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A BILL TO BE ENTITLED
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AN ACT
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relating to preauthorization by certain health benefit plan issuers |
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of certain covered benefits under the health benefit plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter I, Chapter 843, Insurance Code, is |
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amended by adding Section 843.324 to read as follows: |
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Sec. 843.324. PREAUTHORIZATION OF CERTAIN COVERED |
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BENEFITS; WAIVER. (a) The commissioner by rule shall: |
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(1) specify covered benefits provided to an enrollee |
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under a health care plan for which the health maintenance |
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organization is prohibited from requiring a physician or provider |
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to obtain preauthorization from the health maintenance |
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organization in order for the health maintenance organization to |
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pay for the benefit; and |
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(2) establish a simple procedure under which a |
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physician or provider may obtain a waiver of a health maintenance |
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organization's preauthorization requirement for a covered benefit |
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under circumstances specified by rule. |
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(b) Rules adopted under Subsection (a) must provide that the |
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following covered benefits are not subject to preauthorization or |
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are subject to a waiver of preauthorization requirements: |
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(1) if a physician or provider determines that an |
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enrollee has an immediate need for the covered benefit: |
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(A) durable medical equipment, including |
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crutches and wheelchairs; or |
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(B) diagnostic testing; or |
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(2) another health care service under circumstances |
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that take into account: |
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(A) symptoms displayed by the enrollee; |
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(B) the relationship between the physician or |
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provider and the enrollee, including the length of the |
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relationship; and |
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(C) the professional experience of the physician |
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or provider. |
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SECTION 2. Subchapter B, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.070 to read as follows: |
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Sec. 1301.070. PREAUTHORIZATION OF CERTAIN COVERED |
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BENEFITS; WAIVER. (a) The commissioner by rule shall: |
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(1) specify covered benefits provided to an insured |
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under a preferred provider benefit plan for which the insurer is |
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prohibited from requiring a physician or health care provider to |
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obtain preauthorization from the insurer in order for the insurer |
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to pay for the benefit; and |
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(2) establish a simple procedure under which a |
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physician or health care provider may obtain a waiver of an |
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|
insurer's preauthorization requirement for a covered benefit under |
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|
circumstances specified by rule. |
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|
(b) Rules adopted under Subsection (a) must provide that the |
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following covered benefits are not subject to preauthorization or |
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|
are subject to a waiver of preauthorization requirements: |
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|
(1) if a physician or health care provider determines |
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|
that an insured has an immediate need for the covered benefit: |
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|
(A) durable medical equipment, including |
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|
crutches and wheelchairs; or |
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|
(B) diagnostic testing; or |
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|
(2) another health care service under circumstances |
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|
that take into account: |
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|
(A) symptoms displayed by the insured; |
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(B) the relationship between the physician or |
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health care provider and the insured, including the length of the |
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relationship; and |
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(C) the professional experience of the physician |
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or health care provider. |
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SECTION 3. The changes in law made by this Act apply only to |
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a health benefit plan delivered, issued for delivery, or renewed on |
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or after January 1, 2018. A health benefit plan delivered, issued |
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for delivery, or renewed before January 1, 2018, is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2017. |