Bill Text: TX SB1187 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the regulation of utilization review and independent review for health benefit plan coverage.
Spectrum: Slight Partisan Bill (Republican 3-1)
Status: (Introduced - Dead) 2019-03-07 - Referred to Business & Commerce [SB1187 Detail]
Download: Texas-2019-SB1187-Introduced.html
86R6998 SCL-F | ||
By: Buckingham, et al. | S.B. No. 1187 |
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relating to the regulation of utilization review and independent | ||
review for health benefit plan coverage. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 4201.002(12), Insurance Code, is amended | ||
to read as follows: | ||
(12) "Provider of record" means the physician or other | ||
health care provider with primary responsibility for the health | ||
care[ |
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of an enrollee or the physician or other health care provider that | ||
has provided or has been requested to provide the health care | ||
services to the enrollee. The term includes a health care facility | ||
where the health care services are [ |
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inpatient or outpatient basis. | ||
SECTION 2. Sections 4201.151 and 4201.152, Insurance Code, | ||
are amended to read as follows: | ||
Sec. 4201.151. UTILIZATION REVIEW PLAN. A utilization | ||
review agent's utilization review plan, including reconsideration | ||
and appeal requirements, must be reviewed by a physician licensed | ||
to practice medicine in this state and conducted in accordance with | ||
standards developed with input from appropriate health care | ||
providers and approved by a physician licensed to practice medicine | ||
in this state. | ||
Sec. 4201.152. UTILIZATION REVIEW UNDER [ |
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PHYSICIAN. A utilization review agent shall conduct utilization | ||
review under the supervision and direction of a physician licensed | ||
to practice medicine in this [ |
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SECTION 3. Subchapter D, Chapter 4201, Insurance Code, is | ||
amended by adding Section 4201.1525 to read as follows: | ||
Sec. 4201.1525. UTILIZATION REVIEW BY PHYSICIAN. (a) A | ||
utilization review agent that uses a physician to conduct | ||
utilization review may only use a physician licensed to practice | ||
medicine in this state. | ||
(b) A payor that conducts utilization review on the payor's | ||
own behalf is subject to Subsection (a) as if the payor were a | ||
utilization review agent. | ||
SECTION 4. Section 4201.153(d), Insurance Code, is amended | ||
to read as follows: | ||
(d) Screening criteria must be used to determine only | ||
whether to approve the requested treatment. Before issuing an | ||
adverse determination, a utilization review agent must obtain a | ||
determination of medical necessity by referring a proposed [ |
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denial of requested treatment [ |
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(1) an appropriate physician, dentist, or other health | ||
care provider; or | ||
(2) if the treatment is requested, ordered, or | ||
provided by a physician, a physician licensed to practice medicine | ||
in this state who is of the same or similar specialty as that | ||
physician [ |
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SECTION 5. Sections 4201.155, 4201.206, and 4201.251, | ||
Insurance Code, are amended to read as follows: | ||
Sec. 4201.155. LIMITATION ON NOTICE REQUIREMENTS AND REVIEW | ||
PROCEDURES. (a) A utilization review agent may not establish or | ||
impose a notice requirement or other review procedure that is | ||
contrary to the requirements of the health insurance policy or | ||
health benefit plan. | ||
(b) This section may not be construed to release a health | ||
insurance policy or health benefit plan from full compliance with | ||
this chapter or other applicable law. | ||
Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE | ||
ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the | ||
notice requirements of Subchapter G, before an adverse | ||
determination is issued by a utilization review agent who questions | ||
the medical necessity, the [ |
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experimental or investigational nature[ |
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the agent shall provide the health care provider who ordered, | ||
requested, or provided the service a reasonable opportunity to | ||
discuss with a physician licensed to practice medicine in this | ||
state the patient's treatment plan and the clinical basis for the | ||
agent's determination. | ||
(b) If the health care service described by Subsection (a) | ||
was ordered, requested, or provided by a physician, the opportunity | ||
described by that subsection must be with a physician licensed to | ||
practice medicine in this state who is of the same or similar | ||
specialty as that physician. | ||
Sec. 4201.251. DELEGATION OF UTILIZATION REVIEW. A | ||
utilization review agent may delegate utilization review to | ||
qualified personnel in the hospital or other health care facility | ||
in which the health care services to be reviewed were or are to be | ||
provided. The delegation does not release the agent from the full | ||
responsibility for compliance with this chapter or other applicable | ||
law, including the conduct of those to whom utilization review has | ||
been delegated. | ||
SECTION 6. Sections 4201.252(a) and (b), Insurance Code, | ||
are amended to read as follows: | ||
(a) Personnel employed by or under contract with a | ||
utilization review agent to perform utilization review must be | ||
appropriately trained and qualified and meet the requirements of | ||
this chapter and other applicable law, including licensing | ||
requirements. | ||
(b) Personnel, other than a physician licensed to practice | ||
medicine in this state, who obtain oral or written information | ||
directly from a patient's physician or other health care provider | ||
regarding the patient's specific medical condition, diagnosis, or | ||
treatment options or protocols must be a nurse, physician | ||
assistant, or other health care provider qualified and licensed or | ||
otherwise authorized by law and the appropriate licensing agency in | ||
this state to provide the requested service. | ||
SECTION 7. Section 4201.356, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 4201.356. DECISION BY PHYSICIAN REQUIRED; SPECIALTY | ||
REVIEW. (a) The procedures for appealing an adverse determination | ||
must provide that a physician licensed to practice medicine in this | ||
state makes the decision on the appeal, except as provided by | ||
Subsection (b) or (c). | ||
(b) For a health care service ordered, requested, provided, | ||
or to be provided by a physician, the procedures for appealing an | ||
adverse determination must provide that a physician licensed to | ||
practice medicine in this state who is of the same or similar | ||
specialty as that physician makes the decision on appeal, except as | ||
provided by Subsection (c). | ||
(c) If not later than the 10th working day after the date an | ||
appeal is denied the enrollee's health care provider states in | ||
writing good cause for having a particular type of specialty | ||
provider review the case, a health care provider who 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 consideration for review and who is licensed or | ||
otherwise authorized by the appropriate licensing agency in this | ||
state to manage the medical or dental condition, procedure, or | ||
treatment shall review the decision denying the appeal. The | ||
specialty review must be completed within 15 working days of the | ||
date the health care provider's request for specialty review is | ||
received. | ||
SECTION 8. Sections 4201.357(a), (a-1), and (a-2), | ||
Insurance Code, are amended to read as follows: | ||
(a) The procedures for appealing an adverse determination | ||
must include, in addition to the written appeal, a procedure for an | ||
expedited appeal of a denial of emergency care or a denial of | ||
continued hospitalization. That procedure must include a review by | ||
a health care provider who: | ||
(1) has not previously reviewed the case; [ |
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(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; and | ||
(3) for a review of a health care service: | ||
(A) ordered, requested, or provided by a health | ||
care provider who is not a physician, is licensed or otherwise | ||
authorized by the appropriate licensing agency in this state to | ||
provide the service in this state; or | ||
(B) ordered, requested, or provided by a | ||
physician, is licensed to practice medicine in this state. | ||
(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; [ |
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(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; and | ||
(3) for a review of a health care service: | ||
(A) ordered, requested, or provided by a health | ||
care provider who is not a physician, is licensed or otherwise | ||
authorized by the appropriate licensing agency in this state to | ||
provide the service in this state; or | ||
(B) ordered, requested, or provided by a | ||
physician, is licensed to practice medicine in this state. | ||
(a-2) An adverse determination under Section 1369.0546 is | ||
entitled to an expedited appeal. The physician or, if appropriate, | ||
other health care provider deciding the appeal must consider | ||
atypical diagnoses and the needs of atypical patient populations. | ||
The physician must be licensed to practice medicine in this state | ||
and the health care provider must be licensed or otherwise | ||
authorized by the appropriate licensing agency in this state. | ||
SECTION 9. Section 4201.359, Insurance Code, is amended by | ||
adding Subsection (c) to read as follows: | ||
(c) A physician described by Subsection (b)(2) must comply | ||
with this chapter and other applicable laws and be licensed to | ||
practice medicine in this state. A health care provider described | ||
by Subsection (b)(2) must comply with this chapter and other | ||
applicable laws and be licensed or otherwise authorized by the | ||
appropriate licensing agency in this state. | ||
SECTION 10. Sections 4201.453 and 4201.454, Insurance Code, | ||
are amended to read as follows: | ||
Sec. 4201.453. UTILIZATION REVIEW PLAN. A specialty | ||
utilization review agent's utilization review plan, including | ||
reconsideration and appeal requirements, must be: | ||
(1) reviewed by a health care provider of the | ||
appropriate specialty who is licensed or otherwise authorized to | ||
provide the specialty health care service in this state; and | ||
(2) conducted in accordance with standards developed | ||
with input from a health care provider of the appropriate specialty | ||
who is licensed or otherwise authorized to provide the specialty | ||
health care service in this state. | ||
Sec. 4201.454. UTILIZATION REVIEW UNDER DIRECTION OF | ||
PROVIDER OF SAME SPECIALTY. A specialty utilization review agent | ||
shall conduct utilization review under the direction of a health | ||
care provider who is of the same specialty as the agent and who is | ||
licensed or otherwise authorized to provide the specialty health | ||
care service in this [ |
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SECTION 11. Sections 4201.455(a) and (b), Insurance Code, | ||
are amended to read as follows: | ||
(a) Personnel who are employed by or under contract with a | ||
specialty utilization review agent to perform utilization review | ||
must be appropriately trained and qualified and meet the | ||
requirements of this chapter and other applicable law of this | ||
state, including licensing laws. | ||
(b) Personnel who obtain oral or written information | ||
directly from a physician or other health care provider must be a | ||
nurse, physician assistant, or other health care provider of the | ||
same specialty as the agent and who are licensed or otherwise | ||
authorized to provide the specialty health care service in this [ |
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SECTION 12. Sections 4201.456 and 4201.457, Insurance Code, | ||
are amended to read as follows: | ||
Sec. 4201.456. OPPORTUNITY TO DISCUSS TREATMENT BEFORE | ||
ADVERSE DETERMINATION. Subject to the notice requirements of | ||
Subchapter G, before an adverse determination is issued by a | ||
specialty utilization review agent who questions the medical | ||
necessity, the [ |
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investigational nature[ |
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provide the health care provider who ordered, requested, or | ||
provided the service a reasonable opportunity to discuss the | ||
patient's treatment plan and the clinical basis for the agent's | ||
determination with a health care provider who is: | ||
(1) of the same specialty as the agent; and | ||
(2) licensed or otherwise authorized to provide the | ||
specialty health care service in this state. | ||
Sec. 4201.457. APPEAL DECISIONS. A specialty utilization | ||
review agent shall comply with the requirement that a physician or | ||
other health care provider who makes the decision in an appeal of an | ||
adverse determination must be: | ||
(1) of the same or a similar specialty as the health | ||
care provider who would typically manage the specialty condition, | ||
procedure, or treatment under review in the appeal; and | ||
(2) licensed or otherwise authorized to provide the | ||
health care service in this state. | ||
SECTION 13. Section 4202.002, Insurance Code, is amended by | ||
adding Subsection (b-1) to read as follows: | ||
(b-1) The standards adopted under Subsection (b)(3) must: | ||
(1) ensure that personnel conducting independent | ||
review for a health care service are licensed or otherwise | ||
authorized to provide the same or similar health care service in | ||
this state; and | ||
(2) be consistent with the licensing laws of this | ||
state. | ||
SECTION 14. Subchapter B, Chapter 151, Occupations Code, is | ||
amended by adding Section 151.057 to read as follows: | ||
Sec. 151.057. APPLICATION TO UTILIZATION REVIEW. (a) In | ||
this section: | ||
(1) "Adverse determination" means a determination | ||
that health care services provided or proposed to be provided to an | ||
individual in this state by a physician or at the request or order | ||
of a physician are not medically necessary or are experimental or | ||
investigational. | ||
(2) "Payor" has the meaning assigned by Section | ||
4201.002, Insurance Code. | ||
(3) "Utilization review" has the meaning assigned by | ||
Section 4201.002, Insurance Code, and the term includes a review | ||
of: | ||
(A) a step therapy protocol exception request | ||
under Section 1369.0546, Insurance Code; and | ||
(B) prescription drug benefits under Section | ||
1369.056, Insurance Code. | ||
(4) "Utilization review agent" means: | ||
(A) an entity that conducts utilization review | ||
under Chapter 4201, Insurance Code; | ||
(B) a payor that conducts utilization review on | ||
the payor's own behalf or on behalf of another person or entity; | ||
(C) an independent review organization certified | ||
under Chapter 4202, Insurance Code; or | ||
(D) a workers' compensation health care network | ||
certified under Chapter 1305, Insurance Code. | ||
(b) A person who does the following is considered to be | ||
engaged in the practice of medicine in this state and is subject to | ||
appropriate regulation by the board: | ||
(1) makes on behalf of a utilization review agent or | ||
directs a utilization review agent to make an adverse | ||
determination, including: | ||
(A) an adverse determination made on | ||
reconsideration of a previous adverse determination; | ||
(B) an adverse determination in an independent | ||
review under Subchapter I, Chapter 4201, Insurance Code; | ||
(C) a refusal to provide benefits for a | ||
prescription drug under Section 1369.056, Insurance Code; or | ||
(D) a denial of a step therapy protocol exception | ||
request under Section 1369.0546, Insurance Code; | ||
(2) serves as a medical director of an independent | ||
review organization certified under Chapter 4202, Insurance Code; | ||
(3) reviews or approves a utilization review plan | ||
under Section 4201.151, Insurance Code; | ||
(4) supervises and directs utilization review under | ||
Section 4201.152, Insurance Code; or | ||
(5) discusses a patient's treatment plan and the | ||
clinical basis for an adverse determination before the adverse | ||
determination is issued, as provided by Section 4201.206, Insurance | ||
Code. | ||
(c) For purposes of Subsection (b), a denial of health care | ||
services based on the failure to request prospective or concurrent | ||
review is not considered an adverse determination. | ||
SECTION 15. Section 1305.351(d), Insurance Code, is amended | ||
to read as follows: | ||
(d) A [ |
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review agent or an insurance carrier that uses doctors to perform | ||
reviews of health care services provided under this chapter, | ||
including utilization review, or peer reviews under Section | ||
408.0231(g), Labor Code, may only use doctors licensed to practice | ||
in this state. | ||
SECTION 16. Section 1305.355(d), Insurance Code, is amended | ||
to read as follows: | ||
(d) The department shall assign the review request to an | ||
independent review organization. An [ |
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perform reviews of health care services under this chapter may only | ||
use doctors licensed to practice in this state. | ||
SECTION 17. Section 408.023(h), Labor Code, is amended to | ||
read as follows: | ||
(h) A [ |
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utilization review agent or an insurance carrier that uses doctors | ||
to perform reviews of health care services provided under this | ||
subtitle, including utilization review, may only use doctors | ||
licensed to practice in this state. | ||
SECTION 18. Section 413.031(e-2), Labor Code, is amended to | ||
read as follows: | ||
(e-2) An [ |
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reviews of health care services provided under this title may only | ||
use doctors licensed to practice in this state. | ||
SECTION 19. The change in law made by this Act applies only | ||
to utilization or independent review that was requested on or after | ||
the effective date of this Act. Utilization or independent review | ||
requested before the effective date of this Act 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 20. This Act takes effect September 1, 2019. |