89R5015 RDS-F
	By: Plesa	H.B. No. 1594

	A BILL TO BE ENTITLED
	AN ACT
	relating to group health benefit plan coverage for early treatment
	of first episode psychosis.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Section 1355.001, Insurance Code, is amended by
	adding Subdivision (5) to read as follows:
	(5)  "First episode psychosis" means the initial onset
	of psychosis or symptoms associated with psychosis, caused by:
	(A)  medical or neurological conditions;
	(B)  serious mental illness; or
	(C)  substance use.
	SECTION 2.  Subchapter A, Chapter 1355, Insurance Code, is
	amended by adding Section 1355.016 to read as follows:
	Sec. 1355.016.  REQUIRED COVERAGE FOR EARLY TREATMENT OF
	FIRST EPISODE PSYCHOSIS. (a) A group health benefit plan must
	provide coverage, based on medical necessity, as provided by this
	section to an individual who is younger than 26 years of age and who
	is diagnosed with first episode psychosis.
	(b)  The group health benefit plan must provide coverage
	under this section to the enrollee for all generally recognized
	services prescribed in relation to first episode psychosis.
	(c)  For purposes of Subsection (b), "generally recognized
	services" include:
	(1)  coordinated specialty care for first episode
	psychosis treatment, covering each element of the treatment model
	included in the Recovery After an Initial Schizophrenia Episode
	(RAISE) early treatment program study conducted by the National
	Institute of Mental Health regarding treatment for psychosis, as
	completed July 2017, including:
	(A)  psychotherapy;
	(B)  medication management;
	(C)  case management;
	(D)  family education and support; and
	(E)  education and employment support;
	(2)  assertive community treatment as described by the
	Texas Health and Human Services Commission's Texas Resilience and
	Recovery Utilization Management Guidelines: Adult Mental Health
	Services, as updated in April 2017, or a more recently updated
	version adopted by the commissioner; and
	(3)  peer support services, including:
	(A)  recovery and wellness support;
	(B)  mentoring; and
	(C)  advocacy.
	(d)  Only coordinated specialty care or assertive community
	treatment provided by a provider that adheres to the fidelity of the
	applicable treatment model and that has contracted with the Health
	and Human Services Commission to provide coordinated specialty care
	or assertive community treatment for first episode psychosis is
	required to be covered under this section.
	(e)  If a group health benefit plan issuer credentials a
	psychiatrist or licensed clinical leader of a treatment team to
	provide generally recognized services for the treatment of first
	episode psychosis, all members of the treatment team serving under
	the credentialed psychiatrist or licensed clinical leader are
	considered to be credentialed by the issuer.
	(f)  A group health benefit plan issuer shall reimburse a
	provider of coordinated specialty care or assertive community
	treatment for first episode psychosis based on a bundled payment
	model instead of providing reimbursement for each service provided
	to the enrollee by the member of a treatment team.
	(g)  If requested by a group health benefit plan issuer on or
	after March 1, 2027, the department shall contract with an
	independent third party with expertise in analyzing health benefit
	plan premiums and costs to perform an independent analysis of the
	impact of requiring coverage of the team-based treatment models
	described by Subsection (c) on health benefit plan premiums.
	Notwithstanding Subsection (c), if the analysis finds that premiums
	increased annually by more than one percent solely due to requiring
	coverage of a specific treatment model, a group health benefit plan
	is not required to provide coverage under this section for that
	treatment model.
	SECTION 3.  (a) As soon as practicable after the effective
	date of this Act, the Texas Department of Insurance shall convene
	and lead a work group that includes the Health and Human Services
	Commission, providers of generally recognized services described
	by Section 1355.016(c), Insurance Code, as added by this Act, and
	group health benefit plan issuers. The work group shall:
	(1)  develop the criteria to be used to determine
	medical necessity for purposes of coverage under Section 1355.016,
	Insurance Code, as added by this Act; and
	(2)  determine a coding solution that allows for
	coordinated specialty care and assertive community treatment to be
	coded and reimbursed as a bundle of services as required under
	Section 1355.016(f), Insurance Code, as added by this Act.
	(b)  Not later than January 1, 2026, the work group shall
	make recommendations to the department based on its findings.
	(c)  Not later than March 30, 2026, the department shall
	adopt rules:
	(1)  establishing the criteria to be used to determine
	medical necessity under Section 1355.016(a), Insurance Code, as
	added by this Act;
	(2)  creating a coding solution that allows for
	reimbursement based on a bundled payment model for coordinated
	specialty care and assertive community treatment as required by
	Section 1355.016(f), Insurance Code, as added by this Act; and
	(3)  otherwise necessary to implement Section
	1355.016, Insurance Code, as added by this Act.
	SECTION 4.  Section 1355.016, Insurance Code, as added by
	this Act, applies only to a health benefit plan that is delivered,
	issued for delivery, or renewed on or after March 30, 2026. A
	health benefit plan delivered, issued for delivery, or renewed
	before March 30, 2026, is governed by the law as it existed
	immediately before that date, and that law is continued in effect
	for that purpose.
	SECTION 5.  This Act takes effect September 1, 2025.