Bill Text: TX HB2520 | 2019-2020 | 86th Legislature | Comm Sub
Bill Title: Relating to disclosures by certain health benefit plans to enrollees regarding certain preauthorized medical care and health care services.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2019-04-11 - Committee report sent to Calendars [HB2520 Detail]
Download: Texas-2019-HB2520-Comm_Sub.html
86R21994 JES-F | |||
By: J. Johnson of Dallas | H.B. No. 2520 | ||
Substitute the following for H.B. No. 2520: | |||
By: Lucio III | C.S.H.B. No. 2520 |
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relating to disclosures by certain health benefit plans to | ||
enrollees regarding certain preauthorized medical care and health | ||
care services. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subchapter F, Chapter 843, Insurance Code, is | ||
amended by adding Section 843.2025 to read as follows: | ||
Sec. 843.2025. DISCLOSURES CONCERNING CERTAIN | ||
PREAUTHORIZED SERVICES. (a) In this section: | ||
(1) "Elective" means non-emergent, medically | ||
necessary, and able to be scheduled at least 24 hours in advance. | ||
(2) "Facility-based provider" means a physician or | ||
provider who provides a health care service to a patient of a | ||
licensed medical facility and bills for the service provided. | ||
(3) "Licensed medical facility" means: | ||
(A) a hospital licensed under Chapter 241, Health | ||
and Safety Code; | ||
(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. | ||
(4) "Preauthorization" has the meaning assigned by | ||
Section 843.348. | ||
(b) A health maintenance organization that preauthorizes an | ||
enrollee's health care service shall provide a disclosure to the | ||
enrollee at the time the health maintenance organization issues a | ||
determination preauthorizing the service if the service: | ||
(1) will be provided at a licensed medical facility; | ||
(2) is elective; and | ||
(3) must be preauthorized as a condition of payment by | ||
the health maintenance organization for the service. | ||
(c) The disclosure provided to an enrollee under Subsection | ||
(b) must include: | ||
(1) a statement of the name and network status of any | ||
facility-based provider that the health maintenance organization | ||
reasonably expects will provide and bill for the preauthorized | ||
service or any anesthesia, pathology, or radiology services | ||
associated with the preauthorized service; | ||
(2) an estimate of: | ||
(A) the payment that the health maintenance | ||
organization will make for the preauthorized service and any | ||
anesthesia, pathology, or radiology services associated with the | ||
preauthorized service; and | ||
(B) the enrollee's financial responsibility, | ||
including any copayment or other out-of-pocket amount, for the | ||
preauthorized service and any anesthesia, pathology, or radiology | ||
services associated with the preauthorized service; | ||
(3) a statement that the actual charges and payment | ||
for the preauthorized service and the enrollee's financial | ||
responsibility for the service may vary from the estimate provided | ||
by the health maintenance organization based on the enrollee's | ||
actual medical condition and other factors associated with the | ||
performance of the service; | ||
(4) a statement substantially similar to the | ||
following: "This notice may not reflect all the physicians and | ||
health care providers who may be involved in and bill for your care. | ||
Despite your health maintenance organization's best efforts to | ||
disclose all physicians and health care providers who we reasonably | ||
expect to participate in your care, circumstances, including | ||
facility scheduling, staff changes, or complications, or other | ||
factors associated with your care, may result in different or | ||
additional physicians or health care providers providing and | ||
billing for care provided to you."; and | ||
(5) a statement that the enrollee may be personally | ||
liable for the amount charged for health care services provided to | ||
the enrollee depending on the enrollee's health benefit plan | ||
coverage. | ||
(d) A general statement that some facility-based providers | ||
may be out-of-network does not satisfy the requirement in | ||
Subsection (c)(1). | ||
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is | ||
amended by adding Section 1301.1355 to read as follows: | ||
Sec. 1301.1355. DISCLOSURES CONCERNING CERTAIN | ||
PREAUTHORIZED SERVICES. (a) In this section: | ||
(1) "Elective" means non-emergent, medically | ||
necessary, and able to be scheduled at least 24 hours in advance. | ||
(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. | ||
(3) "Licensed medical facility" means: | ||
(A) a hospital licensed under Chapter 241, Health | ||
and Safety Code; | ||
(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. | ||
(b) An insurer that preauthorizes an insured's medical care | ||
or health care service shall provide a disclosure to the insured at | ||
the time the insurer issues a determination preauthorizing the | ||
service if the service: | ||
(1) will be provided at a licensed medical facility; | ||
(2) is elective; and | ||
(3) must be preauthorized as a condition of payment by | ||
the insurer for the service. | ||
(c) The disclosure provided to an insured under Subsection | ||
(b) must include: | ||
(1) a statement of the name and network status of any | ||
facility-based provider that the insurer reasonably expects will | ||
provide and bill for the preauthorized service or any anesthesia, | ||
pathology, or radiology services associated with the preauthorized | ||
service; | ||
(2) an estimate of: | ||
(A) the payment that the insurer will make for | ||
the preauthorized service and any anesthesia, pathology, or | ||
radiology services associated with the preauthorized service; and | ||
(B) the insured's financial responsibility, | ||
including any copayment or other out-of-pocket amount, for the | ||
preauthorized service and any anesthesia, pathology, or radiology | ||
services associated with the preauthorized service; | ||
(3) a statement that the actual charges and payment | ||
for the preauthorized service and the insured's financial | ||
responsibility for the service may vary from the estimate provided | ||
by the insurer based on the insured's actual medical condition and | ||
other factors associated with the performance of the service; | ||
(4) a statement substantially similar to the | ||
following: "This notice may not reflect all the physicians and | ||
health care providers who may be involved in and bill for your care. | ||
Despite your insurer's best efforts to disclose all physicians and | ||
health care providers who we reasonably expect to participate in | ||
your care, circumstances, including facility scheduling, staff | ||
changes, or complications, or other factors associated with your | ||
care, may result in different or additional physicians or health | ||
care providers providing and billing for care provided to you."; | ||
and | ||
(5) a statement that the insured may be personally | ||
liable for the amount charged for medical care or health care | ||
services provided to the insured depending on the insured's health | ||
benefit plan coverage. | ||
(d) A general statement that some facility-based physicians | ||
or health care providers may be out-of-network does not satisfy the | ||
requirement in Subsection (c)(1). | ||
SECTION 3. The changes in law made by this Act apply only to | ||
a health benefit plan that is delivered, issued for delivery, or | ||
renewed on or after January 1, 2020. | ||
SECTION 4. This Act takes effect January 1, 2020. |