By: Bonnen of Galveston H.B. No. 1621
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relat
  ing to utilization review and notice and appeal of certain
  adverse determinations by utilization review agents.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         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. (a)  Except as provided by Section
  4201.057, this chapter does not apply to:
               (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.
         (b)  Sections 4201.304(b), 4201.3555, and 4201.404 do not
  apply to:
               (1)  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;
               (2)  the Employees Retirement System of Texas or
  another entity issuing or administering a coverage plan under
  Chapter 1551;
               (3)  the Teacher Retirement System of Texas or another
  entity issuing or administering a plan under Chapter 1575 or 1579;
  and
               (4)  The Texas A&M University System or The University
  of Texas System or another entity issuing or administering coverage
  under Chapter 1601.
         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.
         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.
         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).
         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).
         SECTION 6.  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.
         SECTION 7.  This Act takes effect September 1, 2015.