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A BILL TO BE ENTITLED
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AN ACT
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relating to health benefit plan preauthorization requirements for |
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participating physicians and providers providing certain 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. Chapter 4201, Insurance Code, is amended by |
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adding Subchapter O to read as follows: |
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SUBCHAPTER O. PREAUTHORIZATION REQUIREMENTS FOR PARTICIPATING |
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PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES |
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Sec. 4201.701. DEFINITIONS. In this subchapter: |
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(1) "Health care services" has the meaning assigned by |
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Section 843.002. |
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(2) "Intervention-necessary care" means health care |
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services, other than emergency care: |
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(A) that are typically provided in a physician's |
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office or other outpatient setting; |
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(B) that are provided to treat an acute injury, |
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illness, or condition; and |
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(C) that: |
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(i) if not provided, would place the |
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individual receiving the health care services at risk of: |
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(a) acquiring an irreversible injury, |
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illness, or condition; or |
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(b) requiring emergency care or other |
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health care services provided in an inpatient setting; or |
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(ii) are provided to an individual with an |
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injury, illness, or condition that is severe or painful enough to |
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lead a prudent layperson possessing an average knowledge of |
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medicine and health to believe that the individual's injury, |
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illness, or condition is of a nature that failure to obtain |
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treatment within a reasonable amount of time would result in |
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serious deterioration of the injury, illness, or condition. |
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(3) "Physician" has the meaning assigned by Section |
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843.002. |
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(4) "Preauthorization" means a determination by a |
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health maintenance organization, insurer, or person contracting |
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with a health maintenance organization or insurer that health care |
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services proposed to be provided to a patient are medically |
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necessary and appropriate. |
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(5) "Provider" has the meaning assigned by Section |
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843.002. |
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Sec. 4201.702. APPLICABILITY OF SUBCHAPTER. This |
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subchapter applies only to: |
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(1) a health benefit plan offered by a health |
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maintenance organization operating under Chapter 843, except that |
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this subchapter does not apply to: |
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(A) the child health plan program under Chapter |
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62, 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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(B) the state Medicaid program, including the |
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Medicaid managed care program operated under Chapter 540, |
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Government Code; |
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(2) a preferred provider benefit plan or exclusive |
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provider benefit plan offered by an insurer under Chapter 1301; and |
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(3) a person who contracts with a health maintenance |
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organization or insurer to issue preauthorization determinations |
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or perform the functions described by this subchapter for a health |
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benefit plan to which this subchapter applies. |
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Sec. 4201.703. CONSTRUCTION OF SUBCHAPTER. This subchapter |
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may not be construed to: |
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(1) authorize a physician or provider to provide a |
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health care service outside the scope of the physician's or |
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provider's applicable license issued under Title 3, Occupations |
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Code; or |
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(2) require a health maintenance organization or |
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insurer to pay for a health care service described by Subdivision |
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(1) that is performed in violation of the laws of this state. |
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Sec. 4201.704. PROHIBITED PREAUTHORIZATION REQUIREMENTS |
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FOR PARTICIPATING PHYSICIANS AND PROVIDERS PROVIDING CERTAIN |
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HEALTH CARE SERVICES. A health maintenance organization or insurer |
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may not require a participating physician or provider to obtain |
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preauthorization for the following health care services: |
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(1) emergency care; |
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(2) intervention-necessary care provided by an |
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individual licensed to practice medicine in this state; |
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(3) outpatient mental health care treatment or |
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outpatient substance use disorder treatment, except for the |
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provision of prescription drugs or intravenous infusions; |
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(4) intravitreal prescription drugs and health care |
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services provided by an ophthalmologist in accordance with National |
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Eye Institute guidelines to treat an eye injury, condition, or |
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illness that may lead to immediate vision loss; |
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(5) health care services with an "A" or "B" |
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recommendation from the United States Preventive Services Task |
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Force; |
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(6) preventive health care services described by 45 |
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C.F.R. Section 147.130; or |
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(7) health care services provided under a fully |
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capitated risk-sharing or capitation arrangement, unless otherwise |
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agreed to by the participating physician or provider. |
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Sec. 4201.705. EFFECT OF PROHIBITED PREAUTHORIZATION |
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REQUIREMENTS. (a) A health maintenance organization or insurer |
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may not deny or reduce payment to a physician or provider for a |
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health care service for which the physician or provider is not |
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required to obtain preauthorization under Section 4201.704 unless |
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the physician or provider: |
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(1) knowingly and materially misrepresented the |
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health care service or the nature of an acute injury, condition, or |
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illness in a request for payment submitted to the health |
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maintenance organization or insurer with the specific intent to |
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deceive and obtain an unlawful payment from the health maintenance |
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organization or insurer; or |
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(2) failed to substantially perform the health care |
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service. |
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(b) A health maintenance organization or an insurer may not |
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conduct a retrospective review of a health care service for which |
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the physician or provider is not required to obtain |
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preauthorization under Section 4201.704 unless the health |
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maintenance organization or insurer has a reasonable cause to |
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suspect a basis for denial exists under Subsection (a). |
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(c) For a retrospective review described by Subsection (b), |
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nothing in this subchapter may be construed to modify or otherwise |
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affect: |
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(1) the requirements under or application of Section |
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4201.305, including any timeframes specified by that section; or |
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(2) any other applicable law, except to prescribe the |
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only circumstances under which: |
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(A) a retrospective utilization review may occur |
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as specified by Subsection (b); or |
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(B) payment may be denied or reduced as specified |
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by Subsection (a). |
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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 is not required to obtain preauthorization under Section |
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4201.704, the health maintenance organization or insurer must |
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promptly provide a written notice to the physician or provider that |
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includes: |
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(1) a statement that the health maintenance |
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organization or insurer may not require preauthorization for that |
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health care service; and |
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(2) a notification of the health maintenance |
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organization's or insurer's payment requirements. |
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SECTION 2. Subchapter O, Chapter 4201, Insurance Code, as |
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added by this Act, applies only to a request for preauthorization |
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under a health benefit plan that is delivered, issued for delivery, |
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or renewed on or after January 1, 2026. |
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SECTION 3. This Act takes effect September 1, 2025. |
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* * * * * |