By: Johnson of Dallas H.B. No. 2035
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to utilization review of emergency care claims under
  health benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 533.005, Government Code, is amended by
  adding Subsection (e) to read as follows:
         (e)  In addition to the requirements under Subsection (a), a
  contract described by that subsection must require the managed care
  organization to comply with Section 541.062, Insurance Code.
         SECTION 2.  Subchapter B, Chapter 541, Insurance Code, is
  amended by adding Section 541.062 to read as follows:
         Sec. 541.062.  EMERGENCY CARE. (a)  In this section,
  "emergency care" has the meanings assigned by Sections 1301.155 and
  4201.002 as applicable.
         (b)  It is an unfair method of competition or an unfair or
  deceptive act or practice in the business of insurance for an
  insurer or an individual or entity acting on behalf of an insurer
  to:
               (1)  violate the requirements of Section 4201.156;
               (2)  deter enrollees from seeking care consistent with
  the prudent layperson standard for emergency care; or
               (3)  engage in a pattern of wrongful denials of claims
  for emergency care.
         (c)  A violation of this section does not create a private
  cause of action under Section 541.151 or Section 541.251.
         SECTION 3.  Section 843.002(7), Insurance Code, is amended
  to read as follows:
               (7)  "Emergency care" means health care services
  provided in a hospital emergency facility, freestanding emergency
  medical care facility, or comparable emergency facility to evaluate
  and stabilize medical conditions of a recent onset and severity,
  including severe pain, regardless of the final diagnosis that is
  given, that would lead a prudent layperson possessing an average
  knowledge of medicine and health to believe that the individual's
  condition, sickness, or injury is of such a nature that failure to
  get immediate medical care could:
                     (A)  place the individual's health in serious
  jeopardy;
                     (B)  result in serious impairment to bodily
  functions;
                     (C)  result in serious dysfunction of a bodily
  organ or part;
                     (D)  result in serious disfigurement; or
                     (E)  for a pregnant woman, result in serious
  jeopardy to the health of the fetus.
         SECTION 4.  Section 1301.155(a), Insurance Code, is amended
  to read as follows:
         (a)  In this section, "emergency care" means health care
  services provided in a hospital emergency facility, freestanding
  emergency medical care facility, or comparable emergency facility
  to evaluate and stabilize a medical condition of a recent onset and
  severity, including severe pain, regardless of the final diagnosis
  that is given, that would lead a prudent layperson possessing an
  average knowledge of medicine and health to believe that the
  person's condition, sickness, or injury is of such a nature that
  failure to get immediate medical care could result in:
               (1)  placing the person's health in serious jeopardy;
               (2)  serious impairment to bodily functions;
               (3)  serious dysfunction of a bodily organ or part;
               (4)  serious disfigurement; or
               (5)  in the case of a pregnant woman, serious jeopardy
  to the health of the fetus.
         SECTION 5.  Section 4201.002(2), Insurance Code, is amended
  to read as follows:
               (2)  "Emergency care" means health care services
  provided in a hospital emergency facility, freestanding emergency
  medical care facility, or comparable emergency facility to evaluate
  and stabilize medical conditions of a recent onset and severity,
  including severe pain, regardless of the final diagnosis that is
  given, that would lead a prudent layperson possessing an average
  knowledge of medicine and health to believe that the individual's
  condition, sickness, or injury is of such a nature that failure to
  get immediate medical care could:
                     (A)  place the individual's health in serious
  jeopardy;
                     (B)  result in serious impairment to bodily
  functions;
                     (C)  result in serious dysfunction of a bodily
  organ or part;
                     (D)  result in serious disfigurement; or
                     (E)  for a pregnant woman, result in serious
  jeopardy to the health of the fetus.
         SECTION 6.  Subchapter D, Chapter 4201, Insurance Code, is
  amended by adding Section 4201.156 to read as follows:
         Sec. 4201.156.  REVIEW PROCEDURES FOR EMERGENCY CARE CLAIMS.  
  (a)  Utilization review of an emergency care claim must be performed
  by a physician:
               (1)  licensed to practice medicine in this state; and
               (2)  board certified in emergency medicine.
         (b)  With respect to an enrollee's medical condition that is
  the basis for an emergency care claim, a utilization review agent:
               (1)  may not make an adverse determination for the
  emergency care claim based, in whole or in part, on the final
  diagnosis that is given, including the classification under a
  Current Procedural Terminology or International Classification of
  Diseases code; and
               (2)  must review the enrollee's medical record before
  making an adverse determination.
         (c)  Nothing in this section may be construed as authorizing
  utilization review of emergency care when otherwise prohibited by
  law.
         SECTION 7.  Sections 541.062 and 4201.156, Insurance Code,
  as added by this Act, apply only to a health benefit plan delivered,
  issued for delivery, or renewed on or after January 1, 2022. A
  health benefit plan delivered, issued for delivery, or renewed
  before January 1, 2022, 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 8.  If before implementing any provision of this Act
  a state agency determines that a waiver or authorization from a
  federal agency is necessary for implementation of that provision,
  the agency affected by the provision shall request the waiver or
  authorization and may delay implementing that provision until the
  waiver or authorization is granted.
         SECTION 9.  This Act takes effect September 1, 2021.