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