SECTION 87.415. Research and Communication with HHS Programs and Agencies that Regulate Health Plans

(a) For a contact involving a consumer receiving services at a state hospital, an LBHA or LMHA, or the AMH program:

(1) OBH staff review all available information about a consumer through inquiry into HHS program systems before referring a contact to the appropriate rights protection officer, who is responsible for receiving complaints from OBH.

(2) Each complaint is investigated to determine if HHS policy was followed by HHS staff and vendors contracted to provide services, including LBHA or LMHA staff. Applicable policies include federal and state law, administrative rules, HHSC contracts, and internal program policies and procedures.

(3) When OBH research through available systems is not sufficient to address the concern or determine whether a complaint can be substantiated, OBH staff request a response from the appropriate rights protection officer, if the consumer has consented to discussion of the contact.

(4) Upon receipt of a response from a rights protection officer, OBH staff review to determine if the concerns have been addressed and if OBH staff can determine whether a complaint can be substantiated. If the response is found to be inadequate by OBH staff or if additional information is required, OBH staff refer the contact back to the rights protection officer for additional review.

(b) For a contact involving a consumer seeking behavioral health services through the consumer's health plan:

(1) OBH staff refer a potential violation of Texas Insurance Code Subchapter F of Chapter 1355, to the appropriate regulatory or oversight agency.

(A) A referral for a consumer with private insurance, the child health plan established under Chapter 62 of the Texas Health and Safety Code or insurance bought through the federal Healthcare.gov Marketplace is made to the Texas Department of Insurance.

(B) A referral for a consumer whose employer offers a self-funded plan is made to the U.S. Department of Labor or, if applicable, the public agency that administers the plan.

(C) A referral for a consumer with Medicaid is made to the HHSC Medicaid & CHIP Services Department.

(D) A referral for a consumer with Medicare is made to the U.S. Department of Health and Human Services' Medicare Ombudsman program.

(E) A referral for a consumer with Tricare is made to the U. S. Department of Defense's Defense Health Agency, Hearing and Claim's Collection Division.

(2) OBH staff attempt to get a consumer to provide a copy of the explanation of benefits or denial letter from the consumer's health plan, which is submitted to the appropriate regulatory or oversight agency.

(3) A contact relating to a potential parity violation is left open until a response is received from the appropriate regulatory or oversight agency.

(4) OBH staff also provide a consumer, the consumer's LAR, or a health care provider information about how to file an appeal or a complaint with the consumer's health plan.

Source Note: The provisions of this §87.415 adopted to be effective January 10, 2019, 44 TexReg 252; amended to be effective December 21, 2022, 47 TexReg 8273