| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to disclosures by certain health benefit plans to |
|
|
enrollees regarding certain preauthorized medical care and health |
|
|
care services. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Subchapter F, Chapter 843, Insurance Code, is |
|
|
amended by adding Section 843.2025 to read as follows: |
|
|
Sec. 843.2025. DISCLOSURES CONCERNING CERTAIN |
|
|
PREAUTHORIZED SERVICES. (a) In this section: |
|
|
(1) "Elective" means non-emergent, medically |
|
|
necessary, and able to be scheduled at least 24 hours in advance. |
|
|
(2) "Facility-based provider" means a physician or |
|
|
provider who provides a health care service to a patient of a |
|
|
licensed medical facility and bills for the service provided. |
|
|
(3) "Licensed medical facility" means: |
|
|
(A) a hospital licensed under Chapter 241, Health |
|
|
and Safety Code; |
|
|
(B) an ambulatory surgical center licensed under |
|
|
Chapter 243, Health and Safety Code; or |
|
|
(C) a birthing center licensed under Chapter 244, |
|
|
Health and Safety Code. |
|
|
(4) "Preauthorization" has the meaning assigned by |
|
|
Section 843.348. |
|
|
(b) A health maintenance organization that preauthorizes an |
|
|
enrollee's health care service shall provide a disclosure to the |
|
|
enrollee at the time the health maintenance organization issues a |
|
|
determination preauthorizing the service if the service: |
|
|
(1) will be provided at a licensed medical facility; |
|
|
(2) is elective; and |
|
|
(3) must be preauthorized as a condition of payment by |
|
|
the health maintenance organization for the service. |
|
|
(c) The disclosure provided to an enrollee under Subsection |
|
|
(b) must include: |
|
|
(1) a statement of the name and network status of any |
|
|
facility-based provider that the health maintenance organization |
|
|
reasonably expects will provide and bill for the preauthorized |
|
|
service or any anesthesia, pathology, or radiology services |
|
|
associated with the preauthorized service; |
|
|
(2) an estimate of: |
|
|
(A) the payment that the health maintenance |
|
|
organization will make for the preauthorized service and any |
|
|
anesthesia, pathology, or radiology services associated with the |
|
|
preauthorized service; and |
|
|
(B) the enrollee's financial responsibility, |
|
|
including any copayment or other out-of-pocket amount, for the |
|
|
preauthorized service and any anesthesia, pathology, or radiology |
|
|
services associated with the preauthorized service; |
|
|
(3) a statement that the actual charges and payment |
|
|
for the preauthorized service and the enrollee's financial |
|
|
responsibility for the service may vary from the estimate provided |
|
|
by the health maintenance organization based on the enrollee's |
|
|
actual medical condition and other factors associated with the |
|
|
performance of the service; |
|
|
(4) a statement substantially similar to the |
|
|
following: "This notice may not reflect all the physicians and |
|
|
health care providers who may be involved in and bill for your care. |
|
|
Despite your health maintenance organization's best efforts to |
|
|
disclose all physicians and health care providers who we reasonably |
|
|
expect to participate in your care, circumstances, including |
|
|
facility scheduling, staff changes, or complications, or other |
|
|
factors associated with your care, may result in different or |
|
|
additional physicians or health care providers providing and |
|
|
billing for care provided to you."; and |
|
|
(5) a statement that the enrollee may be personally |
|
|
liable for the amount charged for health care services provided to |
|
|
the enrollee depending on the enrollee's health benefit plan |
|
|
coverage. |
|
|
(d) A general statement that some facility-based providers |
|
|
may be out-of-network does not satisfy the requirement in |
|
|
Subsection (c)(1). |
|
|
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is |
|
|
amended by adding Section 1301.1355 to read as follows: |
|
|
Sec. 1301.1355. DISCLOSURES CONCERNING CERTAIN |
|
|
PREAUTHORIZED SERVICES. (a) In this section: |
|
|
(1) "Elective" means non-emergent, medically |
|
|
necessary, and able to be scheduled at least 24 hours in advance. |
|
|
(2) "Facility-based provider" means a physician or |
|
|
health care provider who provides a medical care or health care |
|
|
service to a patient of a licensed medical facility and bills for |
|
|
the service provided. |
|
|
(3) "Licensed medical facility" means: |
|
|
(A) a hospital licensed under Chapter 241, Health |
|
|
and Safety Code; |
|
|
(B) an ambulatory surgical center licensed under |
|
|
Chapter 243, Health and Safety Code; or |
|
|
(C) a birthing center licensed under Chapter 244, |
|
|
Health and Safety Code. |
|
|
(b) An insurer that preauthorizes an insured's medical care |
|
|
or health care service shall provide a disclosure to the insured at |
|
|
the time the insurer issues a determination preauthorizing the |
|
|
service if the service: |
|
|
(1) will be provided at a licensed medical facility; |
|
|
(2) is elective; and |
|
|
(3) must be preauthorized as a condition of payment by |
|
|
the insurer for the service. |
|
|
(c) The disclosure provided to an insured under Subsection |
|
|
(b) must include: |
|
|
(1) a statement of the name and network status of any |
|
|
facility-based provider that the insurer reasonably expects will |
|
|
provide and bill for the preauthorized service or any anesthesia, |
|
|
pathology, or radiology services associated with the preauthorized |
|
|
service; |
|
|
(2) an estimate of: |
|
|
(A) the payment that the insurer will make for |
|
|
the preauthorized service and any anesthesia, pathology, or |
|
|
radiology services associated with the preauthorized service; and |
|
|
(B) the insured's financial responsibility, |
|
|
including any copayment or other out-of-pocket amount, for the |
|
|
preauthorized service and any anesthesia, pathology, or radiology |
|
|
services associated with the preauthorized service; |
|
|
(3) a statement that the actual charges and payment |
|
|
for the preauthorized service and the insured's financial |
|
|
responsibility for the service may vary from the estimate provided |
|
|
by the insurer based on the insured's actual medical condition and |
|
|
other factors associated with the performance of the service; |
|
|
(4) a statement substantially similar to the |
|
|
following: "This notice may not reflect all the physicians and |
|
|
health care providers who may be involved in and bill for your care. |
|
|
Despite your insurer's best efforts to disclose all physicians and |
|
|
health care providers who we reasonably expect to participate in |
|
|
your care, circumstances, including facility scheduling, staff |
|
|
changes, or complications, or other factors associated with your |
|
|
care, may result in different or additional physicians or health |
|
|
care providers providing and billing for care provided to you."; |
|
|
and |
|
|
(5) a statement that the insured may be personally |
|
|
liable for the amount charged for medical care or health care |
|
|
services provided to the insured depending on the insured's health |
|
|
benefit plan coverage. |
|
|
(d) A general statement that some facility-based physicians |
|
|
or health care providers may be out-of-network does not satisfy the |
|
|
requirement in Subsection (c)(1). |
|
|
SECTION 3. The changes in law made by this Act apply only to |
|
|
a health benefit plan that is delivered, issued for delivery, or |
|
|
renewed on or after January 1, 2020. |
|
|
SECTION 4. This Act takes effect January 1, 2020. |