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A BILL TO BE ENTITLED
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AN ACT
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relating to the creation of a standard request form for |
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preauthorization of medical care or health care services. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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by adding Chapter 1468 to read as follows: |
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CHAPTER 1468. STANDARD REQUEST FORM FOR PREAUTHORIZATION OF |
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MEDICAL CARE OR HEALTH CARE SERVICES |
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Sec. 1468.001. DEFINITION. In this chapter, |
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"preauthorization" means a determination by an insurer that medical |
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care or health care services proposed to be provided to a patient |
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are medically necessary and appropriate. |
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Sec. 1468.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or a small or large employer group |
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contract or similar coverage document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a fraternal benefit society operating under |
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Chapter 885; |
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(4) a stipulated premium company operating under |
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Chapter 884; |
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(5) a reciprocal exchange operating under Chapter 942; |
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(6) a health maintenance organization operating under |
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Chapter 843; |
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(7) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; or |
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(8) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844. |
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(b) This chapter applies to group health coverage made |
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available by a school district in accordance with Section 22.004, |
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Education Code. |
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(c) Notwithstanding Section 172.014, Local Government Code, |
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or any other law, this chapter applies to health and accident |
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coverage provided by a risk pool created under Chapter 172, Local |
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Government Code. |
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(d) Notwithstanding any provision in Chapter 1551, 1575, |
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1579, or 1601 or any other law, this chapter applies to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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and |
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(4) basic coverage under Chapter 1601. |
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(e) Notwithstanding any other law, this chapter applies to |
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medical benefits provided to an injured employee under a workers' |
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compensation insurance policy or otherwise under Title 5, Labor |
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Code. |
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(f) Notwithstanding any other law, this chapter applies to |
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coverage under: |
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(1) the child health plan program under Chapter 62, |
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Health and Safety Code, or the health benefits plan for children |
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under Chapter 63, Health and Safety Code; and |
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(2) the medical assistance program under Chapter 32, |
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Human Resources Code. |
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Sec. 1468.003. EXCEPTION. This chapter does not apply to: |
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(1) a health benefit plan that provides coverage: |
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(A) only for a specified disease or for another |
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single benefit; |
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(B) only for accidental death or dismemberment; |
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(C) for wages or payments in lieu of wages for a |
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period during which an employee is absent from work because of |
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sickness or injury; |
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(D) as a supplement to a liability insurance |
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policy; |
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(E) for credit insurance; |
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(F) only for dental or vision care; |
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(G) only for hospital expenses; or |
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(H) only for indemnity for hospital confinement; |
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(2) a Medicare supplemental policy as defined by |
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Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss); |
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(3) medical payment insurance coverage provided under |
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a motor vehicle insurance policy; or |
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(4) a long-term care insurance policy, including a |
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nursing home fixed indemnity policy, unless the commissioner |
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determines that the policy provides benefit coverage so |
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comprehensive that the policy is a health benefit plan as described |
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by Section 1468.002. |
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Sec. 1468.004. STANDARD FORM. (a) The commissioner by rule |
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shall: |
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(1) prescribe a single, standard form for requesting |
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preauthorization of medical care or health care services; |
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(2) require a health benefit plan issuer or the agent |
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of the health benefit plan issuer that manages or administers |
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health benefits to use the form for any preauthorization required |
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by the plan of medical care or health care services; |
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(3) require that the department and a health benefit |
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plan issuer or the agent of the health benefit plan issuer that |
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manages or administers health benefits make the form available |
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electronically; and |
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(4) allow a completed form to be submitted |
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electronically by the requesting provider to the health benefit |
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plan issuer or the agent of the health benefit plan issuer that |
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manages or administers health benefits. |
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(b) In prescribing a form under this section, the |
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commissioner shall: |
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(1) limit the form, as printed, to not more than two |
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pages; |
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(2) develop the form with input from the advisory |
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committee on uniform preauthorization forms established under |
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Section 1468.005; and |
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(3) take into consideration: |
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(A) any form for requesting preauthorization of |
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benefits that is widely used in this state or any form currently |
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used by the department; |
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(B) request forms for preauthorization of |
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benefits established by the federal Centers for Medicare and |
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Medicaid Services; and |
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(C) national standards, or draft standards, |
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pertaining to electronic preauthorization of benefits. |
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Sec. 1468.005. ADVISORY COMMITTEE ON UNIFORM |
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PREAUTHORIZATION FORMS. (a) The commissioner shall appoint a |
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committee to advise the commissioner on the technical, operational, |
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and practical aspects of developing the single, standard |
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preauthorization form required under Section 1468.004 for |
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requesting preauthorization of medical care or health care |
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services. |
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(b) The commissioner shall consult the committee with |
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respect to any rule relating to a subject described by Section |
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1468.004 before adopting the rule. |
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(c) The committee shall be composed of an equal number of |
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members from each of the following groups: |
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(1) physicians; |
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(2) other health care providers; |
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(3) hospitals; and |
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(4) medical directors of health benefit plans. |
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(d) A member of the advisory committee serves without |
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compensation. |
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(e) Section 39.003(a) of this code and Chapter 2110, |
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Government Code, do not apply to the advisory committee. |
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Sec. 1468.006. FAILURE TO USE OR RESPOND TO STANDARD FORM. |
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If a health benefit plan issuer or the agent of the health benefit |
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plan issuer that manages or administers health benefits fails to |
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use or accept the form prescribed under this chapter or fails to |
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timely respond to a completed form submitted by a requesting |
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provider, the preauthorization of medical care or health care |
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services is considered granted by the health benefit plan. |
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SECTION 2. Not later than January 1, 2014, the commissioner |
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of insurance by rule shall prescribe a standard form under Section |
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1468.006, Insurance Code, as added by this Act. |
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SECTION 3. The change in law made by this Act applies only |
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to a request for preauthorization of medical care or health care |
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services made on or after March 1, 2014. A request for |
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preauthorization of medical care or health care services made |
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before March 1, 2014, under a health benefit plan delivered, issued |
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for delivery, or renewed before that date is governed by the law in |
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effect immediately before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2013. |