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A BILL TO BE ENTITLED
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AN ACT
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relating to disclosures by certain health benefit plans to |
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enrollees regarding certain preauthorized medical care and health |
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care services. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter F, Chapter 843, Insurance Code, is |
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amended by adding Section 843.2025 to read as follows: |
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Sec. 843.2025. DISCLOSURES CONCERNING CERTAIN |
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PREAUTHORIZED SERVICES. (a) In this section: |
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(1) "Elective health care service" means a covered |
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health care service that is scheduled in advance. |
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(2) "Licensed medical facility" means: |
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(A) a hospital licensed under Chapter 241, Health |
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and Safety Code; |
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(B) an ambulatory surgical center licensed under |
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Chapter 243, Health and Safety Code; or |
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(C) a birthing center licensed under Chapter 244, |
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Health and Safety Code. |
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(3) "Preauthorization" has the meaning assigned by |
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Section 843.348. |
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(b) If a health maintenance organization preauthorizes an |
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elective health care service to be provided at a licensed medical |
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facility, the health maintenance organization shall, within a |
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reasonable period before the date the health care service is |
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scheduled to be performed, provide to the enrollee: |
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(1) a statement of the name and network status of any |
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facility-based physician or provider that the health maintenance |
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organization reasonably expects will provide and charge for the |
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preauthorized service; |
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(2) an estimate of: |
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(A) the payment that will be made for the |
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preauthorized service; and |
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(B) the enrollee's financial responsibility for |
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the preauthorized service, including any copayment or other |
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out-of-pocket amount for which the enrollee is responsible; |
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(3) a statement that the actual charges and payment |
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for the health care service and the enrollee's financial |
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responsibility for the health care service may vary from the |
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estimate provided by the health maintenance organization based on |
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the enrollee's medical condition and other factors associated with |
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the performance of the health care service; and |
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(4) a statement that the enrollee may be personally |
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liable for the amount charged for health care services provided to |
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the enrollee depending on the enrollee's health benefit plan |
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coverage. |
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(c) A general statement that some facility-based physicians |
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or providers may be out-of-network does not satisfy the notice |
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requirement of Subsection (b). |
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SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.1355 to read as follows: |
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Sec. 1301.1355. DISCLOSURES CONCERNING CERTAIN |
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PREAUTHORIZED SERVICES. (a) In this section: |
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(1) "Elective medical care or health care service" |
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means a covered medical care or health care service that is |
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scheduled in advance. |
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(2) "Licensed medical facility" means: |
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(A) a hospital licensed under Chapter 241, Health |
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and Safety Code; |
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(B) an ambulatory surgical center licensed under |
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Chapter 243, Health and Safety Code; or |
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(C) a birthing center licensed under Chapter 244, |
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Health and Safety Code. |
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(b) If an insurer preauthorizes an elective medical care or |
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health care service to be provided at a licensed medical facility, |
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the insurer shall, within a reasonable period before the date the |
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medical care or health care service is scheduled to be performed, |
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provide to the insured: |
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(1) a statement of the name and network status of any |
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facility-based physician or health care provider that the insurer |
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reasonably expects will provide and charge for the preauthorized |
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service; |
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(2) an estimate of: |
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(A) the payment that will be made for the |
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preauthorized service; and |
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(B) the insured's financial responsibility for |
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the preauthorized service, including any copayment, coinsurance, |
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deductible, or other out-of-pocket amount for which the insured is |
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responsible; |
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(3) a statement that the actual charges and payment |
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for the medical care or health care service and the insured's |
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financial responsibility for the medical care or health care |
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service may vary from the estimate provided by the insurer based on |
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the insured's medical condition and other factors associated with |
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the performance of the medical care or health care service; and |
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(4) a statement that the insured may be personally |
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liable for the amount charged for medical care or health care |
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services provided to the insured depending on the insured's health |
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benefit plan coverage. |
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(c) A general statement that some facility-based physicians |
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or health care providers may be out-of-network does not satisfy the |
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notice requirement of Subsection (b). |
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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 that is delivered, issued for delivery, or |
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renewed on or after January 1, 2020. |
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SECTION 4. This Act takes effect January 1, 2020. |