SRC-LBB S.B. 879 78(R)   BILL ANALYSIS


Senate Research Center   S.B. 879
78R5071 AKH-DBy: Whitmire
State Affairs
3/31/2003
As Filed


DIGEST 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), Insurance Code.  However,
there is no provision that requires an HMO to abide by an appeal decision
that favors the enrollee.  As proposed, S.B. 879 amends Chapter 843G to
provide 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

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

SECTION BY SECTION ANALYSIS

SECTION 1.  Amends Chapter 843, Subchapter G, Insurance Code, as effective
June 1, 2003, by adding Section 843.262 as follows: 

Sec. 843.262.  CERTAIN DECISIONS BINDING. Provides that if an enrollee, a
person acting on behalf of an enrollee, or an enrollee's provider of
record appeals an adverse determination as provided under Section 843.261
and the health maintenance organization or utilization review agent, as
applicable, resolves the claim in favor of the enrollee, the decision is
binding on the health maintenance organization.  
SECTION 2.  Effective date:  September 1, 2003. 
            Makes application of this Act prospective to January 1, 2004.