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) 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
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  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[, treatment, and] services provided to or requested on behalf
  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 [if treatment is] provided on an
  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 [DIRECTION OF]
  PHYSICIAN. A utilization review agent shall conduct utilization
  review under the supervision and direction of a physician licensed
  to practice medicine in this [by a] state [licensing agency in the
  United States].
         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 [A]
  denial of requested treatment [must be referred] to:
               (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 [to determine medical necessity].
         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 [or] appropriateness, or the
  experimental or investigational nature[,] of a health care service,
  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; [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; 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; [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; 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 [by a] state [licensing agency in the United
  States].
         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 [by
  a] state [licensing agency in the United States].
         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 [or] appropriateness, or the experimental or
  investigational nature[,] of a health care service, the agent shall
  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 [Notwithstanding Section 4201.152, a] utilization
  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 [Notwithstanding Section
  4202.002, an] independent review organization that uses doctors to
  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 [Notwithstanding Section 4201.152, Insurance Code, a]
  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 [Notwithstanding Section 4202.002, Insurance Code,
  an] independent review organization that uses doctors to perform
  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.
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