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A BILL TO BE ENTITLED
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AN ACT
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relating to preauthorization of certain medical care and health |
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care services by certain health benefit plan issuers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.348(b), Insurance Code, is amended |
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to read as follows: |
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(b) A health maintenance organization that uses a |
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preauthorization process for health care services shall provide |
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each participating physician or provider, not later than the fifth |
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[10th] business day after the date a request is made, a list of |
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health care services that [do not] require preauthorization and |
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information concerning the preauthorization process. |
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SECTION 2. Subchapter J, Chapter 843, Insurance Code, is |
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amended by adding Sections 843.3481, 843.3482, 843.3483, and |
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843.3484 to read as follows: |
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Sec. 843.3481. POSTING PREAUTHORIZATION REQUIREMENTS. (a) |
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A health maintenance organization that uses a preauthorization |
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process for health care services shall make the requirements and |
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information about the preauthorization process readily accessible |
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to enrollees, physicians, providers, and the general public by |
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posting the requirements and information on the health maintenance |
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organization's Internet website. |
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(b) The preauthorization requirements and information |
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described by Subsection (a) must: |
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(1) be conspicuously posted in a location on the |
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Internet website that does not require the use of a log-in or other |
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input of personal information to view the information; |
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(2) be written in plain language that is easily |
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understandable by enrollees, physicians, providers, and the |
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general public; |
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(3) include a detailed description of the |
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preauthorization process and the applicable screening criteria |
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using Current Procedural Terminology codes and International |
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Classification of Diseases codes; and |
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(4) include statistics showing the health maintenance |
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organization's preauthorization approvals and denials, including |
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for each approval or denial the: |
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(A) physician specialty; |
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(B) medication, diagnostic test, or procedure; |
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(C) indication offered; and |
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(D) reason for denial. |
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Sec. 843.3482. CHANGES TO PREAUTHORIZATION REQUIREMENTS. |
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(a) Not later than the 60th day before the date a new or amended |
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preauthorization requirement takes effect, a health maintenance |
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organization that uses a preauthorization process for health care |
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services shall provide each participating physician or provider |
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written notice of the new or amended preauthorization requirement |
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and disclose the new or amended requirement in the health |
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maintenance organization's newsletter or network bulletin, if any. |
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(b) A health maintenance organization shall update its |
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Internet website to disclose any change to the health maintenance |
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organization's preauthorization requirements or process and the |
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date and time the change is effective. A new or amended |
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preauthorization requirement may not take effect before the fifth |
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day after the date the health maintenance organization's Internet |
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website is updated as required by this subsection. |
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(c) A health maintenance organization is not required to |
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comply with Subsection (a) or (b) for a change in a preauthorization |
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requirement or process that removes a health care service from the |
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list of services requiring preauthorization or amends a |
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preauthorization requirement in a way that is less burdensome to |
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enrollees and participating physicians and providers. |
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Sec. 843.3483. EXEMPTION FROM PREAUTHORIZATION |
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REQUIREMENTS. A health maintenance organization that uses a |
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preauthorization process for health care services may not require a |
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physician or provider to obtain preauthorization for health care |
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services if the physician or provider establishes in accordance |
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with standards adopted by the commissioner by rule that the |
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physician or provider routinely submitted claims to the health |
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maintenance organization that were consistent with national |
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evidence-based guidelines and that were preauthorized by the health |
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maintenance organization. |
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Sec. 843.3484. REMEDY FOR NONCOMPLIANCE; AUTOMATIC |
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PREAUTHORIZATION. A health maintenance organization that uses a |
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preauthorization process for health care services that violates |
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this subchapter with respect to a required publication, notice, or |
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response regarding its preauthorization requirements, including by |
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failing to comply with any applicable deadline for the publication, |
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notice, or response, waives the health maintenance organizations |
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preauthorization requirements with respect to any health care |
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service affected by the violation. |
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SECTION 3. Section 1301.135(a), Insurance Code, is amended |
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to read as follows: |
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(a) An insurer that uses a preauthorization process for |
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medical care or [and] health care services shall provide to each |
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preferred provider, not later than the fifth [10th] business day |
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after the date a request is made, a list of medical care and health |
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care services that require preauthorization and information |
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concerning the preauthorization process. |
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SECTION 4. Subchapter C-1, Chapter 1301, Insurance Code, is |
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amended by adding Sections 1301.1351, 1301.1352, 1301.1353, and |
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1301.1354 to read as follows: |
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Sec. 1301.1351. POSTING PREAUTHORIZATION REQUIREMENTS. |
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(a) An insurer that uses a preauthorization process for medical |
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care or health care services shall make the requirements and |
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information about the preauthorization process readily accessible |
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to insureds, physicians, health care providers, and the general |
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public by posting the requirements and information on the insurer's |
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|
Internet website. |
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|
(b) The preauthorization requirements and information |
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|
described by Subsection (a) must: |
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(1) be conspicuously posted in a location on the |
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Internet website that does not require the use of a log-in or other |
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|
input of personal information to view the information; |
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|
(2) be written in plain language that is easily |
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understandable by insureds, physicians, health care providers, and |
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|
the general public; |
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(3) include a detailed description of the |
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preauthorization process and the applicable screening criteria |
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|
using Current Procedural Terminology codes and International |
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|
Classification of Diseases codes; and |
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(4) include statistics showing the insurer's |
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preauthorization approvals and denials, including for each |
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approval or denial the: |
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(A) physician specialty; |
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(B) medication, diagnostic test, or procedure; |
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(C) indication offered; and |
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(D) reason for denial. |
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Sec. 1301.1352. CHANGES TO PREAUTHORIZATION REQUIREMENTS. |
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(a) Not later than the 60th day before the date a new or amended |
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preauthorization requirement takes effect, an insurer that uses a |
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preauthorization process for medical care or health care services |
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shall provide to each preferred provider written notice of the new |
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or amended preauthorization requirement and disclose the new or |
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amended requirement in the insurer's newsletter or network |
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bulletin, if any. |
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(b) An insurer shall update its Internet website to disclose |
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any change to the insurer's preauthorization requirements or |
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process and the date and time the change is effective. A new or |
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amended preauthorization requirement may not take effect before the |
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fifth day after the date the insurer's Internet website is updated |
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as required by this subsection. |
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(c) An insurer is not required to comply with Subsection (a) |
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or (b) for a change in a preauthorization requirement or process |
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that removes a medical care or health care service from the list of |
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services requiring preauthorization or amends a preauthorization |
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requirement in a way that is less burdensome to insureds, |
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physicians, and health care providers. |
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Sec. 1301.1353. EXEMPTION FROM PREAUTHORIZATION |
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REQUIREMENTS. An insurer that uses a preauthorization process for |
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medical care or health care services may not require a physician or |
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health care provider to obtain preauthorization for medical care or |
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health care services if the physician or health care provider |
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establishes in accordance with standards adopted by the |
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commissioner by rule that the physician or health care provider |
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routinely submitted claims to the insurer that were consistent with |
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national evidence-based guidelines and that were preauthorized by |
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the insurer. |
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Sec. 1301.1354. REMEDY FOR NONCOMPLIANCE; AUTOMATIC |
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PREAUTHORIZATION. An insurer that uses a preauthorization process |
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for medical care or health care services that violates this |
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subchapter with respect to a required publication, notice, or |
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response regarding its preauthorization requirements, including by |
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failing to comply with any applicable deadline for the publication, |
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notice, or response, waives the insurer's preauthorization |
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requirements with respect to any medical care or health care |
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service affected by the violation. |
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SECTION 5. 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 January 1, 2020. A request for |
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preauthorization of medical care or health care services made |
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before January 1, 2020, under a health benefit plan delivered, |
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issued for delivery, or renewed before that date is governed by the |
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law in effect immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2019. |