86R14017 LED-D
 
  By: Martinez Fischer H.B. No. 4351
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to utilization review of and health benefit plan coverage
  for emergency care.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle E, Title 8, Insurance Code, is amended
  by adding Chapter 1380 to read as follows:
  CHAPTER 1380. COVERAGE FOR EMERGENCY CARE
         Sec. 1380.0001.  DEFINITIONS. In this chapter:
               (1)  "Emergency care" has the meaning assigned by
  Section 4201.002.
               (2)  "Enrollee" means an individual covered by a health
  benefit plan.
               (3)  "Health benefit plan" means a plan to which this
  chapter applies under Section 1380.0002.
               (4)  "Health benefit plan issuer" means an entity
  authorized under this code or another insurance law of this state
  that provides health insurance or health benefits in this state.
               (5)  "Utilization review" has the meaning assigned by
  Section 4201.002.
         Sec. 1380.0002.  APPLICABILITY OF CHAPTER. (a) This
  chapter 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, or an individual or
  group evidence of coverage or similar coverage document that is
  issued by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a health maintenance organization operating under
  Chapter 843;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846;
               (6)  a stipulated premium company operating under
  Chapter 884;
               (7)  a fraternal benefit society operating under
  Chapter 885;
               (8)  a Lloyd's plan operating under Chapter 941; or
               (9)  an exchange operating under Chapter 942.
         (b)  Notwithstanding any other law, this chapter applies to:
               (1)  a small employer health benefit plan subject to
  Chapter 1501, including coverage provided through a health group
  cooperative under Subchapter B of that chapter;
               (2)  a standard health benefit plan issued under
  Chapter 1507;
               (3)  a basic coverage plan under Chapter 1551;
               (4)  a basic plan under Chapter 1575;
               (5)  a primary care coverage plan under Chapter 1579;
               (6)  a plan providing basic coverage under Chapter
  1601;
               (7)  health benefits provided by or through a church
  benefits board under Subchapter I, Chapter 22, Business
  Organizations Code;
               (8)  group health coverage made available by a school
  district in accordance with Section 22.004, Education Code;
               (9)  a managed care program under the state Medicaid
  program, including the Medicaid managed care program operated under
  Chapter 533, Government Code;
               (10)  a managed care program under the child health
  plan program under Chapter 62, Health and Safety Code;
               (11)  a regional or local health care program operated
  under Section 75.104, Health and Safety Code;
               (12)  a self-funded health benefit plan sponsored by a
  professional employer organization under Chapter 91, Labor Code;
               (13)  county employee group health benefits provided
  under Chapter 157, Local Government Code; and
               (14)  health and accident coverage provided by a risk
  pool created under Chapter 172, Local Government Code.
         Sec. 1380.0003.  EMERGENCY CARE. (a)  When prospective,
  concurrent, or retrospective utilization review is being conducted
  for a health benefit plan issuer or the issuer makes a benefit
  determination to determine the medical necessity and
  appropriateness of emergency care, the health benefit plan issuer
  and any utilization review agent acting on the issuer's behalf
  shall comply with this chapter.
         (b)  The issuer:
               (1)  shall provide coverage for emergency care
  necessary to screen and stabilize an enrollee, as determined by the
  health care provider providing the emergency care;
               (2)  may not require prior authorization of emergency
  care; and
               (3)  shall comply with other applicable provisions of
  this code, including Sections 843.252, 843.258, 1271.155,
  1301.0053, 1301.155, 4201.304, and 4201.357, as applicable.
         (c)  Coverage of emergency care may be subject to applicable
  copayments, coinsurance, and deductibles under the health benefit
  plan.
         (d)  Before a health benefit plan issuer retrospectively
  denies coverage for emergency care based on the determination that
  it was not medically necessary or appropriate to provide the care as
  emergency care, the issuer or the utilization review agent acting
  on the issuer's behalf shall review the enrollee's medical record
  regarding the medical condition for which the emergency care was
  provided.  If the issuer or agent requests a record relating to a
  retrospective review of emergency care, the health care provider
  who provided the emergency care shall submit the record of the
  emergency care to the issuer or agent in accordance with Section
  4201.305.
         (e)  Notwithstanding Section 4201.152, a board-certified
  physician licensed in this state must complete a retrospective
  review of emergency care for a health benefit plan issuer.
         (f)  The process for an appeal of a determination subject to
  this section must comply with Section 4201.357.
         SECTION 2.  Section 1380.0003, 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 January 1, 2020. A
  health benefit plan delivered, issued for delivery, or renewed
  before January 1, 2020, 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 3.  This Act takes effect September 1, 2019.