Bill Text: TX SB1186 | 2019-2020 | 86th Legislature | Introduced


Bill Title: Relating to preauthorization of certain medical care and health care services by certain health benefit plan issuers.

Spectrum: Bipartisan Bill

Status: (Introduced) 2019-03-07 - Referred to Business & Commerce [SB1186 Detail]

Download: Texas-2019-SB1186-Introduced.html
  86R7403 JES-F
 
  By: Buckingham, et al. S.B. No. 1186
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to preauthorization of certain medical care and health
  care services by certain health benefit plan issuers.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 843.348(b), Insurance Code, is amended
  to read as follows:
         (b)  A health maintenance organization that uses a
  preauthorization process for health care services shall provide
  each participating physician or provider, not later than the fifth
  [10th] business day after the date a request is made, a list of
  health care services that [do not] require preauthorization and
  information concerning the preauthorization process.
         SECTION 2.  Subchapter J, Chapter 843, Insurance Code, is
  amended by adding Sections 843.3481, 843.3482, 843.3483, and
  843.3484 to read as follows:
         Sec. 843.3481.  POSTING PREAUTHORIZATION REQUIREMENTS. (a)
  A health maintenance organization that uses a preauthorization
  process for health care services shall 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)  be conspicuously posted 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;
               (2)  be written in plain language that is easily
  understandable by enrollees, physicians, providers, and the
  general public;
               (3)  include a detailed description of the
  preauthorization process and the applicable screening criteria
  using Current Procedural Terminology codes and International
  Classification of Diseases codes; and
               (4)  include statistics showing the health maintenance
  organization's preauthorization approvals and denials, including
  for each approval or denial the:
                     (A)  physician specialty;
                     (B)  medication, diagnostic test, or procedure;
                     (C)  indication offered; and
                     (D)  reason for denial.
         Sec. 843.3482.  CHANGES TO PREAUTHORIZATION REQUIREMENTS.
  (a) Not later than the 60th 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 provide each participating physician or provider
  written notice of the new or amended preauthorization requirement
  and disclose the new or amended requirement in the health
  maintenance organization's newsletter or network bulletin, if any.
         (b)  A health maintenance organization shall update its
  Internet website to disclose any change to the health maintenance
  organization's preauthorization requirements or process and the
  date and time the change is effective. A new or amended
  preauthorization requirement may not take effect before the fifth
  day after the date the health maintenance organization's Internet
  website is updated as required by this subsection.
         (c)  A health maintenance organization is not required to
  comply with Subsection (a) or (b) for a change in a preauthorization
  requirement or process that removes a health care service from the
  list of services requiring preauthorization or amends a
  preauthorization requirement in a way that is less burdensome to
  enrollees and participating physicians and providers.
         Sec. 843.3483.  EXEMPTION FROM PREAUTHORIZATION
  REQUIREMENTS. A health maintenance organization that uses a
  preauthorization process for health care services may not require a
  physician or provider to obtain preauthorization for health care
  services if the physician or provider establishes in accordance
  with standards adopted by the commissioner by rule that the
  physician or provider routinely submitted claims to the health
  maintenance organization that were consistent with national
  evidence-based guidelines and that were preauthorized by the health
  maintenance organization.
         Sec. 843.3484.  REMEDY FOR NONCOMPLIANCE; AUTOMATIC
  PREAUTHORIZATION. A health maintenance organization that uses a
  preauthorization process for health care services that violates
  this subchapter with respect to a required publication, notice, or
  response regarding its preauthorization requirements, including by
  failing to comply with any applicable deadline for the publication,
  notice, or response, waives the health maintenance organizations
  preauthorization requirements with respect to any health care
  service affected by the violation.
         SECTION 3.  Section 1301.135(a), Insurance Code, is amended
  to read as follows:
         (a)  An insurer that uses a preauthorization process for
  medical care or [and] health care services shall provide to each
  preferred provider, not later than the fifth [10th] business day
  after the date a request is made, a list of medical care and health
  care services that require preauthorization and information
  concerning the preauthorization process.
         SECTION 4.  Subchapter C-1, Chapter 1301, Insurance Code, is
  amended by adding Sections 1301.1351, 1301.1352, 1301.1353, and
  1301.1354 to read as follows:
         Sec. 1301.1351.  POSTING PREAUTHORIZATION REQUIREMENTS.
  (a) An insurer that uses a preauthorization process for medical
  care or health care services shall 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)  be conspicuously posted 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;
               (2)  be written in plain language that is easily
  understandable by insureds, physicians, health care providers, and
  the general public;
               (3)  include a detailed description of the
  preauthorization process and the applicable screening criteria
  using Current Procedural Terminology codes and International
  Classification of Diseases codes; and
               (4)  include statistics showing the insurer's
  preauthorization approvals and denials, including for each
  approval or denial the:
                     (A)  physician specialty;
                     (B)  medication, diagnostic test, or procedure;
                     (C)  indication offered; and
                     (D)  reason for denial.
         Sec. 1301.1352.  CHANGES TO PREAUTHORIZATION REQUIREMENTS.
  (a) Not later than the 60th 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 provide to each preferred provider written notice of the new
  or amended preauthorization requirement and disclose the new or
  amended requirement in the insurer's newsletter or network
  bulletin, if any.
         (b)  An insurer shall update its Internet website to disclose
  any change to the insurer's preauthorization requirements or
  process and the date and time the change is effective. A new or
  amended preauthorization requirement may not take effect before the
  fifth day after the date the insurer's Internet website is updated
  as required by this subsection.
         (c)  An insurer is not required to comply with Subsection (a)
  or (b) for a change in a preauthorization requirement or process
  that removes a medical care or health care service from the list of
  services requiring preauthorization or amends a preauthorization
  requirement in a way that is less burdensome to insureds,
  physicians, and health care providers.
         Sec. 1301.1353.  EXEMPTION FROM PREAUTHORIZATION
  REQUIREMENTS. An insurer that uses a preauthorization process for
  medical care or health care services may not require a physician or
  health care provider to obtain preauthorization for medical care or
  health care services if the physician or health care provider
  establishes in accordance with standards adopted by the
  commissioner by rule that the physician or health care provider
  routinely submitted claims to the insurer that were consistent with
  national evidence-based guidelines and that were preauthorized by
  the insurer.
         Sec. 1301.1354.  REMEDY FOR NONCOMPLIANCE; AUTOMATIC
  PREAUTHORIZATION. An insurer that uses a preauthorization process
  for medical care or health care services that violates this
  subchapter with respect to a required publication, notice, or
  response regarding its preauthorization requirements, including by
  failing to comply with any applicable deadline for the publication,
  notice, or response, waives the insurer's preauthorization
  requirements with respect to any medical care or health care
  service affected by the violation.
         SECTION 5.  The change in law made by this Act applies only
  to a request for preauthorization of medical care or health care
  services made on or after January 1, 2020. A request for
  preauthorization of medical care or health care services made
  before January 1, 2020, under a health benefit plan delivered,
  issued for delivery, or renewed before that date is governed by the
  law in effect immediately before the effective date of this Act, and
  that law is continued in effect for that purpose.
         SECTION 6.  This Act takes effect September 1, 2019.
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