Bill Text: TX HB4531 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to preauthorization of medical care or health care services by certain health benefit plan issuers.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2021-03-29 - Referred to Insurance [HB4531 Detail]
Download: Texas-2021-HB4531-Introduced.html
87R8216 RDS-F | ||
By: Oliverson | H.B. No. 4531 |
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relating to preauthorization of medical care or 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, Insurance Code, is amended by | ||
amending Subsections (a) and (g) and adding Subsection (g-1) to | ||
read as follows: | ||
(a) In this section: | ||
(1) "Preauthorization" [ |
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determination by a health maintenance organization that health care | ||
services proposed to be provided to a patient are medically | ||
necessary and appropriate. | ||
(2) "Verification" has the meaning assigned by Section | ||
843.347. | ||
(g) Notwithstanding Section 843.347, if [ |
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maintenance organization has preauthorized health care services, | ||
the health maintenance organization may not deny or reduce payment | ||
to the physician or provider for those services based on: | ||
(1) medical necessity or appropriateness of care | ||
unless the physician or provider has materially misrepresented the | ||
proposed health care services or has substantially failed to | ||
perform the proposed health care services; | ||
(2) an eligibility or coverage determination if the | ||
proposed health care services are provided to the enrollee before | ||
the 31st day after the date the physician or provider received the | ||
determination that the health care services were preauthorized | ||
unless the physician or provider has materially misrepresented the | ||
proposed health care services or has substantially failed to | ||
perform the proposed health care services; | ||
(3) the fact that a physician or provider did not | ||
request or obtain or was not provided a verification from the health | ||
maintenance organization; or | ||
(4) the health maintenance organization declining or | ||
failing to determine an enrollee's eligibility or make coverage | ||
determinations in the time frame required for the issuance of a | ||
preauthorization determination. | ||
(g-1) If a health maintenance organization determines that | ||
a health care service is preauthorized, the health maintenance | ||
organization shall specify any deductibles, copayments, or | ||
coinsurance for which the enrollee is responsible in its | ||
determination. | ||
SECTION 2. Section 1301.135, Insurance Code, is amended by | ||
amending Subsection (f) and adding Subsections (f-1) and (i) to | ||
read as follows: | ||
(f) Notwithstanding Section 1301.133, if [ |
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has preauthorized medical care or health care services, the insurer | ||
may not deny or reduce payment to the physician or health care | ||
provider for those services based on: | ||
(1) medical necessity or appropriateness of care | ||
unless the physician or provider has materially misrepresented the | ||
proposed medical or health care services or has substantially | ||
failed to perform the proposed medical or health care services; | ||
(2) an eligibility or coverage determination if the | ||
proposed medical care or health care services are provided to the | ||
insured before the 31st day after the date the physician or provider | ||
received the determination that the medical care or health care | ||
services were preauthorized unless the physician or provider has | ||
materially misrepresented the proposed medical care or health care | ||
services or has substantially failed to perform the proposed | ||
medical care or health care services; | ||
(3) the fact that a physician or provider did not | ||
request or obtain or was not provided a verification from the | ||
insurer; or | ||
(4) the insurer declining or failing to determine an | ||
insured's eligibility or make coverage determinations in the time | ||
frame required for the issuance of a preauthorization | ||
determination. | ||
(f-1) If an insurer determines that a medical care or health | ||
care service is preauthorized, the insurer shall specify any | ||
deductibles, copayments, or coinsurance for which the insured is | ||
responsible in its determination. | ||
(i) In this section, "verification" has the meaning | ||
assigned by Section 1301.133. | ||
SECTION 3. The change in law made by this Act applies only | ||
to a health benefit plan that is delivered, issued for delivery, or | ||
renewed on or after January 1, 2022. A health benefit plan that is | ||
delivered, issued for delivery, or renewed before January 1, 2022, | ||
is governed by the law as it existed immediately before the | ||
effective date of this Act, and that law is continued in effect for | ||
that purpose. | ||
SECTION 4. This Act takes effect September 1, 2021. |