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A BILL TO BE ENTITLED
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AN ACT
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relating to notice and appeal of an adverse determination by |
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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 4201.304, 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 health care |
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services not later than the 30th day before the date on which the |
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health care services will be discontinued. |
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SECTION 2. 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 HEALTH CARE |
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SERVICES. The procedures for appealing an adverse determination |
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for a concurrent review of health care services must provide that: |
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(1) coverage or benefits for the contested health care |
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services, including prescription drugs, that are the basis of the |
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adverse determination continues 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; and |
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(2) without regard to whether the adverse |
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determination is upheld on appeal, the payor may not charge an |
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enrollee for the cost of the contested health care services, |
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including prescription drugs, received during the period the appeal |
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was considered except for an applicable copayment, coinsurance, or |
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deductible under the enrollee's health insurance policy or health |
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benefit plan. |
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SECTION 3. 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 HEALTH CARE |
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SERVICES. The procedures for an independent review of an appeal of |
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an adverse determination for a concurrent review of health care |
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services must provide that: |
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(1) coverage or benefits for the contested health care |
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services, including prescription drugs, that are the basis of the |
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adverse determination continues 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; and |
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(2) without regard to whether the adverse |
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determination is upheld on review, the payor may not charge an |
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enrollee for the cost of the contested health care services, |
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including prescription drugs, received during the period the review |
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was considered except for an applicable copayment, coinsurance, or |
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deductible under the enrollee's health insurance policy or health |
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benefit plan. |
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SECTION 4. 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 5. This Act takes effect September 1, 2015. |