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A BILL TO BE ENTITLED
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AN ACT
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relating to an explanation of benefits provided by certain health |
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benefit plans to enrollees regarding certain preauthorized medical |
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care and health 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. EXPLANATION OF BENEFITS FOR CERTAIN |
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PREAUTHORIZED SERVICES. (a) In this section: |
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(1) "Elective" means non-emergent and able to be |
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scheduled at least 24 hours 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) This section does not apply to coverage under: |
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(1) the child health plan program under Chapter 62, |
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Health and Safety Code, or the health benefits plan for children |
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under Chapter 63, Health and Safety Code; or |
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(2) the state Medicaid program, including a Medicaid |
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managed care program operated under Chapter 533, Government Code. |
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(c) A health maintenance organization that preauthorizes an |
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enrollee's health care service shall provide an explanation of |
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benefits to the enrollee at the time the health maintenance |
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organization issues a determination preauthorizing the service if |
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the service: |
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(1) will be provided at a licensed medical facility; |
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(2) is elective; and |
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(3) must be preauthorized as a condition of payment by |
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the health maintenance organization for the service. |
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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. EXPLANATION OF BENEFITS FOR CERTAIN |
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PREAUTHORIZED SERVICES. (a) In this section: |
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(1) "Elective" means non-emergent and able to be |
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scheduled at least 24 hours 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) An insurer that preauthorizes an insured's medical care |
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or health care service shall provide an explanation of benefits to |
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the insured at the time the insurer issues a determination |
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preauthorizing the service if the service: |
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(1) will be provided at a licensed medical facility; |
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(2) is elective; and |
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(3) must be preauthorized as a condition of payment by |
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the insurer for the service. |
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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, 2022. |
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SECTION 4. This Act takes effect January 1, 2022. |