SECTION 1. Subchapter B,
Chapter 531, Government Code, is amended by adding Sections 531.02251 and
531.02252 to read as follows:
Sec. 531.02251. OMBUDSMAN
FOR BEHAVIORAL HEALTH ACCESS TO CARE. (a) In this section,
"ombudsman" means the individual designated as the ombudsman for
behavioral health access to care.
(b) The executive
commissioner shall designate an ombudsman for behavioral health access to
care.
(c) The ombudsman is
administratively attached to the office of the ombudsman for the
commission.
(d) The ombudsman serves
as a neutral party to help consumers, including consumers who are uninsured
or have public or private health benefit coverage, and behavioral health
care providers navigate and resolve issues related to consumer access to
behavioral health care, including care for mental health conditions and
substance use disorders.
(e) The ombudsman shall:
(1) interact with
consumers and behavioral health care providers with concerns or complaints
to help the consumers and providers resolve behavioral health care access
issues;
(2) identify, track, and
help report potential violations of state or federal rules, regulations, or
statutes concerning the availability of, and terms and conditions of,
benefits for mental health conditions or substance use disorders, including
potential violations related to nonquantitative treatment limitations;
(3) report concerns,
complaints, and potential violations described by Subdivision (2) to the
appropriate regulatory or oversight agency;
(3) provide appropriate referrals to help consumers obtain
behavioral health care;
(4) develop appropriate
points of contact for referrals to other state and federal agencies; and
(5) provide appropriate referrals and information to help
consumers or providers file appeals or complaints with the appropriate
entities, including insurers and other state and federal agencies.
(f) The ombudsman shall participate
on the mental health condition and substance use disorder parity work group
established under Section 531.02252, and provide summary reports of
concerns, complaints, and potential violations described by Subsection
(e)(2) to the work group. This subsection expires September 1, 2021.
(g) The Texas Department
of Insurance shall appoint a liaison to the ombudsman to receive reports of
concerns, complaints, and potential violations described by Subsection
(e)(2) from the ombudsman, consumers, or behavioral health care providers.
Sec. 531.02252. MENTAL
HEALTH CONDITION AND SUBSTANCE USE DISORDER PARITY WORK GROUP. (a) The
commission shall establish and facilitate a mental health condition and
substance use disorder parity work group at the office of mental health
coordination to increase understanding of and compliance with state and
federal rules, regulations, and statutes concerning the availability of,
and terms and conditions of, benefits for mental health conditions and
substance use disorders.
(b) The work group may be
a part of or a subcommittee of the behavioral health advisory committee.
(c) The work group is
composed of:
(1) a representative of:
(A) Medicaid and the
child health plan program;
(B) the office of mental
health coordination;
(C) the Texas Department
of Insurance;
(D) Medicaid managed care organizations;
(E) commercial health benefit plans;
(F) mental health provider organizations;
(G) substance use disorder providers;
(H) mental health consumer advocates;
(I) substance use disorder treatment consumers;
(J) family members of mental health or substance use disorder
treatment consumers;
(K) physicians;
(L) hospitals;
(M) children's mental
health providers;
(N) utilization review
agents; and
(O) independent review
organizations; and
(2) the ombudsman for
behavioral health access to care.
(d) The work group shall
meet at least quarterly.
(e) The work group shall
study and make recommendations on:
(1) increasing compliance
with the rules, regulations, and statutes described by Subsection (a);
(2) strengthening
enforcement and oversight of these laws at state and federal agencies;
(3) improving the
complaint processes relating to potential violations of these laws for
consumers and providers;
(4) ensuring the
commission and the Texas Department of Insurance can accept information
concerns relating to these laws and investigate potential violations based
on de-identified information and data submitted to providers in addition to
individual complaints; and
(5) increasing public and
provider education on these laws.
(f) The work group shall
develop a strategic plan with metrics to serve as a roadmap to increase
compliance with the rules, regulations, and statutes described by
Subsection (a) in this state and to increase education and outreach
relating to these laws.
(g) Not later than
September 1 of each even-numbered year, the work group shall submit a
report to the appropriate committees of the legislature and the appropriate
state agencies on the findings, recommendations, and strategic plan
required by Subsections (e) and (f).
(h) The work group is
abolished and this section expires September 1, 2021.
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SECTION 1. Subchapter B,
Chapter 531, Government Code, is amended by adding Sections 531.02251 and
531.02252 to read as follows:
Sec. 531.02251. OMBUDSMAN
FOR BEHAVIORAL HEALTH ACCESS TO CARE. (a) In this section, "ombudsman"
means the individual designated as the ombudsman for behavioral health
access to care.
(b) The executive
commissioner shall designate an ombudsman for behavioral health access to
care.
(c) The ombudsman is
administratively attached to the office of the ombudsman for the
commission.
(d) The commission may use an alternate title for the ombudsman
in consumer-facing materials if the commission determines that an alternate
title would be beneficial to consumer understanding or access.
(e) The ombudsman serves
as a neutral party to help consumers, including consumers who are uninsured
or have public or private health benefit coverage, and behavioral health
care providers navigate and resolve issues related to consumer access to
behavioral health care, including care for mental health conditions and
substance use disorders.
(f) The ombudsman shall:
(1) interact with
consumers and behavioral health care providers with concerns or complaints
to help the consumers and providers resolve behavioral health care access
issues;
(2) identify, track, and
help report potential violations of state or federal rules, regulations, or
statutes concerning the availability of, and terms and conditions of,
benefits for mental health conditions or substance use disorders, including
potential violations related to quantitative
and nonquantitative treatment limitations;
(3) report concerns,
complaints, and potential violations described by Subdivision (2) to the
appropriate regulatory or oversight agency;
(4) receive and report concerns and complaints relating to
inappropriate care or mental health commitment;
(5) provide appropriate information to help consumers obtain
behavioral health care;
(6) develop appropriate
points of contact for referrals to other state and federal agencies; and
(7) provide appropriate
information to help consumers or providers file appeals or complaints with
the appropriate entities, including insurers and other state and federal
agencies.
(g) The ombudsman shall
participate in the mental health condition and substance use disorder
parity work group established under Section 531.02252 and provide summary
reports of concerns, complaints, and potential violations described by
Subsection (f)(2) to the work group. This subsection expires September 1,
2021.
(h) The Texas Department
of Insurance shall appoint a liaison to the ombudsman to receive reports of
concerns, complaints, and potential violations described by Subsection
(f)(2) from the ombudsman, consumers, or behavioral health care providers.
Sec. 531.02252. MENTAL
HEALTH CONDITION AND SUBSTANCE USE DISORDER PARITY WORK GROUP. (a) The
commission shall establish and facilitate a mental health condition and
substance use disorder parity work group at the office of mental health
coordination to increase understanding of and compliance with state and
federal rules, regulations, and statutes concerning the availability of,
and terms and conditions of, benefits for mental health conditions and
substance use disorders.
(b) The work group may be
a part of or a subcommittee of the behavioral health advisory committee.
(c) The work group is
composed of:
(1) a representative of:
(A) Medicaid and the
child health plan program;
(B) the office of mental
health coordination;
(C) the Texas Department
of Insurance;
(D) a Medicaid managed care organization;
(E) a commercial health benefit plan;
(F) a mental health provider organization;
(G) physicians;
(H) hospitals;
(I) children's mental
health providers;
(J) utilization review
agents; and
(K) independent review
organizations;
(2) a substance use disorder provider or a professional with
co-occurring mental health and substance use disorder expertise;
(3) a mental health consumer;
(4) a mental health consumer advocate;
(5) a substance use disorder treatment consumer;
(6) a substance use disorder treatment consumer advocate;
(7) a family member of a mental health or substance use
disorder treatment consumer; and
(8) the ombudsman for
behavioral health access to care.
(d) The work group shall
meet at least quarterly.
(e) The work group shall
study and make recommendations on:
(1) increasing compliance
with the rules, regulations, and statutes described by Subsection (a);
(2) strengthening
enforcement and oversight of these laws at state and federal agencies;
(3) improving the
complaint processes relating to potential violations of these laws for
consumers and providers;
(4) ensuring the
commission and the Texas Department of Insurance can accept information on
concerns relating to these laws and investigate potential violations based
on de-identified information and data submitted to providers in addition to
individual complaints; and
(5) increasing public and
provider education on these laws.
(f) The work group shall
develop a strategic plan with metrics to serve as a roadmap to increase
compliance with the rules, regulations, and statutes described by
Subsection (a) in this state and to increase education and outreach
relating to these laws.
(g) Not later than
September 1 of each even-numbered year, the work group shall submit a
report to the appropriate committees of the legislature and the appropriate
state agencies on the findings, recommendations, and strategic plan
required by Subsections (e) and (f).
(h) The work group is
abolished and this section expires September 1, 2021.
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SECTION 2. Chapter 1355,
Insurance Code, is amended by adding Subchapter F to read as follows:
SUBCHAPTER F. COVERAGE FOR
MENTAL HEALTH CONDITIONS AND SUBSTANCE USE DISORDERS
Sec. 1355.251.
DEFINITIONS. In this subchapter:
(1) "Financial requirement" includes a requirement
relating to a deductible, copayment, coinsurance, or other out-of-pocket
expense or an annual or lifetime limit.
(2) "Mental health
benefit" means a benefit relating to an item or service for a mental
health condition, as defined under the terms of a health benefit plan and
in accordance with applicable federal and state law.
(3) "Nonquantitative
treatment limitation"
includes:
(A) a medical management
standard limiting or excluding benefits based on medical necessity or
medical appropriateness or based on whether a treatment is experimental or
investigational;
(B) formulary design for
prescription drugs;
(C) network tier design;
(D) a standard for
provider participation in a network, including reimbursement rates;
(E) a method used by a
health benefit plan to determine usual, customary, and reasonable charges;
(F) a step therapy
protocol;
(G) an exclusion based on
failure to complete a course of treatment; and
(H) a restriction based
on geographic location, facility type, provider specialty, and other
criteria that limit the scope or duration of a benefit.
(4) "Substance use
disorder benefit" means a benefit relating to an item or service for a
substance use disorder, as defined under the terms of a health benefit plan
and in accordance with applicable federal and state law.
(5) "Treatment limitation" includes a limit on the
frequency of treatment, number of visits, days of coverage, or other
similar limit on the scope or duration of treatment. The term includes a
nonquantitative treatment limitation.
Sec. 1355.252.
APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health
benefit plan that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual,
group, blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, an individual or group evidence of
coverage, or a similar coverage document, that is offered by:
(1) an insurance company;
(2) a group hospital
service corporation operating under Chapter 842;
(3) a fraternal benefit
society operating under Chapter 885;
(4) a stipulated premium
company operating under Chapter 884;
(5) a health maintenance
organization operating under Chapter 843;
(6) a reciprocal exchange
operating under Chapter 942;
(7) a Lloyd's plan
operating under Chapter 941;
(8) an approved nonprofit
health corporation that holds a certificate of authority under Chapter 844;
or
(9) a multiple employer
welfare arrangement that holds a certificate of authority under Chapter
846.
(b) Notwithstanding
Section 1501.251 or any other law, this subchapter applies to coverage
under a small employer health benefit plan subject to Chapter 1501.
(c) This subchapter
applies to a standard health benefit plan issued under Chapter 1507.
Sec. 1355.253.
EXCEPTIONS. (a) This subchapter does not apply to:
(1) a plan that provides
coverage:
(A) for wages or payments
in lieu of wages for a period during which an employee is absent from work
because of sickness or injury;
(B) as a supplement to a
liability insurance policy;
(C) for credit insurance;
(D) only for dental or
vision care;
(E) only for hospital
expenses; or
(F) only for indemnity
for hospital confinement;
(2) a Medicare
supplemental policy as defined by Section 1882(g)(1), Social Security Act
(42 U.S.C. Section 1395ss(g)(1));
(3) a workers'
compensation insurance policy;
(4) medical payment
insurance coverage provided under a motor vehicle insurance policy; or
(5) a long-term care
policy, including a nursing home fixed indemnity policy, unless the
commissioner determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described by
Section 1355.252.
(b) To the extent that
this section would otherwise require this state to make a payment under 42
U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by
45 C.F.R. Section 155.20, is not required to provide a benefit under this
subchapter that exceeds the specified essential health benefits required
under 42 U.S.C. Section 18022(b).
Sec. 1355.254. REQUIRED
COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A
health benefit plan must provide benefits for mental health conditions and
substance use disorders under the same terms and conditions applicable to benefits for medical or surgical expenses.
(b) Coverage under Subsection
(a) may not impose treatment limitations or
financial requirements on benefits for a mental health condition or
substance use disorder that are generally more restrictive than treatment
limitations or financial requirements
imposed on coverage of benefits for medical or surgical expenses.
Sec. 1355.255.
DEFINITIONS UNDER PLAN.
Sec. 1355.256.
COORDINATION WITH OTHER LAW; INTENT OF LEGISLATURE.
Sec. 1355.257. RULES.
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SECTION 2. Chapter 1355,
Insurance Code, is amended by adding Subchapter F to read as follows:
SUBCHAPTER F. COVERAGE FOR
MENTAL HEALTH CONDITIONS AND SUBSTANCE USE DISORDERS
Sec. 1355.251.
DEFINITIONS. In this subchapter:
(1) "Mental health
benefit" means a benefit relating to an item or service for a mental
health condition, as defined under the terms of a health benefit plan and
in accordance with applicable federal and state law.
(2) "Nonquantitative
treatment limitation" means a limit
on the scope or duration of treatment that is not expressed numerically. The
term includes:
(A) a medical management
standard limiting or excluding benefits based on medical necessity or
medical appropriateness or based on whether a treatment is experimental or
investigational;
(B) formulary design for
prescription drugs;
(C) network tier design;
(D) a standard for
provider participation in a network, including reimbursement rates;
(E) a method used by a
health benefit plan to determine usual, customary, and reasonable charges;
(F) a step therapy
protocol;
(G) an exclusion based on
failure to complete a course of treatment; and
(H) a restriction based
on geographic location, facility type, provider specialty, and other
criteria that limit the scope or duration of a benefit.
(3) "Quantitative treatment limitation" means a
treatment limitation that determines whether, or to what extent, benefits
are provided based on an accumulated amount such as an annual or lifetime
limit on days of coverage or number of visits. The term includes a
deductible, a copayment, coinsurance, or another out-of-pocket expense or
annual or lifetime limit, or another financial requirement.
(4) "Substance use
disorder benefit" means a benefit relating to an item or service for a
substance use disorder, as defined under the terms of a health benefit plan
and in accordance with applicable federal and state law.
Sec. 1355.252.
APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health
benefit plan that provides benefits or
coverage for medical or surgical expenses incurred as a result of a
health condition, accident, or sickness and
for treatment expenses incurred as a result of a mental health condition or
substance use disorder, including an individual, group, blanket, or
franchise insurance policy or insurance agreement, a group hospital service
contract, an individual or group evidence of coverage, or a similar
coverage document, that is offered by:
(1) an insurance company;
(2) a group hospital
service corporation operating under Chapter 842;
(3) a fraternal benefit
society operating under Chapter 885;
(4) a stipulated premium
company operating under Chapter 884;
(5) a health maintenance
organization operating under Chapter 843;
(6) a reciprocal exchange
operating under Chapter 942;
(7) a Lloyd's plan
operating under Chapter 941;
(8) an approved nonprofit
health corporation that holds a certificate of authority under Chapter 844;
or
(9) a multiple employer
welfare arrangement that holds a certificate of authority under Chapter
846.
(b) Notwithstanding
Section 1501.251 or any other law, this subchapter applies to coverage
under a small employer health benefit plan subject to Chapter 1501.
(c) This subchapter
applies to a standard health benefit plan issued under Chapter 1507.
Sec. 1355.253.
EXCEPTIONS. (a) This subchapter does not apply to:
(1) a plan that provides
coverage:
(A) for wages or payments
in lieu of wages for a period during which an employee is absent from work
because of sickness or injury;
(B) as a supplement to a
liability insurance policy;
(C) for credit insurance;
(D) only for dental or
vision care;
(E) only for hospital
expenses;
(F) only for indemnity
for hospital confinement; or
(G) only for accidents;
(2) a Medicare
supplemental policy as defined by Section 1882(g)(1), Social Security Act
(42 U.S.C. Section 1395ss(g)(1));
(3) a workers'
compensation insurance policy;
(4) medical payment
insurance coverage provided under a motor vehicle insurance policy; or
(5) a long-term care
policy, including a nursing home fixed indemnity policy, unless the
commissioner determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described by
Section 1355.252.
(b) To the extent that
this section would otherwise require this state to make a payment under 42
U.S.C. Section 18031(d)(3)(B)(ii), a qualified health plan, as defined by
45 C.F.R. Section 155.20, is not required to provide a benefit under this
subchapter that exceeds the specified essential health benefits required
under 42 U.S.C. Section 18022(b).
Sec. 1355.254. COVERAGE
FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health
benefit plan must provide benefits and
coverage for mental health conditions and substance use disorders
under the same terms and conditions applicable to the plan's medical and surgical benefits and coverage.
(b) Coverage under
Subsection (a) may not impose quantitative
or nonquantitative treatment limitations on benefits for a mental
health condition or substance use disorder that are generally more
restrictive than quantitative or
nonquantitative treatment limitations imposed on coverage of
benefits for medical or surgical expenses.
Sec. 1355.255. COMPLIANCE. The commissioner shall enforce
compliance with Section 1355.254 by evaluating the benefits and coverage
offered by a health benefit plan for quantitative and nonquantitative
treatment limitations in the following categories:
(1) in-network and out-of-network inpatient care;
(2) in-network and out-of-network outpatient care;
(3) emergency care; and
(4) prescription drugs.
Sec. 1355.256.
DEFINITIONS UNDER PLAN.
Sec. 1355.257.
COORDINATION WITH OTHER LAW; INTENT OF LEGISLATURE.
Sec. 1355.258. RULES.
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