H.B. No. 1621

	AN ACT
	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 [CERTAIN] OTHER STATE HEALTH OR
	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 [mental
	retardation] services; or
	(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 [A] utilization review agent shall
	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, [OR] CONTINUED HOSPITALIZATION, PRESCRIPTION DRUGS OR
	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 [condition] other than a situation
	described by Subdivision (1) [life-threatening condition], not
	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