By Smithee H.B. No. 3021
76R6535 AJA-F
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; the denial,
1-14 reduction, or termination of a service for reasons not related to
1-15 medical necessity; the way a service is provided; or
1-16 disenrollment decisions, expressed by a complainant. The term does
1-17 not include [A complaint is not] a misunderstanding or a problem
1-18 of misinformation that is resolved promptly by clearing up the
1-19 misunderstanding or supplying the appropriate information to the
1-20 satisfaction of the enrollee and does not include a provider's or
1-21 enrollee's oral or written dissatisfaction or disagreement with an
1-22 adverse determination.
1-23 SECTION 2. Section 12, Texas Health Maintenance Organization
1-24 Act (Article 20A.12, Vernon's Texas Insurance Code), as amended by
2-1 Chapters 163 and 1026, Acts of the 75th Legislature, Regular
2-2 Session, 1997, is amended to read as follows:
2-3 Sec. 12. COMPLAINT SYSTEM. (a) Every health maintenance
2-4 organization shall implement [establish] and maintain a complaint
2-5 system to provide reasonable procedures for the resolution of oral
2-6 and written complaints initiated by enrollees or providers
2-7 concerning health care services [an internal system for the
2-8 resolution of complaints], including a process for the notice and
2-9 appeal of complaints.
2-10 (b) The commissioner may adopt reasonable rules as necessary
2-11 or proper to implement and administer this section. [Each health
2-12 maintenance organization shall implement and maintain a system for
2-13 the resolution of complaints as provided by this section.]
2-14 (c) [(b)] If a complainant notifies the health maintenance
2-15 organization orally or in writing of a complaint, the health
2-16 maintenance organization, not later than the fifth business day
2-17 after the date of the receipt of the complaint, shall send to the
2-18 complainant a letter acknowledging the date of receipt of the
2-19 complaint that includes a description of the organization's
2-20 complaint procedures and time frames. If the complaint is received
2-21 orally, the health maintenance organization shall also enclose a
2-22 one-page complaint form. The one-page complaint form must
2-23 prominently and clearly state that the complaint form must be
2-24 returned to the health maintenance organization for prompt
2-25 resolution of the complaint.
2-26 (d) [(c)] The health maintenance organization shall
2-27 investigate each oral and written complaint received in accordance
3-1 with its own policies and in compliance with this Act.
3-2 (e) [(d)] The total time for acknowledgment, investigation,
3-3 and resolution of the complaint by the health maintenance
3-4 organization may not exceed 30 calendar days after the date the
3-5 health maintenance organization receives the written complaint or
3-6 one-page complaint form from the complainant.
3-7 (f) [(e)] Subsections (c) [(b)] and (e) [(d)] of this
3-8 section do not apply to complaints concerning emergencies or
3-9 denials of continued stays for hospitalization. Investigation and
3-10 resolution of complaints concerning emergencies or denials of
3-11 continued stays for hospitalization shall be concluded in
3-12 accordance with the medical or dental immediacy of the case and may
3-13 not exceed one business day from receipt of the complaint.
3-14 (g) [(f)] After the health maintenance organization has
3-15 investigated a complaint, the health maintenance organization shall
3-16 issue a response letter to the complainant explaining the health
3-17 maintenance organization's resolution of the complaint within the
3-18 time frame set forth in Subsection (e) [(d)] of this section. The
3-19 letter must include a statement of the specific medical and
3-20 contractual reasons for the resolution and the specialization of
3-21 any physician or other provider consulted. [If the resolution is
3-22 to deny services based on an adverse determination of medical
3-23 necessity, the clinical basis used to reach that decision must be
3-24 included.] The response letter must contain a full description of
3-25 the process for appeal, including the time frames for the appeals
3-26 process and the time frames for the final decision on the appeal.
3-27 (h) [(g)] If the complaint is not resolved to the
4-1 satisfaction of the complainant, the health maintenance
4-2 organization shall provide an appeals process that includes the
4-3 right of the complainant either to appear in person before a
4-4 complaint appeal panel where the enrollee normally receives health
4-5 care services, unless another site is agreed to by the complainant,
4-6 or to address a written appeal to the complaint appeal panel. The
4-7 health maintenance organization shall complete the appeals process
4-8 under this section not later than the 30th calendar day after the
4-9 date of the receipt of the written request for appeal.
4-10 (i) [(h)] The health maintenance organization shall send an
4-11 acknowledgment letter to the complainant not later than the fifth
4-12 business day after the date of receipt of the written request for
4-13 appeal.
4-14 (j) [(i)] The health maintenance organization shall appoint
4-15 members to the complaint appeal panel, which shall advise the
4-16 health maintenance organization on the resolution of the dispute.
4-17 The complaint appeal panel shall be composed of equal numbers of
4-18 health maintenance organization staff, physicians or other
4-19 providers, and enrollees. A member of the complaint appeal panel
4-20 may not have been previously involved in the disputed decision.
4-21 The physicians or other providers must have experience in the area
4-22 of care that is in dispute and must be independent of any physician
4-23 or provider who made any prior determination. If specialty care is
4-24 in dispute, the appeal panel must include a [an additional] person
4-25 who is a specialist in the field of care to which the appeal
4-26 relates. The enrollees may not be employees of the health
4-27 maintenance organization.
5-1 (k) [(j)] Not later than the fifth business day before the
5-2 scheduled meeting of the panel, unless the complainant agrees
5-3 otherwise, the health maintenance organization shall provide to the
5-4 complainant or the complainant's designated representative:
5-5 (1) any documentation to be presented to the panel by
5-6 the health maintenance organization staff;
5-7 (2) the specialization of any physicians or providers
5-8 consulted during the investigation; and
5-9 (3) the name and affiliation of each health
5-10 maintenance organization representative on the panel.
5-11 (l) [(k)] The complainant, or designated representative if
5-12 the enrollee is a minor or disabled, is entitled to:
5-13 (1) appear in person before the complaint appeal
5-14 panel;
5-15 (2) present alternative expert testimony; and
5-16 (3) request the presence of and question any person
5-17 responsible for making the prior determination that resulted in the
5-18 appeal.
5-19 (m) [(l)] Investigation and resolution of appeals relating
5-20 to ongoing emergencies or denials of continued stays for
5-21 hospitalization shall be concluded in accordance with the medical
5-22 or dental immediacy of the case but in no event to exceed one
5-23 business day after the complainant's request for appeal. Due to
5-24 the ongoing emergency or continued hospital stay, and at the
5-25 request of the complainant, the health maintenance organization
5-26 shall provide, in lieu of a complaint appeal panel, a review by a
5-27 physician or provider who has not previously reviewed the case and
6-1 is of the same or similar specialty as typically manages the
6-2 medical condition, procedure, or treatment under discussion for
6-3 review of the appeal. The physician or provider reviewing the
6-4 appeal may interview the patient or the patient's designated
6-5 representative and shall render a decision on the appeal. Initial
6-6 notice of the decision may be delivered orally if followed by
6-7 written notice of the determination within three days.
6-8 Investigation and resolution of appeals after emergency care has
6-9 been provided shall be conducted in accordance with the process
6-10 established under this section, including the right to a review by
6-11 an appeal panel.
6-12 (n) [(m)] Notice of the final decision of the health
6-13 maintenance organization on the appeal must include a statement of
6-14 the specific medical determination, clinical basis, and contractual
6-15 criteria used to reach the final decision. The notice must also
6-16 include the toll-free telephone number and the address of the Texas
6-17 Department of Insurance.
6-18 (o) [(n)] The health maintenance organization shall maintain
6-19 a record of each complaint and any complaint proceeding and any
6-20 actions taken on a complaint for three years from the date of the
6-21 receipt of the complaint. A complainant is entitled to a copy of
6-22 the record on the applicable complaint and any complaint
6-23 proceeding.
6-24 (p) [(o)] Each health maintenance organization shall
6-25 maintain a complaint and appeal log regarding each complaint.
6-26 (q) [(p)] Each health maintenance organization shall
6-27 maintain documentation on each complaint received and the action
7-1 taken on the complaint until the third anniversary of the date of
7-2 receipt of the complaint. The Texas Department of Insurance may
7-3 review documentation maintained under this subsection during any
7-4 investigation of the health maintenance organization.
7-5 (r) [(q)] The commissioner may examine the complaint system
7-6 for compliance with this Act and may require the health maintenance
7-7 organization to make corrections as considered necessary by the
7-8 commissioner.
7-9 SECTION 3. Section 12A, Texas Health Maintenance
7-10 Organization Act (Article 20A.12A, Vernon's Texas Insurance Code),
7-11 as added by Chapter 163, Acts of the 75th Legislature, Regular
7-12 Session, 1997, is amended to read as follows:
7-13 Sec. 12A. APPEAL [REVIEW] OF ADVERSE DETERMINATIONS.
7-14 (a) [The complaint system required by Section 12 of this Act must
7-15 include:]
7-16 [(1) notification to the enrollee of the enrollee's
7-17 right to appeal an adverse determination to an independent review
7-18 organization;]
7-19 [(2) notification to the enrollee of the procedures
7-20 for appealing an adverse determination to an independent review
7-21 organization; and]
7-22 [(3) notification to an enrollee who has a
7-23 life-threatening condition of the enrollee's right to immediate
7-24 review by an independent review organization and the procedures to
7-25 obtain that review.]
7-26 [(b) The provisions of Article 21.58A, Insurance Code, that
7-27 relate to independent review apply to a health maintenance
8-1 organization under this section as if the health maintenance
8-2 organization were a utilization review agent.]
8-3 [(c)] In this section:
8-4 (1) "Adverse determination" means a determination by a
8-5 health maintenance organization or a utilization review agent that
8-6 the health care services furnished or proposed to be furnished to
8-7 an enrollee are not medically necessary.
8-8 (2) "Independent review organization" means an
8-9 organization selected as provided under Article 21.58C, Insurance
8-10 Code.
8-11 (3) "Life-threatening condition" has the meaning
8-12 assigned by Section 6, Article 21.58A, Insurance Code.
8-13 (b) A health maintenance organization shall implement and
8-14 maintain an internal appeal system that provides reasonable
8-15 procedures for the resolution of an oral or written appeal
8-16 concerning dissatisfaction or disagreement with an adverse
8-17 determination that is initiated by an enrollee, a person acting on
8-18 behalf of an enrollee, or an enrollee's provider of record. The
8-19 appeal system must include procedures for notification, review, and
8-20 appeal of an adverse determination in accordance with Article
8-21 21.58A, Insurance Code.
8-22 (c) When an enrollee, a person acting on behalf of an
8-23 enrollee, or an enrollee's provider of record expresses orally or
8-24 in writing any dissatisfaction or disagreement with an adverse
8-25 determination, the health maintenance organization or utilization
8-26 review agent shall regard the expression of dissatisfaction or
8-27 disagreement as an appeal of the adverse determination and shall
9-1 review and resolve the appeal in accordance with Article 21.58A,
9-2 Insurance Code.
9-3 (d) A health maintenance organization may integrate its
9-4 appeal procedures related to adverse determinations with the
9-5 complaint and appeal procedures established by the health
9-6 maintenance organization under Section 12 of this Act only if the
9-7 procedures related to adverse determinations comply with this
9-8 section and Article 21.58A, Insurance Code.
9-9 SECTION 4. Section 12A, Texas Health Maintenance
9-10 Organization Act (Article 20A.12A, Vernon's Texas Insurance Code),
9-11 as added by Chapter 1026, Acts of the 75th Legislature, Regular
9-12 Session, 1997, is redesignated as Section 12B, Texas Health
9-13 Maintenance Organization Act, to read as follows:
9-14 Sec. 12B [12A]. FILING OF COMPLAINTS WITH TEXAS DEPARTMENT
9-15 OF INSURANCE. (a) Any person, including persons who have
9-16 attempted to resolve complaints through a health maintenance
9-17 organization's complaint system process who are dissatisfied with
9-18 the resolution, may report an alleged violation of this Act to the
9-19 Texas Department of Insurance.
9-20 (b) The commissioner shall investigate a complaint against a
9-21 health maintenance organization to determine compliance with this
9-22 Act within 60 days after the Texas Department of Insurance's
9-23 receipt of the complaint and all information necessary for the
9-24 department to determine compliance. The commissioner may extend
9-25 the time necessary to complete an investigation in the event any of
9-26 the following circumstances occur:
9-27 (1) additional information is needed;
10-1 (2) an on-site review is necessary;
10-2 (3) the health maintenance organization, the physician
10-3 or provider, or the complainant does not provide all documentation
10-4 necessary to complete the investigation; or
10-5 (4) other circumstances beyond the control of the
10-6 department occur.
10-7 SECTION 5. This Act takes effect September 1, 1999, and
10-8 applies only to a complaint expressed or appeal related to an
10-9 adverse determination made on or after that date. A complaint
10-10 expressed or appeal made before that date is governed by the law as
10-11 it existed immediately before the effective date of this Act, and
10-12 that law is continued in effect for that purpose.
10-13 SECTION 6. The importance of this legislation and the
10-14 crowded condition of the calendars in both houses create an
10-15 emergency and an imperative public necessity that the
10-16 constitutional rule requiring bills to be read on three several
10-17 days in each house be suspended, and this rule is hereby suspended.