HB1594 - Relating to group health benefit plan coverage for early treatment of first episode psychosis.

  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.