88R7329 RDS-F
 
  By: Plesa, Rose, Price, Perez, Cortez, H.B. No. 4713
      et al.
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to group health benefit plan coverage for early treatment
  of first episode psychosis.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1355.001, Insurance Code, is amended by
  adding Subdivision (5) to read as follows:
               (5)  "First episode psychosis" means the initial onset
  of psychosis or symptoms associated with psychosis, caused by:
                     (A)  medical or neurological conditions;
                     (B)  serious mental illness; or
                     (C)  substance use.
         SECTION 2.  Section 1355.002, Insurance Code, is amended by
  adding Subsection (c) to read as follows:
         (c)  Notwithstanding any other law, Section 1355.016 applies
  to the state Medicaid program, including the Medicaid managed care
  program operated under Chapter 533, Government Code.
         SECTION 3.  Subchapter A, Chapter 1355, Insurance Code, is
  amended by adding Section 1355.016 to read as follows:
         Sec. 1355.016.  REQUIRED COVERAGE FOR EARLY TREATMENT OF
  FIRST EPISODE PSYCHOSIS. (a) A group health benefit plan must
  provide coverage, based on medical necessity, as provided by this
  section to an individual who is younger than 26 years of age and who
  is diagnosed with first episode psychosis.
         (b)  The group health benefit plan must provide coverage
  under this section to the enrollee for all generally recognized
  services prescribed in relation to first episode psychosis.
         (c)  For purposes of Subsection (b), "generally recognized
  services" include:
               (1)  coordinated specialty care for first episode
  psychosis treatment, covering each element of the treatment model
  included in the Recovery After an Initial Schizophrenia Episode
  (RAISE) early treatment program study conducted by the National
  Institute of Mental Health regarding treatment for psychosis, as
  completed July 2017, including:
                     (A)  psychotherapy;
                     (B)  medication management;
                     (C)  case management;
                     (D)  family education and support; and
                     (E)  education and employment support;
               (2)  assertive community treatment as described by the
  Texas Health and Human Services Commission's Texas Resilience and
  Recovery Utilization Management Guidelines: Adult Mental Health
  Services, as updated in April 2017, or a more recently updated
  version adopted by the commissioner; and 
               (3)  peer support services, including:
                     (A)  recovery and wellness support;
                     (B)  mentoring; and 
                     (C)  advocacy. 
         (d)  Only coordinated specialty care or assertive community
  treatment provided by a provider that adheres to the fidelity of the
  applicable treatment model and that has contracted with the Health
  and Human Services Commission to provide coordinated specialty care
  or assertive community treatment for first episode psychosis is
  required to be covered under this section.
         (e)  If a group health benefit plan issuer credentials a
  psychiatrist or licensed clinical leader of a treatment team to
  provide generally recognized services for the treatment of first
  episode psychosis, all members of the treatment team serving under
  the credentialed psychiatrist or licensed clinical leader are
  considered to be credentialed by the health benefit plan issuer.
         (f)  A group health benefit plan issuer shall reimburse a
  provider of coordinated specialty care or assertive community
  treatment for first episode psychosis based on a bundled payment
  model instead of providing reimbursement for each service provided
  to the enrollee by the member of a treatment team.
         (g)  If requested by a group health benefit plan issuer on or
  after March 1, 2029, the department shall contract with an
  independent third party with expertise in analyzing health benefit
  plan premiums and costs to perform an independent analysis of the
  impact of requiring coverage of the team-based treatment models
  described by Subsection (c) on health benefit plan premiums.
  Notwithstanding Subsection (c), if the analysis finds that premiums
  increased annually by more than one percent solely due to requiring
  coverage of a specific treatment model, a group health benefit plan
  is not required to provide coverage under this section for that
  treatment model.
         SECTION 4.  (a) As soon as practicable after the effective
  date of this Act, the Texas Department of Insurance shall convene
  and lead a work group that includes the Health and Human Services
  Commission, providers of generally recognized services described
  by Section 1355.016(c), Insurance Code, as added by this Act, and
  group health benefit plan issuers. The work group shall:
               (1)  develop the criteria to be used to determine
  medical necessity for purposes of coverage under Section 1355.016,
  Insurance Code, as added by this Act; and
               (2)  determine a coding solution that allows for
  coordinated specialty care and assertive community treatment to be
  coded and reimbursed as a bundle of services as required under
  Section 1355.016(f), Insurance Code, as added by this Act.
         (b)  Not later than January 1, 2024, the work group shall
  make recommendations to the department based on its findings.
         (c)  Not later than March 30, 2024, the department shall
  adopt rules:
               (1)  establishing the criteria to be used to determine
  medical necessity under Section 1355.016(a), Insurance Code, as
  added by this Act;
               (2)  creating a coding solution that allows for
  reimbursement based on a bundled payment model for coordinated
  specialty care and assertive community treatment as required by
  Section 1355.016(f), Insurance Code, as added by this Act; and
               (3)  otherwise necessary to implement Section
  1355.016, Insurance Code, as added by this Act.
         SECTION 5.  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 6.  Section 1355.016, Insurance Code, as added by
  this Act, applies only to a health benefit plan that is delivered,
  issued for delivery, or renewed on or after March 30, 2024. A
  health benefit plan delivered, issued for delivery, or renewed
  before March 30, 2024, is governed by the law as it existed
  immediately before that date, and that law is continued in effect
  for that purpose.
         SECTION 7.  This Act takes effect September 1, 2023.