Bill Text: TX HB1621 | 2015-2016 | 84th Legislature | Enrolled
Bill Title: Relating to utilization review and notice and appeal of certain adverse determinations by utilization review agents.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Passed) 2015-06-19 - Effective on 9/1/15 [HB1621 Detail]
Download: Texas-2015-HB1621-Enrolled.html
H.B. No. 1621 |
|
||
relating 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 [ |
||
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 [ |
||
|
||
(6) a program of the Texas Department of Criminal | ||
Justice. | ||
(b) Sections 4201.303(c), 4201.304(b), 4201.357(a-1), and | ||
4201.3601 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; | ||
(4) The Texas A&M University System or The University | ||
of Texas System or another entity issuing or administering coverage | ||
under Chapter 1601; and | ||
(5) a managed care organization providing a Medicaid | ||
managed care plan under Chapter 533, Government Code. | ||
SECTION 2. Section 4201.054, Insurance Code, is amended by | ||
adding Subsection (b) to read as follows: | ||
(b) Sections 4201.303(c), 4201.304(b), 4201.357(a-1), and | ||
4201.3601 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 4201.303, Insurance Code, is amended by | ||
adding Subsection (c) to read as follows: | ||
(c) For an enrollee who is denied the provision of | ||
prescription drugs or intravenous infusions for which the patient | ||
is receiving benefits under the health insurance policy, the notice | ||
required by Subsection (a)(4) must include a description of the | ||
enrollee's right to an immediate review by an independent review | ||
organization and of the procedures to obtain that review. | ||
SECTION 4. 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 [ |
||
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 for which the patient | ||
is receiving health benefits under the health insurance policy not | ||
later than the 30th day before the date on which the provision of | ||
prescription drugs or intravenous infusions will be discontinued. | ||
SECTION 5. The heading to Section 4201.357, Insurance Code, | ||
is amended to read as follows: | ||
Sec. 4201.357. EXPEDITED APPEAL FOR DENIAL OF EMERGENCY | ||
CARE, [ |
||
INTRAVENOUS INFUSIONS. | ||
SECTION 6. Section 4201.357, Insurance Code, is amended by | ||
adding Subsection (a-1) to read as follows: | ||
(a-1) The procedures for appealing an adverse determination | ||
must include, in addition to the written appeal and the appeal | ||
described by Subsection (a), a procedure for an expedited appeal of | ||
a denial of prescription drugs or intravenous infusions for which | ||
the patient is receiving benefits under the health insurance | ||
policy. That procedure must include a review by a health care | ||
provider who: | ||
(1) has not previously reviewed the case; and | ||
(2) is of the same or a similar specialty as the health | ||
care provider who would typically manage the medical or dental | ||
condition, procedure, or treatment under review in the appeal. | ||
SECTION 7. Subchapter H, Chapter 4201, Insurance Code, is | ||
amended by adding Section 4201.3601 to read as follows: | ||
Sec. 4201.3601. IMMEDIATE APPEAL TO INDEPENDENT REVIEW | ||
ORGANIZATION FOR DENIAL OF PRESCRIPTION DRUGS OR INTRAVENOUS | ||
INFUSIONS. Notwithstanding any other law, in a circumstance | ||
involving the provision of prescription drugs or intravenous | ||
infusions for which the patient is receiving benefits under the | ||
health insurance policy, the enrollee is: | ||
(1) entitled to an immediate appeal to an independent | ||
review organization as provided by Subchapter I; and | ||
(2) not required to comply with procedures for an | ||
internal review of the utilization review agent's adverse | ||
determination. | ||
SECTION 8. Section 4202.003, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4202.003. REQUIREMENTS REGARDING TIMELINESS OF | ||
DETERMINATION. The standards adopted under Section 4202.002 must | ||
require each independent review organization to make the | ||
organization's determination: | ||
(1) for a life-threatening condition as defined by | ||
Section 4201.002 or the provision of prescription drugs or | ||
intravenous infusions for which the patient is receiving benefits | ||
under the health insurance policy, not later than the earlier of the | ||
third day after the date the organization receives the information | ||
necessary to make the determination or, with respect to: | ||
(A) a review of a health care service provided to | ||
a person with a life-threatening condition eligible for workers' | ||
compensation medical benefits, the eighth day after the date the | ||
organization receives the request that the determination be made; | ||
or | ||
(B) a review of a health care service other than a | ||
service described by Paragraph (A), the third day after the date the | ||
organization receives the request that the determination be made; | ||
or | ||
(2) for a situation [ |
||
described by Subdivision (1) [ |
||
later than the earlier of: | ||
(A) the 15th day after the date the organization | ||
receives the information necessary to make the determination; or | ||
(B) the 20th day after the date the organization | ||
receives the request that the determination be made. | ||
SECTION 9. 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 10. This Act takes effect September 1, 2015. | ||
______________________________ | ______________________________ | |
President of the Senate | Speaker of the House | |
I certify that H.B. No. 1621 was passed by the House on May 5, | ||
2015, by the following vote: Yeas 140, Nays 5, 2 present, not | ||
voting; and that the House concurred in Senate amendments to H.B. | ||
No. 1621 on May 29, 2015, by the following vote: Yeas 142, Nays 3, | ||
2 present, not voting. | ||
______________________________ | ||
Chief Clerk of the House | ||
I certify that H.B. No. 1621 was passed by the Senate, with | ||
amendments, on May 27, 2015, by the following vote: Yeas 31, Nays | ||
0. | ||
______________________________ | ||
Secretary of the Senate | ||
APPROVED: __________________ | ||
Date | ||
__________________ | ||
Governor |