By:  Whitmire                                                     S.B. No. 879
	(In the Senate - Filed March 5, 2003; March 11, 2003, read 
first time and referred to Committee on State Affairs; 
May 12, 2003, reported adversely, with favorable Committee 
Substitute by the following vote:  Yeas 5, Nays 0; May 12, 2003, 
sent to printer.)


COMMITTEE SUBSTITUTE FOR S.B. No. 879                                    By:  Ellis


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.



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