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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 prior |
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authorization 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 A, Title 8, Insurance Code, is amended |
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by adding Chapter 1217 to read as follows: |
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CHAPTER 1217. STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF |
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HEALTH CARE SERVICES |
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Sec. 1217.001. DEFINITIONS. In this chapter: |
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(1) "Health benefit plan issuer" means an entity |
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authorized under this code or another insurance law of this state |
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that delivers or issues for delivery a health benefit plan or other |
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coverage that is covered under this chapter as described by Section |
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1217.002. The term includes: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a fraternal benefit society operating under |
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Chapter 885; |
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(D) a stipulated premium company operating under |
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Chapter 884; |
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(E) a reciprocal exchange operating under |
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Chapter 942; |
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(F) a health maintenance organization operating |
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under Chapter 843; |
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(G) a multiple employer welfare arrangement that |
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holds a certificate of authority under Chapter 846; or |
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(H) an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844. |
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(2) "Health care services" includes medical or health |
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care treatments, consultations, procedures, drugs, supplies, |
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imaging and diagnostic services, inpatient and outpatient care, |
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medical devices, and durable medical equipment. The term does not |
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include prescription drugs as defined by Section 551.003, |
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Occupations Code. |
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Sec. 1217.002. 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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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) a Medicaid managed care program operated under |
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Chapter 533, Government Code, or a Medicaid program operated under |
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Chapter 32, Human Resources Code. |
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Sec. 1217.003. 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) only for wages or payments in lieu of wages |
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for a 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, 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 1217.002. |
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Sec. 1217.004. STANDARD FORM. (a) The commissioner by |
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rule shall: |
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(1) prescribe a single, standard form for requesting |
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prior authorization of 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 care services benefits to use the form for any prior |
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authorization required by the plan of health care services; and |
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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 care services benefits make the form |
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available in paper form and electronically on the website of: |
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(A) the department; |
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(B) the health benefit plan issuer; and |
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(C) the agent of the health benefit plan issuer. |
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(b) Not later than the second anniversary of the date |
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national standards for electronic prior authorization of benefits |
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are adopted, a health benefit plan issuer or the agent of the health |
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benefit plan issuer that manages or administers health care |
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services benefits shall exchange prior authorization requests |
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electronically with a physician or health care provider who has |
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electronic capability and who initiates a request electronically. |
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For requests initiated on paper, a health benefit plan issuer or the |
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agent of the health benefit plan issuer that manages or administers |
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health care services benefits shall accept prior authorization |
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requests using the standard paper form developed pursuant to this |
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chapter. |
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(c) In prescribing a form under this section, the |
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commissioner shall: |
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(1) develop the form with input from the advisory |
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committee on uniform prior authorization forms for health care |
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services benefits established under Section 1217.005; and |
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(2) take into consideration: |
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(A) any form for requesting prior authorization |
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of health care services benefits that is widely used in this state |
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or any form currently used by the department; |
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(B) request forms for prior authorization of |
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health care services benefits established by the federal Centers |
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for Medicare and Medicaid Services; and |
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(C) national standards, or draft standards, |
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pertaining to electronic prior authorization of benefits. |
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Sec. 1217.005. ADVISORY COMMITTEE ON UNIFORM PRIOR |
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AUTHORIZATION 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 prior |
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authorization form required under Section 1217.004 for requesting |
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prior authorization of health care services, including: |
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(1) requirements for the health benefit plan issuer or |
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agent of the health benefit plan issuer to acknowledge receipt of |
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the standard form; |
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(2) timelines under which the health benefit plan |
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issuer or agent of the health benefit plan issuer must acknowledge |
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receipt of the standard form; and |
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(3) implications, including administrative penalties, |
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for the failure of a health benefit plan issuer or agent of a health |
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benefit plan issuer to: |
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(A) timely acknowledge receipt of the standard |
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form; or |
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(B) use or accept the form. |
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(b) The commissioner shall consult the advisory committee |
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with respect to any rule relating to a subject described by Section |
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1217.004 before adopting the rule and may consult the committee as |
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needed with respect to a subsequent amendment of an adopted rule. |
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(c) The advisory committee shall be composed of an equal |
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number of members from each of the following groups of |
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stakeholders: |
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(1) physicians; |
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(2) health care providers other than physicians; |
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(3) hospitals; |
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(4) medical representatives of health benefit plans; |
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and |
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(5) Health and Human Services Commission |
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representatives. |
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(d) A physician may not serve on the advisory committee as a |
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physician member under Subsection (c)(1) if the physician is or has |
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been employed by or consults or has consulted for an insurance |
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company. |
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(e) A member of the advisory committee serves without |
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compensation. |
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(f) 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. 1217.006. FAILURE TO PRESCRIBE STANDARD FORM. Nothing |
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in this chapter may be construed as authorizing the commissioner to |
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decline to prescribe the form required by Section 1217.004. |
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Sec. 1217.007. CONSTRUCTION WITH OTHER LAW. Nothing in |
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this chapter may be construed as permitting a health benefit plan |
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issuer or an agent of a health benefit plan issuer to require prior |
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authorization of health care services benefits when otherwise |
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prohibited by law. |
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SECTION 2. Not later than January 1, 2015, the commissioner |
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of insurance by rule shall prescribe a standard form under Section |
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1217.004, 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 prior authorization of health care services made on |
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or after September 1, 2015. A request for prior authorization of |
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health care services made before September 1, 2015, under a health |
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benefit plan delivered, issued for delivery, or renewed before that |
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date is governed by the law in effect immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 4. This Act takes effect September 1, 2013. |