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

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

Spectrum: Bipartisan Bill

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

Download: Texas-2019-SB1186-Introduced.html

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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.