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No significant fiscal implication to the State is anticipated.
The bill would amend the
Insurance Code relating to notice and appeal of an adverse determination by
utilization review agents.
Based on information provided by the Teacher Retirement System, Employees Retirement System, Texas Department of Insurance, Texas A&M University System Administration, and the University of Texas System Administration, it is assumed that all duties and responsibilities necessary to implement the provisions of the bill could be accomplished within existing resources.
HB 1621 would make changes to Chapter 4201 of the Insurance Code, which regulates Utilization Review Agents (URAs). This legislation would make changes to the procedures for notifying health care patients of a utilization review stemming from an adverse determination. It would also make changes to the appeal process for patients contesting a utilization review determination.
Under the provisions of this bill, if an URA denies a health insurance enrollee prescription drugs or intravenous infusions, which are covered under the enrollee’s insurance policy, that URA must notify that enrollee’s right to an immediate review by an independent review organization. Additionally this notice must explain the procedures that enrollee must take to obtain that review.
As mentioned above this legislation would amend the procedures for appealing an adverse determination by an URA. This means that in addition to a written appeal, HB 1621 would require a procedure to allow for an expedited appeal relating to the denial of prescription drugs or intravenous infusions for which the patient is currently receiving benefits from and is currently covered by that patient’s health insurer. These procedures must include a review by a third-party health care provider who has not previously worked on the case.
Lastly, the new provisions in HB 1621 would not apply to the Child Health Program under Chapter 62 (Health and Safety Code), the Employees Retirement System of Texas (ERS), the Teacher Retirement System of Texas (TRS), The Texas A&M University System or The University of Texas System, or a managed care organization that provides a Medicaid managed care plan under Chapter 533 (Government Code).
This legislation would make it clear that an enrollee is entitled to an immediate appeal to an independent review organization.
The Texas Department of Insurance (TDI) says, “Utilization Review Agents (URAs) are registered or licensed entities that review requests for health care services being provided (concurrent), proposed to be provided (prospective) or already provided (retrospective). URAs determine whether services are medically necessary and appropriate and may also determine if services are experimental and investigational.”
Currently, a URA must provide an insured with notice of an adverse determination relating to that insured’s coverage or benefits under his or her health insurance policy. Additionally, a patient is currently allowed to appeal that determination. However, according to the author’s statement of intent, “During the appeal, the contested treatment is not covered by the insurer, forcing the insured to pay for the treatment out-of-pocket or go without treatment.” HB 1621 aims to address this issue.
We support HB 1621 because if a patient’s insurance policy specifically covers a certain treatment but the URA later determines that the treatment is unnecessary, a patient should be allowed time to contest the decision while the insurer continues to pay for the treatment that it has been covering from the beginning. This legislation aligns with our individual liberty principle and personal responsibility principle.
It should be noted that if the health insurance market was allowed to operate freely legislation like this would be needless because a health insurer would not last in the free market if it was discovered that it cuts coverage benefits to customers on determination of an adverse determination and before those customers can contest the findings.
The Senate chamber sponsor is Senator Seliger.