84R13565 SCL-F

By: Klick H.B. No. 3919

A BILL TO BE ENTITLED

AN ACT

relating to prior authorization from a health benefit plan issuer to obtain health care services under the health benefit plan.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 32.072(a), Human Resources Code, is amended to read as follows:

(a) Notwithstanding any other law, a recipient of medical assistance is entitled to:

(1) select an ophthalmologist or therapeutic optometrist who is a medical assistance provider to provide eye health care services, other than surgery, that are within the scope of:

(A) services provided under the medical assistance program; and

(B) the professional specialty practice for which the ophthalmologist or therapeutic optometrist is licensed and credentialed; and

(2) have direct access to the selected ophthalmologist or therapeutic optometrist for the provision of the nonsurgical services without any requirement by the patient or ophthalmologist or therapeutic optometrist to obtain:

(A) a referral from a primary care physician or other gatekeeper or health care coordinator; or

(B) any other prior authorization or precertification.

SECTION 2. Subchapter I, Chapter 843, Insurance Code, is amended by adding Section 843.324 to read as follows:

Sec. 843.324. PRIOR AUTHORIZATION FOR COVERED BENEFIT PROHIBITED. Notwithstanding any other law, a health maintenance organization may not require a physician or provider to obtain prior authorization from the health maintenance organization for the health maintenance organization to pay for a covered benefit provided to an enrollee.

SECTION 3. Chapter 1217, Insurance Code, is amended by adding Section 1217.008 to read as follows:

Sec. 1217.008. PRIOR AUTHORIZATION STUDY. (a) The department shall conduct a study of:

(1) the use and effect of prior authorization in this state from a health benefit plan issuer to pay for a covered benefit for an enrollee; and

(2) the circumstances that give rise to prior authorization from a health benefit plan issuer.

(b) The commissioner shall implement the results of the study by adopting rules regulating, limiting, or prohibiting prior authorization practices.

SECTION 4. Subchapter B, Chapter 1301, Insurance Code, is amended by adding Section 1301.070 to read as follows:

Sec. 1301.070. PRIOR AUTHORIZATION FOR COVERED BENEFIT PROHIBITED. Notwithstanding any other law, an insurer may not require a physician or health care provider to obtain prior authorization from the insurer for the insurer to pay for a covered benefit provided to an enrollee.

SECTION 5. The Texas Department of Insurance shall prepare a report of the results of the study conducted under Section 1217.008, Insurance Code, as added by this Act. Not later than December 1, 2016, the department shall provide the report to the governor, lieutenant governor, speaker of the house of representatives, and chairs of the house and senate standing committees with primary jurisdiction over insurance.

SECTION 6. The changes in law made by this Act apply only to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2016. A health benefit plan delivered, issued for delivery, or renewed before January 1, 2016, is governed by the law in effect immediately before the effective date of this Act, and that law is continued in effect for that purpose.

SECTION 7. This Act takes effect September 1, 2015.