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  89R5923 RDS-F
 
  By: Oliverson H.B. No. 4681
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to disclosures of preauthorization requirements and
  explanations of benefits for medical and health care services and
  supplies covered by health maintenance organizations and preferred
  provider benefit plans; imposing administrative penalties.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter D, Chapter 843, Insurance Code, is
  amended by adding Section 843.114 to read as follows:
         Sec. 843.114.  EXPLANATION OF BENEFITS. A health
  maintenance organization shall provide a written explanation of
  benefits to an enrollee for a health care service or supply
  submitted by a physician or health care provider to the health
  maintenance organization for payment.  The explanation must
  include:
               (1)  a plain-language description of the health care
  service or supply that adequately identifies for the enrollee the
  health care service or supply received by the enrollee from the
  physician or provider; and
               (2)  a plain-language description of each identifying
  code, including a denial code, provided in the explanation of
  benefits that adequately informs and defines the identifying code
  for the enrollee.
         SECTION 2.  Section 843.3481, Insurance Code, is amended by
  amending Subsections (a) and (b) and adding Subsection (e) to read
  as follows:
         (a)  A health maintenance organization that uses a
  preauthorization process for health care services shall display in
  a prominent location on or through a dedicated link that is
  prominently displayed on the home page of the health maintenance
  organization's Internet website all [make the] requirements and
  information about the preauthorization process [readily accessible
  to enrollees, physicians, providers, and the general public by
  posting the requirements and information on the health maintenance
  organization's Internet website].
         (b)  The preauthorization requirements and information
  described by Subsection (a) [must]:
               (1)  must be [posted]:
                     (A)  available free of charge;
                     (B)  formatted in a manner that is digitally
  searchable and prescribed by the commissioner;
                     (C)  accessible to a common commercial operator of
  an Internet search engine as reasonably necessary for the search
  engine to:
                           (i)  index the requirements and information;
  and
                           (ii)  display the requirements and
  information as a result in a response to a search query initiated by
  a user of the search engine; and
                     (D)  [(A)  except as provided by Subsection (c) or
  (d), conspicuously in a location on the Internet website that does
  not require the use of a log-in or other input of personal
  information to view the information; and
                     [(B)  in a format that is easily searchable and
  accessible;
               [(2)  except for the screening criteria under
  Subdivision (4)(C), be] written in plain language that is easily
  understandable by enrollees, physicians, providers, and the
  general public;
               (2)  may not require an individual to:
                     (A)  establish a user account or password;
                     (B)  submit personal identifying information; or
                     (C)  overcome any other impediment to accessing
  the requirements and information, including a requirement that the
  individual enter a code to access the requirements and information;
               (3)  must include a detailed description of the
  preauthorization process and procedure; and
               (4)  must include an accurate and current list of the
  health care services for which the health maintenance organization
  requires preauthorization that includes the following information
  specific to each service:
                     (A)  the effective date of the preauthorization
  requirement;
                     (B)  a list or description of any supporting
  documentation that the health maintenance organization requires
  from the physician or provider ordering or requesting the service
  to approve a request for that service;
                     (C)  the applicable screening criteria, which may
  include Current Procedural Terminology codes and International
  Classification of Diseases codes; and
                     (D)  statistics regarding preauthorization
  approval and denial rates for the service in the preceding calendar
  year, including statistics in the following categories:
                           (i)  physician or provider type and
  specialty, if any;
                           (ii)  indication offered;
                           (iii)  reasons for request denial, which may
  not be in the form of alphanumeric codes;
                           (iv)  initial denials;
                           (v)  denials overturned on internal appeal;
                           (vi) [(v)]  denials overturned by an
  independent review organization;
                           (vii)  approvals and denials of expedited
  preauthorization requests;
                           (viii)  [and
                           [(vi)]  total annual preauthorization
  requests, approvals, and denials for the service; and
                           (ix)  average and median times that elapsed
  between the submission of a preauthorization request and a decision
  by the health maintenance organization, sorted by standard
  preauthorization requests and expedited preauthorization requests.
         (e)  The provisions of this section may not be waived by
  contract.
         SECTION 3.  Section 843.3482, Insurance Code, is amended to
  read as follows:
         Sec. 843.3482.  CHANGES TO PREAUTHORIZATION REQUIREMENTS.  
  (a)  Except as provided by Subsection (b), not later than the 60th
  business day before the date a new or amended preauthorization
  requirement takes effect, a health maintenance organization that
  uses a preauthorization process for health care services shall, in
  accordance with Section 843.3481:
               (1)  provide written notice of the new or amended
  preauthorization requirement and the date and time the requirement
  goes into effect to each enrollee and each participating physician
  and provider in the health maintenance organization's network who
  provides a health care service subject to the requirement; and
               (2)  disclose the new or amended requirement and the
  date and time the requirement goes into effect in the health
  maintenance organization's newsletter or network bulletin, if any,
  and on the health maintenance organization's Internet website.
         (b)  For a change in a preauthorization requirement or
  process that removes a service from the list of health care services
  requiring preauthorization or amends a preauthorization
  requirement in a way that is less burdensome to enrollees or
  participating physicians or providers, a health maintenance
  organization shall, in accordance with Section 843.3481:
               (1)  provide written notice of the change in the
  preauthorization requirement and the date and time the change goes
  into effect to each enrollee and each participating physician and
  provider in the health maintenance organization's network who
  provides the health care service; and
               (2)  disclose the change and the date and time the
  change goes into effect in the health maintenance organization's
  newsletter or network bulletin, if any, and on the health
  maintenance organization's Internet website [not later than the
  fifth day before the date the change takes effect].
         (c)  Not later than the fifth day before the date a new or
  amended preauthorization requirement takes effect, a health
  maintenance organization shall update its Internet website to
  disclose the change to the health maintenance organization's
  preauthorization requirements or process and the date and time the
  change is effective in accordance with Section 843.3481.
         (d)  A new or amended preauthorization requirement imposed
  by a health maintenance organization must take effect on a business
  day.
         (e)  The provisions of this section may not be waived by
  contract.
         SECTION 4.  Subchapter J, Chapter 843, Insurance Code, is
  amended by adding Section 843.3484 to read as follows:
         Sec. 843.3484.  ADDITIONAL ENFORCEMENT FOR PREAUTHORIZATION
  VIOLATION. (a) In addition to any other penalty or remedy provided
  by law and if the commissioner determines that a health maintenance
  organization has violated Section 843.348, 843.3481, or 843.3482,
  the commissioner shall issue a notice of the violation to the health
  maintenance organization and order the health maintenance
  organization to submit a corrective action plan to the department.
  The notice must:
               (1)  indicate the form and manner in which the
  corrective action plan must be submitted to the department; and
               (2)  clearly state the date by which the health
  maintenance organization must submit the plan.
         (b)  A health maintenance organization that receives a
  notice under Subsection (a) shall, on or before the date described
  by Subsection (a)(2):
               (1)  submit a corrective action plan in the form and
  manner prescribed by the notice; and
               (2)  as soon as practicable after submission of a
  corrective action plan under Subdivision (1), act to comply with
  the plan.
         (c)  A corrective action plan submitted to the department
  must provide:
               (1)  a detailed description of the corrective action
  the health maintenance organization will take to address each
  violation identified by the commissioner and included in the notice
  provided under Subsection (a); and
               (2)  a date by which the health maintenance
  organization will complete the corrective action described by
  Subdivision (1).
         (d)  In addition to any other penalty or remedy provided by
  law, the commissioner shall impose an administrative penalty under
  Chapter 84 on a health maintenance organization for each violation
  of this section or Section 843.348, 843.3481, or 843.3482 by the
  health maintenance organization.  For purposes of determining a
  penalty under Subsection (e), each day a violation continues is
  considered a separate violation.
         (e)  The commissioner shall set the amount of the
  administrative penalty described by Subsection (d) in an amount not
  to exceed:
               (1)  for a health maintenance organization with a total
  gross revenue of less than $10 million during the preceding
  calendar year, $10 for each violation;
               (2)  for a health maintenance organization with a total
  gross revenue of $10 million or more but less than $100 million
  during the preceding calendar year, $100 for each violation; or
               (3)  for a health maintenance organization with a total
  gross revenue of $100 million or more during the preceding calendar
  year, $1,000 for each violation.
         SECTION 5.  Subchapter A, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.011 to read as follows:
         Sec. 1301.011.  EXPLANATION OF BENEFITS. An insurer shall
  provide a written explanation of benefits to an insured for a health
  care service or supply submitted by a physician or health care
  provider to the insurer for payment.  The explanation must include:
               (1)  a plain-language description of the health care
  service or supply that adequately identifies for the insured the
  health care service or supply received by the insured from the
  physician or provider; and
               (2)  a plain-language description of each identifying
  code, including a denial code, provided in the explanation of
  benefits that adequately informs and defines the identifying code
  for the insured.
         SECTION 6.  Sections 1301.1351(a) and (b), Insurance Code,
  are amended to read as follows:
         (a)  An insurer that uses a preauthorization process for
  medical care or health care services shall display in a prominent
  location on or through a dedicated link that is prominently
  displayed on the home page of the insurer's Internet website all
  [make the] requirements and information about the preauthorization
  process [readily accessible to insureds, physicians, health care
  providers, and the general public by posting the requirements and
  information on the insurer's Internet website].
         (b)  The preauthorization requirements and information
  described by Subsection (a) [must]:
               (1)  must be [posted]:
                     (A)  available free of charge;
                     (B)  formatted in a manner that is digitally
  searchable and prescribed by the commissioner;
                     (C)  accessible to a common commercial operator of
  an Internet search engine as reasonably necessary for the search
  engine to:
                           (i)  index the requirements and information;
  and
                           (ii)  display the requirements and
  information as a result in response to a search query initiated by a
  user of the search engine; and
                     (D)  [(A)  except as provided by Subsection (c) or
  (d), conspicuously in a location on the Internet website that does
  not require the use of a log-in or other input of personal
  information to view the information; and
                     [(B)  in a format that is easily searchable and
  accessible;
               [(2)  except for the screening criteria under
  Subdivision (4)(C), be] written in plain language that is easily
  understandable by insureds, physicians, health care providers, and
  the general public;
               (2)  may not require an individual to:
                     (A)  establish a user account or password;
                     (B)  submit personal identifying information; or
                     (C)  overcome any other impediment to accessing
  the requirements and information, including a requirement that the
  individual enter a code to access the requirements and information;
               (3)  must include a detailed description of the
  preauthorization process and procedure; and
               (4)  must include an accurate and current list of
  medical care and health care services for which the insurer
  requires preauthorization that includes the following information
  specific to each service:
                     (A)  the effective date of the preauthorization
  requirement;
                     (B)  a list or description of any supporting
  documentation that the insurer requires from the physician or
  health care provider ordering or requesting the service to approve
  a request for the service;
                     (C)  the applicable screening criteria, which may
  include Current Procedural Terminology codes and International
  Classification of Diseases codes; and
                     (D)  statistics regarding the insurer's
  preauthorization approval and denial rates for the medical care or
  health care service in the preceding calendar year, including
  statistics in the following categories:
                           (i)  physician or health care provider type
  and specialty, if any;
                           (ii)  indication offered;
                           (iii)  reasons for request denial, which may
  not be in the form of alphanumeric codes;
                           (iv)  initial denials;
                           (v)  denials overturned on internal appeal;
                           (vi) [(v)]  denials overturned by an
  independent review organization;
                           (vii)  approvals and denials of expedited
  preauthorization requests;
                           (viii)  [and
                           [(vi)]  total annual preauthorization
  requests, approvals, and denials for the service; and
                           (ix)  average and median times that elapsed
  between the submission of a preauthorization request and a decision
  by the insurer, sorted by standard preauthorization requests and
  expedited preauthorization requests.
         SECTION 7.  Section 1301.1352, Insurance Code, is amended by
  amending Subsections (a), (b), and (c) and adding Subsection (c-1)
  to read as follows:
         (a)  Except as provided by Subsection (b), not later than the
  60th business day before the date a new or amended preauthorization
  requirement takes effect, an insurer that uses a preauthorization
  process for medical care or health care services shall, in
  accordance with Section 1301.1351:
               (1)  provide written notice of the new or amended
  preauthorization requirement and the date and time the requirement
  goes into effect to each insured and each participating provider in
  the insurer's network who provides the medical care or health care
  service subject to the requirement; and
               (2)  disclose the new or amended requirement and the
  date and time the requirement goes into effect in the insurer's
  newsletter or network bulletin, if any, and on the insurer's
  Internet website.
         (b)  For a change in a preauthorization requirement or
  process that removes a service from the list of medical care or
  health care services requiring preauthorization or amends a
  preauthorization requirement in a way that is less burdensome to
  insureds, physicians, or health care providers, an insurer shall,
  in accordance with Section 1301.1351:
               (1)  provide written notice of the change in the
  preauthorization requirement and the date and time the change goes
  into effect to each insured, participating physician, and health
  care provider in the insurer's network who provides the medical
  care or health care service; and
               (2)  disclose the change and the date and time the
  change goes into effect in the insurer's newsletter or network
  bulletin, if any, and on the insurer's Internet website [not later
  than the fifth day before the date the change takes effect].
         (c)  Not later than the fifth day before the date a new or
  amended preauthorization requirement takes effect, an insurer
  shall update its Internet website to disclose the change to the
  insurer's preauthorization requirements or process and the date and
  time the change is effective in accordance with Section 1301.1351.
         (c-1)  A new or amended preauthorization requirement imposed
  by an insurer must take effect on a business day.
         SECTION 8.  Subchapter C-1, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.1354 to read as follows:
         Sec. 1301.1354.  ADDITIONAL ENFORCEMENT FOR
  PREAUTHORIZATION VIOLATION. (a) In addition to any other penalty
  or remedy provided by law and if the commissioner determines that an
  insurer has violated Section 1301.135, 1301.1351, or 1301.1352, the
  commissioner shall issue a notice of the violation to the insurer
  and order the insurer to submit a corrective action plan to the
  department. The notice must:
               (1)  indicate the form and manner in which the
  corrective action plan must be submitted to the department; and
               (2)  clearly state the date by which the insurer must
  submit the plan.
         (b)  An insurer that receives a notice under Subsection (a)
  shall, on or before the date described by Subsection (a)(2):
               (1)  submit a corrective action plan in the form and
  manner prescribed by the notice; and
               (2)  as soon as practicable after submission of a
  corrective action plan under Subdivision (1), act to comply with
  the plan.
         (c)  A corrective action plan submitted to the department
  must provide:
               (1)  a detailed description of the corrective action
  the insurer will take to address each violation identified by the
  commissioner and included in the notice provided under Subsection
  (a); and
               (2)  a date by which the insurer will complete the
  corrective action described by Subdivision (1).
         (d)  In addition to any other penalty or remedy provided by
  law, the commissioner shall impose an administrative penalty under
  Chapter 84 on an insurer for each violation of this section or
  Section 1301.135, 1301.1351, or 1301.1352.  For purposes of
  determining a penalty under Subsection (e), each day a violation
  continues is considered a separate violation.
         (e)  The commissioner shall set the amount of an
  administrative penalty described by Subsection (d) in an amount not
  to exceed:
               (1)  for an insurer with a total gross revenue of less
  than $10 million during the preceding calendar year, $10 for each
  violation;
               (2)  for an insurer with a total gross revenue of $10
  million or more but less than $100 million during the preceding
  calendar year, $100 for each violation; or
               (3)  for an insurer with a total gross revenue of $100
  million or more during the preceding calendar year, $1,000 for each
  violation.
         SECTION 9.  The following provisions of the Insurance Code
  are repealed:
               (1)  Sections 843.3481(c) and (d);
               (2)  Section 843.3483;
               (3)  Sections 1301.1351(c) and (d); and
               (4)  Section 1301.1353.
         SECTION 10.  Sections 843.114 and 1301.011, Insurance Code,
  as added by this Act, apply only to a health benefit plan delivered,
  issued for delivery, or renewed on or after January 1, 2026.
         SECTION 11.  A health maintenance organization and insurer
  shall update the health maintenance organization's or insurer's
  Internet website to conform with Section 843.3481 or 1301.1351,
  Insurance Code, as amended by this Act, as applicable, not later
  than January 1, 2026.
         SECTION 12.  Sections 843.3481, 843.3482, 1301.1351, and
  1301.1352, Insurance Code, as amended by this Act, and Sections
  843.3484 and 1301.1354, Insurance Code, as added by this Act, apply
  only to a request for preauthorization of medical care or health
  care services made on or after January 1, 2026, under a health
  benefit plan delivered, issued for delivery, or renewed on or after
  that date.  A request for preauthorization of medical care or health
  care services made before January 1, 2026, or on or after January 1,
  2026, under a health benefit plan delivered, issued for delivery,
  or renewed before that date is governed by the law as it existed
  immediately before the effective date of this Act, and that law is
  continued in effect for that purpose.
         SECTION 13.  This Act takes effect September 1, 2025.