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A BILL TO BE ENTITLED
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AN ACT
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relating to the preauthorization of medical or health care services |
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by a health maintenance organization or an insurer. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.348, Insurance Code, is amended by |
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amending Subsection (g) and adding Subsection (g-1) to read as |
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follows: |
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(g) Unless a physician or provider has materially |
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misrepresented the proposed health care services or has |
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substantially failed to perform the proposed health care services, |
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if [If] the health maintenance organization has preauthorized |
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health care services, the health maintenance organization may not |
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deny or reduce payment to the physician or provider for those |
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services based on: |
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(1) medical necessity or appropriateness of care; or |
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(2) eligibility or coverage determinations if the |
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proposed health care service is provided to the enrollee before the |
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31st day after the date the health care service was preauthorized |
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and coverage is not terminated during that period [unless the |
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physician or provider has materially misrepresented the proposed |
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health care services or has substantially failed to perform the |
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proposed health care services]. |
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(g-1) Notwithstanding Section 843.347 or any other law, and |
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for the purposes of Subsection (g), a health maintenance |
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organization may not require that the physician or provider request |
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verification. |
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SECTION 2. Section 1301.135, Insurance Code, is amended by |
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amending Subsection (f) and adding Subsection (f-1) to read as |
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follows: |
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(f) Unless a physician or health care provider has |
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materially misrepresented the proposed medical or health care |
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services or has substantially failed to perform the proposed |
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medical or health care services, if [If] an insurer has |
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preauthorized medical care or health care services, the insurer may |
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not deny or reduce payment to the physician or [health care] |
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provider for those services based on: |
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(1) medical necessity or appropriateness of care; or |
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(2) eligibility or coverage determinations if the |
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proposed medical or health care service is provided to the insured |
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before the 31st day after the date the medical or health care |
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service was preauthorized and coverage is not terminated during |
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that period [unless the physician or provider has materially |
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misrepresented the proposed medical or health care services or has |
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substantially failed to perform the proposed medical or health care |
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services]. |
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(f-1) Notwithstanding Section 1301.133 or any other law, |
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and for the purposes of Subsection (f), an insurer may not require |
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that the physician or health care provider request verification. |
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SECTION 3. The changes in law made by this Act apply only to |
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a request for preauthorization of medical care or health care |
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services made on or after January 1, 2024, under a health benefit |
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plan delivered, issued for delivery, or renewed on or after that |
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date. A request for preauthorization of medical care or health care |
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services made before January 1, 2024, or on or after January 1, |
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2024, under a health benefit plan delivered, issued for delivery, |
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or renewed before that date, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2023. |