Bill Text: TX SB860 | 2017-2018 | 85th Legislature | Comm Sub
Bill Title: Relating to access to and benefits for mental health conditions and substance use disorders.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2017-04-12 - Committee report printed and distributed [SB860 Detail]
Download: Texas-2017-SB860-Comm_Sub.html
By: Zaffirini | S.B. No. 860 | |
(In the Senate - Filed February 14, 2017; February 27, 2017, | ||
read first time and referred to Committee on Business & Commerce; | ||
April 12, 2017, reported adversely, with favorable Committee | ||
Substitute by the following vote: Yeas 9, Nays 0; April 12, 2017, | ||
sent to printer.) | ||
COMMITTEE SUBSTITUTE FOR S.B. No. 860 | By: Zaffirini |
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relating to access to and benefits for mental health conditions and | ||
substance use disorders. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter B, Chapter 531, Government Code, is | ||
amended by adding Sections 531.02251 and 531.02252 to read as | ||
follows: | ||
Sec. 531.02251. OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO | ||
CARE. (a) In this section, "ombudsman" means the individual | ||
designated as the ombudsman for behavioral health access to care. | ||
(b) The executive commissioner shall designate an ombudsman | ||
for behavioral health access to care. | ||
(c) The ombudsman is administratively attached to the | ||
office of the ombudsman for the commission. | ||
(d) The commission may use an alternate title for the | ||
ombudsman in consumer-facing materials if the commission | ||
determines that an alternate title would be beneficial to consumer | ||
understanding or access. | ||
(e) The ombudsman serves as a neutral party to help | ||
consumers, including consumers who are uninsured or have public or | ||
private health benefit coverage, and behavioral health care | ||
providers navigate and resolve issues related to consumer access to | ||
behavioral health care, including care for mental health conditions | ||
and substance use disorders. | ||
(f) The ombudsman shall: | ||
(1) interact with consumers and behavioral health care | ||
providers with concerns or complaints to help the consumers and | ||
providers resolve behavioral health care access issues; | ||
(2) identify, track, and help report potential | ||
violations of state or federal rules, regulations, or statutes | ||
concerning the availability of, and terms and conditions of, | ||
benefits for mental health conditions or substance use disorders, | ||
including potential violations related to quantitative and | ||
nonquantitative treatment limitations; | ||
(3) report concerns, complaints, and potential | ||
violations described by Subdivision (2) to the appropriate | ||
regulatory or oversight agency; | ||
(4) receive and report concerns and complaints | ||
relating to inappropriate care or mental health commitment; | ||
(5) provide appropriate information to help consumers | ||
obtain behavioral health care; | ||
(6) develop appropriate points of contact for | ||
referrals to other state and federal agencies; and | ||
(7) provide appropriate information to help consumers | ||
or providers file appeals or complaints with the appropriate | ||
entities, including insurers and other state and federal agencies. | ||
(g) The ombudsman shall participate in the mental health | ||
condition and substance use disorder parity work group established | ||
under Section 531.02252 and provide summary reports of concerns, | ||
complaints, and potential violations described by Subsection | ||
(f)(2) to the work group. This subsection expires September 1, | ||
2021. | ||
(h) The Texas Department of Insurance shall appoint a | ||
liaison to the ombudsman to receive reports of concerns, | ||
complaints, and potential violations described by Subsection | ||
(f)(2) from the ombudsman, consumers, or behavioral health care | ||
providers. | ||
Sec. 531.02252. MENTAL HEALTH CONDITION AND SUBSTANCE USE | ||
DISORDER PARITY WORK GROUP. (a) The commission shall establish | ||
and facilitate a mental health condition and substance use disorder | ||
parity work group at the office of mental health coordination to | ||
increase understanding of and compliance with state and federal | ||
rules, regulations, and statutes concerning the availability of, | ||
and terms and conditions of, benefits for mental health conditions | ||
and substance use disorders. | ||
(b) The work group may be a part of or a subcommittee of the | ||
behavioral health advisory committee. | ||
(c) The work group is composed of: | ||
(1) a representative of: | ||
(A) Medicaid and the child health plan program; | ||
(B) the office of mental health coordination; | ||
(C) the Texas Department of Insurance; | ||
(D) a Medicaid managed care organization; | ||
(E) a commercial health benefit plan; | ||
(F) a mental health provider organization; | ||
(G) physicians; | ||
(H) hospitals; | ||
(I) children's mental health providers; | ||
(J) utilization review agents; and | ||
(K) independent review organizations; | ||
(2) a substance use disorder provider or a | ||
professional with co-occurring mental health and substance use | ||
disorder expertise; | ||
(3) a mental health consumer; | ||
(4) a mental health consumer advocate; | ||
(5) a substance use disorder treatment consumer; | ||
(6) a substance use disorder treatment consumer | ||
advocate; | ||
(7) a family member of a mental health or substance use | ||
disorder treatment consumer; and | ||
(8) the ombudsman for behavioral health access to | ||
care. | ||
(d) The work group shall meet at least quarterly. | ||
(e) The work group shall study and make recommendations on: | ||
(1) increasing compliance with the rules, | ||
regulations, and statutes described by Subsection (a); | ||
(2) strengthening enforcement and oversight of these | ||
laws at state and federal agencies; | ||
(3) improving the complaint processes relating to | ||
potential violations of these laws for consumers and providers; | ||
(4) ensuring the commission and the Texas Department | ||
of Insurance can accept information on concerns relating to these | ||
laws and investigate potential violations based on de-identified | ||
information and data submitted to providers in addition to | ||
individual complaints; and | ||
(5) increasing public and provider education on these | ||
laws. | ||
(f) The work group shall develop a strategic plan with | ||
metrics to serve as a roadmap to increase compliance with the rules, | ||
regulations, and statutes described by Subsection (a) in this state | ||
and to increase education and outreach relating to these laws. | ||
(g) Not later than September 1 of each even-numbered year, | ||
the work group shall submit a report to the appropriate committees | ||
of the legislature and the appropriate state agencies on the | ||
findings, recommendations, and strategic plan required by | ||
Subsections (e) and (f). | ||
(h) The work group is abolished and this section expires | ||
September 1, 2021. | ||
SECTION 2. Chapter 1355, Insurance Code, is amended by | ||
adding Subchapter F to read as follows: | ||
SUBCHAPTER F. COVERAGE FOR MENTAL HEALTH CONDITIONS AND SUBSTANCE | ||
USE DISORDERS | ||
Sec. 1355.251. DEFINITIONS. In this subchapter: | ||
(1) "Mental health benefit" means a benefit relating | ||
to an item or service for a mental health condition, as defined | ||
under the terms of a health benefit plan and in accordance with | ||
applicable federal and state law. | ||
(2) "Nonquantitative treatment limitation" means a | ||
limit on the scope or duration of treatment that is not expressed | ||
numerically. The term includes: | ||
(A) a medical management standard limiting or | ||
excluding benefits based on medical necessity or medical | ||
appropriateness or based on whether a treatment is experimental or | ||
investigational; | ||
(B) formulary design for prescription drugs; | ||
(C) network tier design; | ||
(D) a standard for provider participation in a | ||
network, including reimbursement rates; | ||
(E) a method used by a health benefit plan to | ||
determine usual, customary, and reasonable charges; | ||
(F) a step therapy protocol; | ||
(G) an exclusion based on failure to complete a | ||
course of treatment; and | ||
(H) a restriction based on geographic location, | ||
facility type, provider specialty, and other criteria that limit | ||
the scope or duration of a benefit. | ||
(3) "Quantitative treatment limitation" means a | ||
treatment limitation that determines whether, or to what extent, | ||
benefits are provided based on an accumulated amount such as an | ||
annual or lifetime limit on days of coverage or number of visits. | ||
The term includes a deductible, a copayment, coinsurance, or | ||
another out-of-pocket expense or annual or lifetime limit, or | ||
another financial requirement. | ||
(4) "Substance use disorder benefit" means a benefit | ||
relating to an item or service for a substance use disorder, as | ||
defined under the terms of a health benefit plan and in accordance | ||
with applicable federal and state law. | ||
Sec. 1355.252. APPLICABILITY OF SUBCHAPTER. (a) This | ||
subchapter applies only to a health benefit plan that provides | ||
benefits or coverage for medical or surgical expenses incurred as a | ||
result of a health condition, accident, or sickness and for | ||
treatment expenses incurred as a result of a mental health | ||
condition or substance use disorder, including an individual, | ||
group, blanket, or franchise insurance policy or insurance | ||
agreement, a group hospital service contract, an individual or | ||
group evidence of coverage, or a similar coverage document, that is | ||
offered by: | ||
(1) an insurance company; | ||
(2) a group hospital service corporation operating | ||
under Chapter 842; | ||
(3) a fraternal benefit society operating under | ||
Chapter 885; | ||
(4) a stipulated premium company operating under | ||
Chapter 884; | ||
(5) a health maintenance organization operating under | ||
Chapter 843; | ||
(6) a reciprocal exchange operating under Chapter 942; | ||
(7) a Lloyd's plan operating under Chapter 941; | ||
(8) an approved nonprofit health corporation that | ||
holds a certificate of authority under Chapter 844; or | ||
(9) a multiple employer welfare arrangement that holds | ||
a certificate of authority under Chapter 846. | ||
(b) Notwithstanding Section 1501.251 or any other law, this | ||
subchapter applies to coverage under a small employer health | ||
benefit plan subject to Chapter 1501. | ||
(c) This subchapter applies to a standard health benefit | ||
plan issued under Chapter 1507. | ||
Sec. 1355.253. EXCEPTIONS. (a) This subchapter does not | ||
apply to: | ||
(1) a plan that provides coverage: | ||
(A) for wages or payments in lieu of wages for a | ||
period during which an employee is absent from work because of | ||
sickness or injury; | ||
(B) as a supplement to a liability insurance | ||
policy; | ||
(C) for credit insurance; | ||
(D) only for dental or vision care; | ||
(E) only for hospital expenses; | ||
(F) only for indemnity for hospital confinement; | ||
or | ||
(G) only for accidents; | ||
(2) a Medicare supplemental policy as defined by | ||
Section 1882(g)(1), Social Security Act (42 U.S.C. Section | ||
1395ss(g)(1)); | ||
(3) a workers' compensation insurance policy; | ||
(4) medical payment insurance coverage provided under | ||
a motor vehicle insurance policy; or | ||
(5) a long-term care policy, including a nursing home | ||
fixed indemnity policy, unless the commissioner determines that the | ||
policy provides benefit coverage so comprehensive that the policy | ||
is a health benefit plan as described by Section 1355.252. | ||
(b) To the extent that this section would otherwise require | ||
this state to make a payment under 42 U.S.C. Section | ||
18031(d)(3)(B)(ii), a qualified health plan, as defined by 45 | ||
C.F.R. Section 155.20, is not required to provide a benefit under | ||
this subchapter that exceeds the specified essential health | ||
benefits required under 42 U.S.C. Section 18022(b). | ||
Sec. 1355.254. COVERAGE FOR MENTAL HEALTH CONDITIONS AND | ||
SUBSTANCE USE DISORDERS. (a) A health benefit plan must provide | ||
benefits and coverage for mental health conditions and substance | ||
use disorders under the same terms and conditions applicable to the | ||
plan's medical and surgical benefits and coverage. | ||
(b) Coverage under Subsection (a) may not impose | ||
quantitative or nonquantitative treatment limitations on benefits | ||
for a mental health condition or substance use disorder that are | ||
generally more restrictive than quantitative or nonquantitative | ||
treatment limitations imposed on coverage of benefits for medical | ||
or surgical expenses. | ||
Sec. 1355.255. COMPLIANCE. The commissioner shall enforce | ||
compliance with Section 1355.254 by evaluating the benefits and | ||
coverage offered by a health benefit plan for quantitative and | ||
nonquantitative treatment limitations in the following categories: | ||
(1) in-network and out-of-network inpatient care; | ||
(2) in-network and out-of-network outpatient care; | ||
(3) emergency care; and | ||
(4) prescription drugs. | ||
Sec. 1355.256. DEFINITIONS UNDER PLAN. (a) A health | ||
benefit plan must define a condition to be a mental health condition | ||
or not a mental health condition in a manner consistent with | ||
generally recognized independent standards of medical practice. | ||
(b) A health benefit plan must define a condition to be a | ||
substance use disorder or not a substance use disorder in a manner | ||
consistent with generally recognized independent standards of | ||
medical practice. | ||
Sec. 1355.257. COORDINATION WITH OTHER LAW; INTENT OF | ||
LEGISLATURE. This subchapter supplements Subchapters A and B of | ||
this chapter and Chapter 1368 and the department rules adopted | ||
under those statutes. It is the intent of the legislature that | ||
Subchapter A or B of this chapter or Chapter 1368 or a department | ||
rule adopted under those statutes controls in any circumstance in | ||
which that other law requires: | ||
(1) a benefit that is not required by this subchapter; | ||
or | ||
(2) a more extensive benefit than is required by this | ||
subchapter. | ||
Sec. 1355.258. RULES. The commissioner shall adopt rules | ||
necessary to implement this subchapter. | ||
SECTION 3. (a) The Texas Department of Insurance shall | ||
conduct a study and prepare a report on benefits for medical or | ||
surgical expenses and for mental health conditions and substance | ||
use disorders. | ||
(b) In conducting the study, the department must collect and | ||
compare data from health benefit plan issuers subject to Subchapter | ||
F, Chapter 1355, Insurance Code, as added by this Act, on medical or | ||
surgical benefits and mental health condition or substance use | ||
disorder benefits that are: | ||
(1) subject to prior authorization or utilization | ||
review; | ||
(2) denied as not medically necessary or experimental | ||
or investigational; | ||
(3) internally appealed, including data that | ||
indicates whether the appeal was denied; or | ||
(4) subject to an independent external review, | ||
including data that indicates whether the denial was upheld. | ||
(c) Not later than September 1, 2018, the department shall | ||
report the results of the study and the department's findings. | ||
SECTION 4. (a) The Health and Human Services Commission | ||
shall conduct a study and prepare a report on benefits for medical | ||
or surgical expenses and for mental health conditions and substance | ||
use disorders provided by Medicaid managed care organizations. | ||
(b) In conducting the study, the commission must collect and | ||
compare data from Medicaid managed care organizations on medical or | ||
surgical benefits and mental health condition or substance use | ||
disorder benefits that are: | ||
(1) subject to prior authorization or utilization | ||
review; | ||
(2) denied as not medically necessary or experimental | ||
or investigational; | ||
(3) internally appealed, including data that | ||
indicates whether the appeal was denied; or | ||
(4) subject to an independent external review, | ||
including data that indicates whether the denial was upheld. | ||
(c) Not later than September 1, 2018, the commission shall | ||
report the results of the study and the commission's findings. | ||
SECTION 5. Subchapter F, Chapter 1355, Insurance Code, as | ||
added by this Act, applies only to a health benefit plan delivered, | ||
issued for delivery, or renewed on or after January 1, 2018. A | ||
health benefit plan delivered, issued for delivery, or renewed | ||
before January 1, 2018, 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 6. This Act takes effect September 1, 2017. | ||
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