88R9251 KBB-F

By: Vo H.B. No. 4067

A BILL TO BE ENTITLED

AN ACT

relating to examinations of health maintenance organizations and insurers by the commissioner of insurance regarding compliance with certain utilization review and preauthorization requirements; authorizing a fee.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 843.154(f), Insurance Code, is amended to read as follows:

(f) A health maintenance organization shall pay to the commissioner a fee in an amount assessed by the commissioner and paid in accordance with rules adopted by the commissioner for the expenses of an examination under Section 843.156(a) or (a-1) that:

(1) are incurred by the commissioner or under the commissioner's authority; and

(2) are directly attributable to that examination, including the actual salaries and expenses of the examiners directly attributable to that examination, as determined under rules adopted by the commissioner.

SECTION 2. Section 843.156, Insurance Code, is amended by adding Subsections (a-1) and (a-2) to read as follows:

(a-1) The commissioner shall examine a health maintenance organization to determine the health maintenance organization's compliance with applicable requirements related to utilization review, including requirements under this chapter, Chapter 1222, Chapter 1369, and Chapter 4201 that relate to the preauthorization of health care services. The commissioner may conduct an examination under this subsection as often as the commissioner considers necessary but shall conduct an examination at least once annually. Documentation provided to the commissioner during an examination conducted under this subsection is confidential and is not subject to disclosure as public information under Chapter 552, Government Code. In this subsection and Subsection (a-2), "utilization review" has the meaning assigned by Section 4201.002.

(a-2) If in a certain year the commissioner examines or will examine a health maintenance organization's compliance with applicable requirements related to utilization review as part of an examination other than the examination required by Subsection (a-1), the commissioner is not required to examine the health maintenance organization under Subsection (a-1) in that year.

SECTION 3. Section 1301.0056, Insurance Code, is amended by adding Subsections (a-1) and (a-2) to read as follows:

(a-1) The commissioner shall examine an insurer to determine the insurer's compliance with applicable requirements related to utilization review, including requirements under this chapter, Chapter 1222, Chapter 1369, and Chapter 4201 that relate to the preauthorization of medical care or health care services. The commissioner may conduct an examination under this subsection as often as the commissioner considers necessary but shall conduct an examination at least once annually. In this subsection and Subsection (a-2), "utilization review" has the meaning assigned by Section 4201.002.

(a-2) If in a certain year the commissioner examines or will examine an insurer's compliance with applicable requirements related to utilization review as part of an examination other than the examination required by Subsection (a-1), the commissioner is not required to examine the insurer under Subsection (a-1) in that year.

SECTION 4. This Act takes effect September 1, 2023.