78R5071 AKH-D

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. 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.  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.