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A BILL TO BE ENTITLED
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AN ACT
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relating to preauthorization requirements for certain medical and |
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health care services and utilization review for certain health |
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benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter J, Chapter 843, Insurance Code, is |
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amended by adding Section 843.3484 to read as follows: |
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Sec. 843.3484. EXEMPTION FROM PREAUTHORIZATION |
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REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH |
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CARE SERVICES. (a) 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 a particular |
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health care service if, in the preceding calendar year: |
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(1) the physician or provider submitted not less than |
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five preauthorization requests for the particular health care |
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service; and |
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(2) the health maintenance organization approved not |
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less than 80 percent of the preauthorization requests submitted by |
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the physician or provider for the particular health care service. |
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(b) An exemption from preauthorization requirements under |
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Subsection (a) lasts for one calendar year. |
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(c) Not later than January 30 of each calendar year, a |
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health maintenance organization must provide to a physician or |
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provider who qualifies for an exemption from preauthorization |
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requirements under Subsection (a) a notice that includes: |
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(1) a statement that the physician or provider |
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qualifies for an exemption from preauthorization requirements |
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under Subsection (a); |
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(2) a list of the health care services to which the |
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exemption applies; and |
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(3) a statement that the exemption applies only for |
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the calendar year in which the physician or provider receives the |
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notice. |
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(d) If a physician or provider submits a preauthorization |
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request for a health care service for which the physician or |
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provider qualifies for an exemption from preauthorization |
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requirements under Subsection (a), the health maintenance |
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organization must promptly provide a notice to the physician or |
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provider that includes: |
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(1) the information described by Subsection (c); and |
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(2) a notification of the health maintenance |
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organization payment requirements described by Subsection (e). |
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(e) A health maintenance organization may not deny or reduce |
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payment to a physician or provider for a health care service to |
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which the physician or provider qualifies for an exemption from |
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preauthorization requirements under Subsection (a) based on |
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medical necessity or appropriateness of care. |
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SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.1354 to read as follows: |
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Sec. 1301.1354. EXEMPTION FROM PREAUTHORIZATION |
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REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING |
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CERTAIN HEALTH CARE SERVICES. (a) An insurer that uses a |
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preauthorization process for medical care or health care services |
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may not require a physician or health care provider to obtain |
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preauthorization for a particular medical or health care service |
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if, in the preceding calendar year: |
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(1) the physician or health care provider submitted |
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not less than five preauthorization requests for the particular |
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medical or health care service; and |
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(2) the insurer approved not less than 80 percent of |
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the preauthorization requests submitted by the physician or health |
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care provider for the particular medical or health care service. |
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(b) An exemption from preauthorization requirements under |
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Subsection (a) lasts for one calendar year. |
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(c) Not later than January 30 of each calendar year, an |
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insurer must provide to a physician or health care provider who |
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qualifies for an exemption from preauthorization requirements |
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under Subsection (a) a notice that includes: |
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(1) a statement that the physician or health care |
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provider qualifies for an exemption from preauthorization |
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requirements under Subsection (a); |
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(2) a list of the medical or health care services to |
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which the exemption applies; and |
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(3) a statement that the exemption applies only for |
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the calendar year in which the physician or health care provider |
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receives the notice. |
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(d) If a physician or health care provider submits a |
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preauthorization request for a medical or health care service for |
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which the physician or health care provider qualifies for an |
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exemption from preauthorization requirements under Subsection (a), |
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the insurer must promptly provide a notice to the physician or |
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health care provider that includes: |
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(1) the information described by Subsection (c); and |
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(2) a notification of the insurer payment requirements |
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described by Subsection (e). |
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(e) An insurer may not deny or reduce payment to a physician |
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or health care provider for a medical or health care service to |
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which the physician or health care provider qualifies for an |
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exemption from preauthorization requirements under Subsection (a) |
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based on medical necessity or appropriateness of care. |
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SECTION 3. Section 4201.206, Insurance Code, is amended to |
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read as follows: |
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Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE |
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ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the |
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notice requirements of Subchapter G, before an adverse |
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determination is issued by a utilization review agent who questions |
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the medical necessity, the appropriateness, or the experimental or |
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investigational nature of a health care service, the agent shall |
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provide the health care provider who ordered, requested, provided, |
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or is to provide the service a reasonable opportunity to discuss |
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with a physician licensed to practice medicine in this state the |
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patient's treatment plan and the clinical basis for the agent's |
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determination. |
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(b) If the health care service described by Subsection (a) |
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was ordered, requested, or provided, or is to be provided by a |
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physician, the opportunity described by that subsection must be |
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with a physician licensed to practice medicine in this state and who |
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has the same or similar specialty as the physician. |
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SECTION 4. The changes in law made by this Act to Chapters |
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843 and 1301, Insurance Code, apply only to a request for |
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preauthorization of medical care or health care services made on or |
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after January 1, 2022. A request for preauthorization of medical |
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care or health care services made before January 1, 2022, is |
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governed by the law as it existed immediately before the effective |
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date of this Act, and that law is continued in effect for that |
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purpose. |
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SECTION 5. Section 4201.206, Insurance Code, as amended by |
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this Act, applies only to a utilization review requested on or after |
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the effective date of this Act. A utilization review requested |
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before the effective date of this Act is governed by the law as it |
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existed immediately before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2021. |
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* * * * * |