8-9 (2) "Independent review organization" means an
8-10 organization selected as provided under Article 21.58C, Insurance
8-11 Code.
8-12 (3) "Life-threatening condition" has the meaning
8-13 assigned by Section 6, Article 21.58A, Insurance Code.
8-14 (b) A health maintenance organization shall implement and
8-15 maintain an internal appeal system that provides reasonable
8-16 procedures for the resolution of an oral or written appeal
8-17 concerning dissatisfaction or disagreement with an adverse
8-18 determination that is initiated by an enrollee, a person acting on
8-19 behalf of an enrollee, or an enrollee's provider of record. The
8-20 appeal system must include procedures for notification, review, and
8-21 appeal of an adverse determination, as defined by this section, in
8-22 accordance with Article 21.58A, Insurance Code.
8-23 (c) When an enrollee, a person acting on behalf of an
8-24 enrollee, or an enrollee's provider of record expresses orally or
8-25 in writing any dissatisfaction or disagreement with an adverse
8-26 determination, the health maintenance organization or utilization
8-27 review agent shall regard the expression of dissatisfaction or
9-1 disagreement as an appeal of the adverse determination, as defined
9-2 by this section, and shall review and resolve the appeal in
9-3 accordance with Article 21.58A, Insurance Code.
9-4 (d) A health maintenance organization may integrate its
9-5 appeal procedures related to adverse determinations with the
9-6 complaint and appeal procedures established by the health
9-7 maintenance organization under Section 12 of this Act only if the
9-8 procedures related to adverse determinations comply with this
9-9 section and Article 21.58A, Insurance Code.
9-10 SECTION 4. Section 12A, Texas Health Maintenance
9-11 Organization Act (Article 20A.12A, Vernon's Texas Insurance Code),
9-12 as added by Chapter 1026, Acts of the 75th Legislature, Regular
9-13 Session, 1997, is redesignated as Section 12B, Texas Health
9-14 Maintenance Organization Act, to read as follows:
9-15 Sec. 12B [12A]. FILING OF COMPLAINTS WITH THE TEXAS
9-16 DEPARTMENT OF INSURANCE. (a) Any person, including persons who
9-17 have attempted to resolve complaints through a health maintenance
9-18 organization's complaint system process who are dissatisfied with
9-19 the resolution, may report an alleged violation of this Act to the
9-20 Texas Department of Insurance.
9-21 (b) The commissioner shall investigate a complaint against a
9-22 health maintenance organization to determine compliance with this
9-23 Act within 60 days after the Texas Department of Insurance's
9-24 receipt of the complaint and all information necessary for the
9-25 department to determine compliance. The commissioner may extend
9-26 the time necessary to complete an investigation in the event any of
9-27 the following circumstances occur:
10-1 (1) additional information is needed;
10-2 (2) an on-site review is necessary;
10-3 (3) the health maintenance organization, the physician
10-4 or provider, or the complainant does not provide all documentation
10-5 necessary to complete the investigation; or
10-6 (4) other circumstances beyond the control of the
10-7 department occur.
10-8 SECTION 5. Subchapter G, Chapter 3, Insurance Code, is
10-9 amended by adding Article 3.70-3D to read as follows:
10-10 Art. 3.70-3D. INDEPENDENT CONSUMER ASSISTANCE PROGRAM FOR
10-11 HEALTH MAINTENANCE ORGANIZATIONS. (a) The independent consumer
10-12 assistance program for health maintenance organizations is
10-13 established. The Office of Public Insurance Counsel shall
10-14 contract, through a request for proposals, with a nonprofit
10-15 organization to operate the program.
10-16 (b) The nonprofit organization:
10-17 (1) must not be involved in providing health care or
10-18 health care plans and must demonstrate that it has expertise in
10-19 providing direct assistance to consumers with respect to their
10-20 concerns and problems with health maintenance organizations; and
10-21 (2) may establish an advisory committee composed of
10-22 consumers, health care providers, and health care plan
10-23 representatives.
10-24 (c) The program shall:
10-25 (1) assist individual consumers in complaints or
10-26 appeals within the operation of a health maintenance organization,
10-27 including mediations and arbitrations, and outside of the operation
11-1 of a health maintenance organization, including appeals under
11-2 Article 21.58A of this code or in Medicaid and Medicare fair
11-3 hearings;
11-4 (2) supplement and not duplicate the functions
11-5 provided by existing programs or state agencies and shall refer
11-6 consumers to other programs or agencies if appropriate; and
11-7 (3) operate a statewide toll-free assistance telephone
11-8 number.
11-9 (d) The program may:
11-10 (1) serve as a statewide clearinghouse for objective
11-11 consumer information about health care coverage, including options
11-12 for obtaining health care coverage; and
11-13 (2) accept gifts, grants, or donations from any source
11-14 for the purpose of operating the program. The program may charge
11-15 reasonable fees to consumers to support the program.
11-16 SECTION 6. This Act takes effect September 1, 1999, and
11-17 applies only to a complaint expressed or appeal related to an
11-18 adverse determination made on or after that date. A complaint
11-19 expressed or appeal made before that date is governed by the law as
11-20 it existed immediately before the effective date of this Act, and
11-21 that law is continued in effect for that purpose.
11-22 SECTION 7. The importance of this legislation and the
11-23 crowded condition of the calendars in both houses create an
11-24 emergency and an imperative public necessity that the
11-25 constitutional rule requiring bills to be read on three several
11-26 days in each house be suspended, and this rule is hereby suspended.