By: Whitmire S.B. No. 879
A BILL TO BE ENTITLED
AN ACT
relating to appeals of adverse determinations made by health
maintenance organizations.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter G, Chapter 843, Insurance Code, as
effective June 1, 2003, is amended by adding Section 843.262 to read
as follows:
Sec. 843.262. CERTAIN DECISIONS BINDING. (a) 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.
(b) After a binding decision in favor of an enrollee
relating to a proposed health care service, the health maintenance
organization shall provide or arrange for the health care service
within a time frame that is appropriate for the treatment of the
medical condition that was the subject of the appeal.
(c) After a binding decision in favor of an enrollee
relating to a health care service already provided, the health
maintenance organization shall pay the cost of the service, if not
already paid by the health maintenance organization, not later than
the 45th day after the date the health maintenance organization
receives notice of the binding decision. A health maintenance
organization that fails to pay the cost of service as required by
this subsection is subject to penalties provided under Section
843.342.
(d) This section applies only to a health care plan of a
political subdivision that is exempt from application of the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
1001 et seq.).
SECTION 2. This Act takes effect September 1, 2003, and
applies only to an adverse determination under an evidence of
coverage that is delivered, issued for delivery, or renewed on or
after January 1, 2004. An adverse determination under an evidence
of coverage that is delivered, issued for delivery, or renewed
before January 1, 2004, is governed by the law as it existed
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.