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 - Dead) 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 |
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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 | ||
[ |
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health care services that [ |
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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 [ |
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preferred provider, not later than the fifth [ |
||
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. |