Insurers Can Drop Psychosis Treatments If Premiums Rise Over 1%

The text as introduced · 873 words

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.