| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to preauthorization requirements for certain medical and |
|
|
health care services and utilization review for certain health |
|
|
benefit plans. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Subchapter J, Chapter 843, Insurance Code, is |
|
|
amended by adding Section 843.3484 to read as follows: |
|
|
Sec. 843.3484. EXEMPTION FROM PREAUTHORIZATION |
|
|
REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH |
|
|
CARE SERVICES. (a) A health maintenance organization that uses a |
|
|
preauthorization process for health care services may not require a |
|
|
physician or provider to obtain preauthorization for a particular |
|
|
health care service if, in the preceding calendar year: |
|
|
(1) the physician or provider submitted not less than |
|
|
five preauthorization requests for the particular health care |
|
|
service; and |
|
|
(2) the health maintenance organization approved not |
|
|
less than 80 percent of the preauthorization requests submitted by |
|
|
the physician or provider for the particular health care service. |
|
|
(b) An exemption from preauthorization requirements under |
|
|
Subsection (a) lasts for one calendar year. |
|
|
(c) Not later than January 30 of each calendar year, a |
|
|
health maintenance organization must provide to a physician or |
|
|
provider who qualifies for an exemption from preauthorization |
|
|
requirements under Subsection (a) a notice that includes: |
|
|
(1) a statement that the physician or provider |
|
|
qualifies for an exemption from preauthorization requirements |
|
|
under Subsection (a); |
|
|
(2) a list of the health care services to which the |
|
|
exemption applies; and |
|
|
(3) a statement that the exemption applies only for |
|
|
the calendar year in which the physician or provider receives the |
|
|
notice. |
|
|
(d) If a physician or provider submits a preauthorization |
|
|
request for a health care service for which the physician or |
|
|
provider qualifies for an exemption from preauthorization |
|
|
requirements under Subsection (a), the health maintenance |
|
|
organization must promptly provide a notice to the physician or |
|
|
provider that includes: |
|
|
(1) the information described by Subsection (c); and |
|
|
(2) a notification of the health maintenance |
|
|
organization payment requirements described by Subsection (e). |
|
|
(e) A health maintenance organization may not deny or reduce |
|
|
payment to a physician or provider for a health care service to |
|
|
which the physician or provider qualifies for an exemption from |
|
|
preauthorization requirements under Subsection (a) based on |
|
|
medical necessity or appropriateness of care. |
|
|
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is |
|
|
amended by adding Section 1301.1354 to read as follows: |
|
|
Sec. 1301.1354. EXEMPTION FROM PREAUTHORIZATION |
|
|
REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING |
|
|
CERTAIN HEALTH CARE SERVICES. (a) An insurer that uses a |
|
|
preauthorization process for medical care or health care services |
|
|
may not require a physician or health care provider to obtain |
|
|
preauthorization for a particular medical or health care service |
|
|
if, in the preceding calendar year: |
|
|
(1) the physician or health care provider submitted |
|
|
not less than five preauthorization requests for the particular |
|
|
medical or health care service; and |
|
|
(2) the insurer approved not less than 80 percent of |
|
|
the preauthorization requests submitted by the physician or health |
|
|
care provider for the particular medical or health care service. |
|
|
(b) An exemption from preauthorization requirements under |
|
|
Subsection (a) lasts for one calendar year. |
|
|
(c) Not later than January 30 of each calendar year, an |
|
|
insurer must provide to a physician or health care provider who |
|
|
qualifies for an exemption from preauthorization requirements |
|
|
under Subsection (a) a notice that includes: |
|
|
(1) a statement that the physician or health care |
|
|
provider qualifies for an exemption from preauthorization |
|
|
requirements under Subsection (a); |
|
|
(2) a list of the medical or health care services to |
|
|
which the exemption applies; and |
|
|
(3) a statement that the exemption applies only for |
|
|
the calendar year in which the physician or health care provider |
|
|
receives the notice. |
|
|
(d) If a physician or health care provider submits a |
|
|
preauthorization request for a medical or health care service for |
|
|
which the physician or health care provider qualifies for an |
|
|
exemption from preauthorization requirements under Subsection (a), |
|
|
the insurer must promptly provide a notice to the physician or |
|
|
health care provider that includes: |
|
|
(1) the information described by Subsection (c); and |
|
|
(2) a notification of the insurer payment requirements |
|
|
described by Subsection (e). |
|
|
(e) An insurer may not deny or reduce payment to a physician |
|
|
or health care provider for a medical or health care service to |
|
|
which the physician or health care provider qualifies for an |
|
|
exemption from preauthorization requirements under Subsection (a) |
|
|
based on medical necessity or appropriateness of care. |
|
|
SECTION 3. Section 4201.206, Insurance Code, is amended to |
|
|
read as follows: |
|
|
Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE |
|
|
ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the |
|
|
notice requirements of Subchapter G, before an adverse |
|
|
determination is issued by a utilization review agent who questions |
|
|
the medical necessity, the appropriateness, or the experimental or |
|
|
investigational nature of a health care service, the agent shall |
|
|
provide the health care provider who ordered, requested, provided, |
|
|
or is to provide the service a reasonable opportunity to discuss |
|
|
with a physician licensed to practice medicine in this state the |
|
|
patient's treatment plan and the clinical basis for the agent's |
|
|
determination. |
|
|
(b) If the health care service described by Subsection (a) |
|
|
was ordered, requested, or provided, or is to be provided by a |
|
|
physician, the opportunity described by that subsection must be |
|
|
with a physician licensed to practice medicine in this state and who |
|
|
has the same or similar specialty as the physician. |
|
|
SECTION 4. The changes in law made by this Act to Chapters |
|
|
843 and 1301, Insurance Code, apply only to a request for |
|
|
preauthorization of medical care or health care services made on or |
|
|
after January 1, 2022. A request for preauthorization of medical |
|
|
care or health care services made before January 1, 2022, 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 5. Section 4201.206, Insurance Code, as amended by |
|
|
this Act, applies only to a utilization review requested on or after |
|
|
the effective date of this Act. A utilization review requested |
|
|
before the effective date of this Act 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, 2021. |