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A BILL TO BE ENTITLED
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AN ACT
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relating to preauthorization of medical care or health care |
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services by certain health benefit plan issuers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.348, Insurance Code, is amended by |
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amending Subsections (a) and (g) and adding Subsection (g-1) to |
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read as follows: |
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(a) In this section: |
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(1) "Preauthorization" [, "preauthorization"] means a |
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determination by a health maintenance organization that health care |
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services proposed to be provided to a patient are medically |
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necessary and appropriate. |
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(2) "Verification" has the meaning assigned by Section |
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843.347. |
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(g) Notwithstanding Section 843.347, if [If] the health |
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maintenance organization has preauthorized health care services, |
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the health maintenance organization may not deny or reduce payment |
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to the physician or provider for those services based on: |
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(1) medical necessity or appropriateness of care |
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unless the physician or provider has materially misrepresented the |
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proposed health care services or has substantially failed to |
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perform the proposed health care services; |
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(2) an eligibility or coverage determination if the |
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proposed health care services are provided to the enrollee before |
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the 31st day after the date the physician or provider received the |
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determination that the health care services were preauthorized |
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unless the physician or provider has materially misrepresented the |
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proposed health care services or has substantially failed to |
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perform the proposed health care services; |
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(3) the fact that a physician or provider did not |
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request or obtain or was not provided a verification from the health |
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maintenance organization; or |
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(4) the health maintenance organization declining or |
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failing to determine an enrollee's eligibility or make coverage |
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determinations in the time frame required for the issuance of a |
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preauthorization determination. |
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(g-1) If a health maintenance organization determines that |
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a health care service is preauthorized, the health maintenance |
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organization shall specify any deductibles, copayments, or |
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coinsurance for which the enrollee is responsible in its |
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determination. |
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SECTION 2. Section 1301.135, Insurance Code, is amended by |
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amending Subsection (f) and adding Subsections (f-1) and (i) to |
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read as follows: |
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(f) Notwithstanding Section 1301.133, if [If] an insurer |
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has preauthorized medical care or health care services, the insurer |
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may not deny or reduce payment to the physician or health care |
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provider for those services based on: |
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(1) medical necessity or appropriateness of care |
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unless the physician or provider has materially misrepresented the |
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proposed medical or health care services or has substantially |
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failed to perform the proposed medical or health care services; |
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(2) an eligibility or coverage determination if the |
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proposed medical care or health care services are provided to the |
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insured before the 31st day after the date the physician or provider |
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received the determination that the medical care or health care |
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services were preauthorized unless the physician or provider has |
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materially misrepresented the proposed medical care or health care |
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services or has substantially failed to perform the proposed |
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medical care or health care services; |
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(3) the fact that a physician or provider did not |
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request or obtain or was not provided a verification from the |
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insurer; or |
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(4) the insurer declining or failing to determine an |
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insured's eligibility or make coverage determinations in the time |
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frame required for the issuance of a preauthorization |
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determination. |
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(f-1) If an insurer determines that a medical care or health |
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care service is preauthorized, the insurer shall specify any |
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deductibles, copayments, or coinsurance for which the insured is |
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responsible in its determination. |
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(i) In this section, "verification" has the meaning |
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assigned by Section 1301.133. |
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SECTION 3. The change in law made by this Act applies only |
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to a health benefit plan that is delivered, issued for delivery, or |
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renewed on or after January 1, 2022. A health benefit plan that is |
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delivered, issued for delivery, or renewed before January 1, 2022, |
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is governed by the law as it existed immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 4. This Act takes effect September 1, 2021. |