C.S.H.B. 3029 78(R)    BILL ANALYSIS


C.S.H.B. 3029
By: Van Arsdale
Insurance
Committee Report (Substituted)



BACKGROUND AND PURPOSE 

Currently, an enrollee in a health maintenance organization (HMO) may
appeal an adverse determination made by the HMO in accordance with the
provisions of Chapter 843G (Dispute Resolution) of the Insurance Code.
However, there is no provision that requires an HMO to abide by an appeal
decision that favors the enrollee.  C.S.H.B. 3029 specifies that if an
adverse determination is appealed and a decision is rendered in favor of
the enrollee, the decision is binding on the HMO.  

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any
additional rulemaking authority to a state officer, department, agency, or
institution. 

ANALYSIS

C.S.H.B. 3029 amends the Insurance Code to provide that if an adverse
determination is appealed and the health maintenance organization (HMO) or
utilization review resolves the claim in favor of the enrollee, the
decision is binding on the HMO.  The bill requires an HMO to provide or
arrange for the health care service that was the subject of the appeal
within an appropriate time frame.  The bill requires an HMO to pay the
cost of a service that was already provided, not later than the 45th day
after the date the HMO  receives notice of the binding decision.  The bill
provides for penalties if an HMO fails to pay the cost of a service, as
required. 

The provisions of the Act apply only to a health care plan of a political
subdivision that is exempt from application of the Employee Retirement
Income Security Act of 1974. 

EFFECTIVE DATE

This Act takes effect September 1, 2003.

COMPARISON OF ORIGINAL TO SUBSTITUTE

C.S.H.B. 3029 modifies the original by adding requirements relating to the
payment or provision of health care services that are the subject of an
appeal.  The substitute specifies the health care plans to which the
provisions of the Act apply.