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A BILL TO BE ENTITLED
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AN ACT
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relating to access to and benefits for mental health conditions and |
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substance use disorders. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter B, Chapter 531, Government Code, is |
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amended by adding Sections 531.02251 and 531.02252 to read as |
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follows: |
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Sec. 531.02251. OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO |
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CARE. (a) In this section, "ombudsman" means the individual |
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designated as the ombudsman for behavioral health access to care. |
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(b) The executive commissioner shall designate an ombudsman |
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for behavioral health access to care. |
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(c) The ombudsman is administratively attached to the |
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office of the ombudsman for the commission. |
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(d) The ombudsman serves as a neutral party to help |
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consumers, including consumers who are uninsured or have public or |
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private health benefit coverage, and behavioral health care |
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providers navigate and resolve issues related to consumer access to |
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behavioral health care, including care for mental health conditions |
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and substance use disorders. |
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(e) The ombudsman shall: |
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(1) interact with consumers and behavioral health care |
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providers with concerns or complaints to help the consumers and |
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providers resolve behavioral health care access issues; |
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(2) identify, track, and help report potential |
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violations of state or federal rules, regulations, or statutes |
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concerning the availability of, and terms and conditions of, |
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benefits for mental health conditions or substance use disorders, |
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including potential violations related to nonquantitative |
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treatment limitations; |
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(3) report concerns, complaints, and potential |
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violations described by Subdivision (2) to the appropriate |
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regulatory or oversight agency; |
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(3) provide appropriate referrals to help consumers |
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obtain behavioral health care; |
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(4) develop appropriate points of contact for |
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referrals to other state and federal agencies; and |
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(5) provide appropriate referrals and information to |
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help consumers or providers file appeals or complaints with the |
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appropriate entities, including insurers and other state and |
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federal agencies. |
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(f) The ombudsman shall participate on the mental health |
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condition and substance use disorder parity work group established |
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under Section 531.02252, and provide summary reports of concerns, |
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complaints, and potential violations described by Subsection |
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(e)(2) to the work group. This subsection expires September 1, |
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2021. |
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(g) The Texas Department of Insurance shall appoint a |
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liaison to the ombudsman to receive reports of concerns, |
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complaints, and potential violations described by Subsection |
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(e)(2) from the ombudsman, consumers, or behavioral health care |
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providers. |
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Sec. 531.02252. MENTAL HEALTH CONDITION AND SUBSTANCE USE |
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DISORDER PARITY WORK GROUP. (a) The commission shall establish and |
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facilitate a mental health condition and substance use disorder |
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parity work group at the office of mental health coordination to |
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increase understanding of and compliance with state and federal |
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rules, regulations, and statutes concerning the availability of, |
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and terms and conditions of, benefits for mental health conditions |
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and substance use disorders. |
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(b) The work group may be a part of or a subcommittee of the |
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behavioral health advisory committee. |
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(c) The work group is composed of: |
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(1) a representative of: |
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(A) Medicaid and the child health plan program; |
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(B) the office of mental health coordination; |
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(C) the Texas Department of Insurance; |
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(D) Medicaid managed care organizations; |
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(E) commercial health benefit plans; |
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(F) mental health provider organizations; |
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(G) substance use disorder providers; |
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(H) mental health consumer advocates; |
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(I) substance use disorder treatment consumers; |
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(J) family members of mental health or substance |
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use disorder treatment consumers; |
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(K) physicians; |
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(L) hospitals; |
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(M) children's mental health providers; |
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(N) utilization review agents; and |
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(O) independent review organizations; and |
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(2) the ombudsman for behavioral health access to |
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care. |
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(d) The work group shall meet at least quarterly. |
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(e) The work group shall study and make recommendations on: |
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(1) increasing compliance with the rules, |
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regulations, and statutes described by Subsection (a); |
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(2) strengthening enforcement and oversight of these |
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laws at state and federal agencies; |
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(3) improving the complaint processes relating to |
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potential violations of these laws for consumers and providers; |
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(4) ensuring the commission and the Texas Department |
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of Insurance can accept information concerns relating to these laws |
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and investigate potential violations based on de-identified |
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information and data submitted to providers in addition to |
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individual complaints; and |
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(5) increasing public and provider education on these |
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laws. |
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(f) The work group shall develop a strategic plan with |
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metrics to serve as a roadmap to increase compliance with the rules, |
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regulations, and statutes described by Subsection (a) in this state |
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and to increase education and outreach relating to these laws. |
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(g) Not later than September 1 of each even-numbered year, |
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the work group shall submit a report to the appropriate committees |
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of the legislature and the appropriate state agencies on the |
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findings, recommendations, and strategic plan required by |
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Subsections (e) and (f). |
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(h) The work group is abolished and this section expires |
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September 1, 2021. |
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SECTION 2. Chapter 1355, Insurance Code, is amended by |
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adding Subchapter F to read as follows: |
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SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE |
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USE DISORDERS |
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Sec. 1355.251. DEFINITIONS. In this subchapter: |
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(1) "Financial requirement" includes a requirement |
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relating to a deductible, copayment, coinsurance, or other |
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out-of-pocket expense or an annual or lifetime limit. |
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(2) "Mental health benefit" means a benefit relating |
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to an item or service for a mental health condition, as defined |
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under the terms of a health benefit plan and in accordance with |
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applicable federal and state law. |
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(3) "Nonquantitative treatment limitation" includes: |
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(A) a medical management standard limiting or |
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excluding benefits based on medical necessity or medical |
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appropriateness or based on whether a treatment is experimental or |
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investigational; |
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(B) formulary design for prescription drugs; |
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(C) network tier design; |
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(D) a standard for provider participation in a |
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network, including reimbursement rates; |
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(E) a method used by a health benefit plan to |
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determine usual, customary, and reasonable charges; |
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(F) a step therapy protocol; |
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(G) an exclusion based on failure to complete a |
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course of treatment; and |
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(H) a restriction based on geographic location, |
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facility type, provider specialty, and other criteria that limit |
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the scope or duration of a benefit. |
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(4) "Substance use disorder benefit" means a benefit |
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relating to an item or service for a substance use disorder, as |
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defined under the terms of a health benefit plan and in accordance |
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with applicable federal and state law. |
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(5) "Treatment limitation" includes a limit on the |
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frequency of treatment, number of visits, days of coverage, or |
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other similar limit on the scope or duration of treatment. The term |
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includes a nonquantitative treatment limitation. |
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Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, an individual or |
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group evidence of coverage, or a similar coverage document, that is |
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offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) a health maintenance organization operating under |
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Chapter 843; |
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(6) a reciprocal exchange operating under Chapter 942; |
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(7) a Lloyd's plan operating under Chapter 941; |
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(8) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; or |
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(9) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846. |
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(b) Notwithstanding Section 1501.251 or any other law, this |
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subchapter applies to coverage under a small employer health |
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benefit plan subject to Chapter 1501. |
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(c) This subchapter applies to a standard health benefit |
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plan issued under Chapter 1507. |
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Sec. 1355.253. EXCEPTIONS. (a) This subchapter does not |
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apply to: |
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(1) a plan that provides coverage: |
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(A) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(B) as a supplement to a liability insurance |
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policy; |
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(C) for credit insurance; |
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(D) only for dental or vision care; |
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(E) only for hospital expenses; or |
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(F) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section |
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1395ss(g)(1)); |
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(3) a workers' compensation insurance policy; |
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(4) medical payment insurance coverage provided under |
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a motor vehicle insurance policy; or |
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(5) a long-term care policy, including a nursing home |
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fixed indemnity policy, unless the commissioner determines that the |
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policy provides benefit coverage so comprehensive that the policy |
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is a health benefit plan as described by Section 1355.252. |
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(b) To the extent that this section would otherwise require |
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this state to make a payment under 42 U.S.C. Section |
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18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 |
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C.F.R. Section 155.20, is not required to provide a benefit under |
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this subchapter that exceeds the specified essential health |
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benefits required under 42 U.S.C. Section 18022(b). |
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Sec. 1355.254. REQUIRED COVERAGE FOR MENTAL HEALTH |
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CONDITIONS AND SUBSTANCE USE DISORDERS. (a) A health benefit plan |
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must provide benefits for mental health conditions and substance |
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use disorders under the same terms and conditions applicable to |
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benefits for medical or surgical expenses. |
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(b) Coverage under Subsection (a) may not impose treatment |
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limitations or financial requirements on benefits for a mental |
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health condition or substance use disorder that are generally more |
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restrictive than treatment limitations or financial requirements |
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imposed on coverage of benefits for medical or surgical expenses. |
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Sec. 1355.255. DEFINITIONS UNDER PLAN. (a) A health |
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benefit plan must define a condition to be a mental health condition |
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or not a mental health condition in a manner consistent with |
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generally recognized independent standards of medical practice. |
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(b) A health benefit plan must define a condition to be a |
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substance use disorder or not a substance use disorder in a manner |
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consistent with generally recognized independent standards of |
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medical practice. |
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Sec. 1355.256. COORDINATION WITH OTHER LAW; INTENT OF |
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LEGISLATURE. This subchapter supplements Subchapters A and B of |
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this chapter and Chapter 1368 and the department rules adopted |
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under those statutes. It is the intent of the legislature that |
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Subchapter A or B of this chapter or Chapter 1368 or the department |
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rules adopted under those statutes controls in any circumstance in |
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which that other law requires: |
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(1) a benefit that is not required by this subchapter; |
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or |
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(2) a more extensive benefit than is required by this |
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subchapter. |
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Sec. 1355.257. RULES. The commissioner shall adopt rules |
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necessary to implement this subchapter. |
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SECTION 3. (a) The Texas Department of Insurance shall |
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conduct a study and prepare a report on benefits for medical or |
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surgical expenses and for mental health conditions and substance |
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use disorders. |
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(b) In conducting the study, the department must collect and |
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compare data from health benefit plan issuers subject to Subchapter |
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F, Chapter 1355, Insurance Code, as added by this Act, on medical or |
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surgical benefits and mental health condition or substance use |
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disorder benefits that are: |
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(1) subject to prior authorization or utilization |
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review; |
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(2) denied as not medically necessary or experimental |
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or investigational; |
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(3) internally appealed, including data that |
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indicates whether the appeal was denied; or |
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(4) subject to an independent external review, |
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including data that indicates whether the denial was upheld. |
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(c) Not later than September 1, 2018, the department shall |
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report the results of the study and the department's findings. |
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SECTION 4. (a) The Health and Human Services Commission |
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shall conduct a study and prepare a report on benefits for medical |
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or surgical expenses and for mental health conditions and substance |
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use disorders provided by Medicaid managed care organizations. |
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(b) In conducting the study, the commission must collect and |
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compare data from Medicaid managed care organizations on medical or |
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surgical benefits and mental health condition or substance use |
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disorder benefits that are: |
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(1) subject to prior authorization or utilization |
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review; |
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(2) denied as not medically necessary or experimental |
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or investigational; |
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(3) internally appealed, including data that |
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indicates whether the appeal was denied; or |
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(4) subject to an independent external review, |
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including data that indicates whether the denial was upheld. |
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(c) Not later than September 1, 2018, the commission shall |
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report the results of the study and the commission's findings. |
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SECTION 5. Subchapter F, Chapter 1355, Insurance Code, as |
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added by this Act, applies only to a health benefit plan delivered, |
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issued for delivery, or renewed on or after January 1, 2018. A |
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health benefit plan delivered, issued for delivery, or renewed |
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before January 1, 2018, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2017. |