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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" means non-emergent and able to be |
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scheduled at least 24 hours in advance. |
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(2) "Facility-based provider" means a physician or |
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provider who provides a health care service to a patient of a |
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licensed medical facility and bills for the service provided. |
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(3) "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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(4) "Preauthorization" has the meaning assigned by |
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Section 843.348. |
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(b) A health maintenance organization that preauthorizes an |
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enrollee's health care service shall provide a disclosure to the |
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enrollee at the time the health maintenance organization issues a |
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determination 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 health maintenance organization for the service. |
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(c) The disclosure provided to an enrollee under Subsection |
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(b) must include: |
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(1) a statement of the name and network status of the |
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licensed medical facility and any facility-based provider that the |
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health maintenance organization reasonably expects will provide |
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and bill for the preauthorized service or any services associated |
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with the preauthorized service; |
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(2) an itemized estimate of: |
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(A) the payments that the health maintenance |
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organization will make to: |
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(i) each facility-based provider for the |
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preauthorized service and any services associated with the |
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preauthorized service; and |
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(ii) the licensed medical facility for the |
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preauthorized service and any services associated with the |
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preauthorized service; and |
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(B) the enrollee's financial responsibility, |
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including any copayment, coinsurance, deductible or other |
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out-of-pocket amount, for the preauthorized service and any |
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services associated with the preauthorized service; |
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(3) a statement that the actual charges and payment |
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for the services and the enrollee's financial responsibility for |
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the services may vary from the estimate provided by the health |
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maintenance organization based on the enrollee's actual medical |
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condition and other factors associated with the performance of the |
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service; |
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(4) a statement substantially similar to the |
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following: "This notice may not reflect all the physicians and |
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health care providers who may be involved in and bill for your care. |
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Despite your health maintenance organization's best efforts to |
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disclose all physicians and health care providers who we reasonably |
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expect to participate in your care, circumstances, including |
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facility scheduling, staff changes, or complications, or other |
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factors associated with your care, may result in different or |
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additional physicians or health care providers providing and |
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billing for care provided to you."; and |
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(5) 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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(d) A general statement that some facility-based providers |
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may be out-of-network does not satisfy the requirement in |
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Subsection (c)(1). |
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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" means non-emergent and able to be |
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|
scheduled at least 24 hours in advance. |
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|
(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. |
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|
(3) "Licensed medical facility" means: |
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|
(A) a hospital licensed under Chapter 241, Health |
|
|
and Safety Code; |
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|
(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. |
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(b) An insurer that preauthorizes an insured's medical care |
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or health care service shall provide a disclosure to the insured at |
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the time the insurer issues a determination preauthorizing the |
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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 |
|
|
the insurer for the service. |
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|
(c) The disclosure provided to an insured under Subsection |
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(b) must include: |
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(1) a statement of the name and network status of the |
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|
licensed medical facility and any facility-based provider that the |
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|
insurer reasonably expects will provide and bill for the |
|
|
preauthorized service or any services associated with the |
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|
preauthorized service; |
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(2) an itemized estimate of: |
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(A) the payment that the insurer will make to: |
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(i) each facility-based provider for the |
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preauthorized service and any services associated with the |
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preauthorized service; and |
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(ii) the licensed medical facility for the |
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|
preauthorized service and any services associated with the |
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|
preauthorized service; and |
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(B) the insured's financial responsibility, |
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including any copayment, coinsurance, deductible or other |
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|
out-of-pocket amount, for the preauthorized service and any |
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|
services associated with the preauthorized service; |
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(3) a statement that the actual charges and payment |
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for the services and the insured's financial responsibility for the |
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services may vary from the estimate provided by the insurer based on |
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the insured's actual medical condition and other factors associated |
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|
with the performance of the service; |
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(4) a statement substantially similar to the |
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following: "This notice may not reflect all the physicians and |
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health care providers who may be involved in and bill for your care. |
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Despite your insurer's best efforts to disclose all physicians and |
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health care providers who we reasonably expect to participate in |
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your care, circumstances, including facility scheduling, staff |
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|
changes, or complications, or other factors associated with your |
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|
care, may result in different or additional physicians or health |
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|
care providers providing and billing for care provided to you."; |
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and |
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(5) 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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(d) A general statement that some facility-based providers |
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may be out-of-network does not satisfy the requirement in |
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Subsection (c)(1). |
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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. |