INTRODUCED
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HOUSE COMMITTEE
SUBSTITUTE
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No
equivalent provision.
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SECTION 1. Section 4201.053,
Insurance Code, is amended to read as follows:
Sec. 4201.053. MEDICAID AND
[CERTAIN] OTHER STATE HEALTH OR MENTAL HEALTH PROGRAMS. Except as
provided by Section 4201.057, this chapter does not apply to a health or
mental health program operated by this state, including:
(1) the state Medicaid
program;
(2) the services program for
children with special health care needs under Chapter 35, Health and Safety
Code;
(3) a program administered
under Title 2, Human Resources Code;
(4) a program of the
Department of State Health Services relating to mental health services;
(5) a program of the Department
of Aging and Disability Services relating to intellectual disability
[mental retardation] services; [or]
(6) a program of the Texas
Department of Criminal Justice;
(7) the child health
program under Chapter 62, Health and Safety Code, or the health benefits
plan for children under Chapter 63, Health and Safety Code;
(8) the Employees
Retirement System of Texas or another entity issuing or administering a
coverage plan under Chapter 1551;
(9) the Teacher
Retirement System of Texas or another entity issuing or administering a
plan under Chapter 1575 or 1579; and
(10) The Texas A&M
University System or The University of Texas System or another entity
issuing or administering coverage under Chapter 1601.
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No
equivalent provision.
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SECTION 2. Section 4201.054,
Insurance Code, is amended by adding Subsection (b) to read as follows:
(b) Sections 4201.304(b),
4201.3555, and 4201.404 do not apply to utilization review of a health care
service provided to a person eligible for workers' compensation benefits
under Title 5, Labor Code.
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SECTION 1. Section 4201.304,
Insurance Code, is amended to read as follows:
Sec. 4201.304. TIME FOR
NOTICE OF ADVERSE DETERMINATION. (a) Subject to Subsection (b), a
[A] utilization review agent shall provide notice of an adverse
determination required by this subchapter as follows:
(1) with respect to a
patient who is hospitalized at the time of the adverse determination,
within one working day by either telephone or electronic transmission to
the provider of record, followed by a letter within three working days
notifying the patient and the provider of record of the adverse
determination;
(2) with respect to a
patient who is not hospitalized at the time of the adverse determination,
within three working days in writing to the provider of record and the
patient; or
(3) within the time
appropriate to the circumstances relating to the delivery of the services
to the patient and to the patient's condition, provided that when denying
poststabilization care subsequent to emergency treatment as requested by a
treating physician or other health care provider, the agent shall provide
the notice to the treating physician or other health care provider not
later than one hour after the time of the request.
(b) A utilization review
agent shall provide notice of an adverse determination for a concurrent
review of health care services not
later than the 30th day before the date on which the health care services will be discontinued.
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SECTION 3. Section 4201.304,
Insurance Code, is amended to read as follows:
Sec. 4201.304. TIME FOR
NOTICE OF ADVERSE DETERMINATION. (a) Subject to Subsection (b), a
[A] utilization review agent shall provide notice of an adverse
determination required by this subchapter as follows:
(1) with respect to a
patient who is hospitalized at the time of the adverse determination,
within one working day by either telephone or electronic transmission to
the provider of record, followed by a letter within three working days
notifying the patient and the provider of record of the adverse
determination;
(2) with respect to a
patient who is not hospitalized at the time of the adverse determination,
within three working days in writing to the provider of record and the
patient; or
(3) within the time
appropriate to the circumstances relating to the delivery of the services
to the patient and to the patient's condition, provided that when denying
poststabilization care subsequent to emergency treatment as requested by a
treating physician or other health care provider, the agent shall provide
the notice to the treating physician or other health care provider not
later than one hour after the time of the request.
(b) A utilization review
agent shall provide notice of an adverse determination for a concurrent
review of the provision of prescription
drugs or intravenous infusions not later than the 30th day before
the date on which the provision of
prescription drugs or intravenous infusions will be discontinued.
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SECTION 2. Subchapter H,
Chapter 4201, Insurance Code, is amended by adding Section 4201.3555 to
read as follows:
Sec. 4201.3555.
CONTINUATION OF CONCURRENT HEALTH CARE SERVICES.
The procedures for
appealing an adverse determination for a concurrent review of health care services must provide that:
(1) coverage or benefits
for the contested health care services,
including prescription drugs, that are the basis of the adverse
determination continues under the enrollee's health insurance policy or
health benefit plan while the appeal is being considered; and
(2) without regard to
whether the adverse determination is upheld on appeal, the payor may not charge an enrollee for the cost
of the contested health care services, including prescription drugs,
received during the period the appeal was considered except for an
applicable copayment, coinsurance, or deductible under the enrollee's
health insurance policy or health benefit plan.
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SECTION 4. Subchapter H,
Chapter 4201, Insurance Code, is amended by adding Section 4201.3555 to
read as follows:
Sec. 4201.3555.
CONTINUATION OF CONCURRENT PROVISION OF PRESCRIPTION DRUGS OR INTRAVENOUS
INFUSIONS.
The procedures for
appealing an adverse determination for a concurrent review of the provision of prescription drugs or
intravenous infusions must provide that:
(1) coverage or benefits
for the contested prescription drugs or
intravenous infusions that are the basis of the adverse
determination continue under the enrollee's health insurance policy or
health benefit plan while the appeal is being considered to the same extent and in the same manner as if
there had been no adverse determination;
(2) without regard to
whether the adverse determination is upheld on appeal, the payor shall cover the contested prescription
drugs or intravenous infusions received during the period the appeal was
considered to the same extent and in the same manner, including the same
benefit level, as if there had been no adverse determination; and
(3) without regard to whether the adverse determination is upheld
on appeal, the payor may not recoup, based on an adverse determination, any
payment made to a physician or health care provider for the continuation of
coverage or benefits under Subdivision (1) or (2).
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SECTION 3. Subchapter I,
Chapter 4201, Insurance Code, is amended by adding Section 4201.404 to read
as follows:
Sec. 4201.404.
CONTINUATION OF CONCURRENT HEALTH CARE SERVICES.
The procedures for an
independent review of an appeal of an adverse determination for a
concurrent review of health care services
must provide that:
(1) coverage or benefits
for the contested health care services,
including prescription drugs, that are the basis of the adverse
determination continues under the enrollee's health insurance policy or
health benefit plan while the review is being considered; and
(2) without regard to
whether the adverse determination is upheld on review, the payor may not charge an enrollee for the cost
of the contested health care services, including prescription drugs,
received during the period the review was considered except for an
applicable copayment, coinsurance, or deductible under the enrollee's
health insurance policy or health benefit plan.
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SECTION 5. Subchapter I,
Chapter 4201, Insurance Code, is amended by adding Section 4201.404 to read
as follows:
Sec. 4201.404.
CONTINUATION OF CONCURRENT PROVISION OF PRESCRIPTION DRUGS OR INTRAVENOUS
INFUSIONS. The procedures for an independent review of an appeal of an
adverse determination for a concurrent review of the provision of prescription drugs or intravenous infusions
must provide that:
(1) coverage or benefits
for the contested prescription drugs or
intravenous infusions that are the basis of the adverse
determination continue under the enrollee's health insurance policy or
health benefit plan while the review is being considered to the same extent and in the same manner as if
there had been no adverse determination;
(2) without regard to
whether the adverse determination is upheld on review, the payor shall cover the contested prescription
drugs or intravenous infusions received during the period the review was
considered to the same extent and in the same manner, including the same
benefit level, as if there had been no adverse determination; and
(3) without regard to whether the adverse determination is upheld
on review, the payor may not recoup, based on an adverse determination, any
payment made to a physician or health care provider for the continuation of
coverage or benefits under Subdivision (1) or (2).
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SECTION 4. This Act applies
only to an adverse determination made in relation to coverage or benefits
under a health insurance policy or health benefit plan delivered, issued
for delivery, or renewed on or after January 1, 2016. An adverse
determination made in relation to coverage or benefits under a policy or
plan delivered, issued for delivery, or renewed before January 1, 2016, 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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SECTION 6. Same as introduced
version.
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SECTION 5. This Act takes
effect September 1, 2015.
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SECTION 7. Same as introduced
version.
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