By: Eltife S.B. No. 1216
(S. Davis of Harris)
A BILL TO BE ENTITLED
AN ACT
relating to the creation of a standard request form for prior
authorization of medical care or health care services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle A, Title 8, Insurance Code, is amended
by adding Chapter 1217 to read as follows:
CHAPTER 1217. STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF
HEALTH CARE SERVICES
Sec. 1217.001. DEFINITIONS. In this chapter:
(1) "Health benefit plan issuer" means an entity
authorized under this code or another insurance law of this state
that delivers or issues for delivery a health benefit plan or other
coverage that is covered under this chapter as described by Section
1217.002. The term includes:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884;
(E) a reciprocal exchange operating under
Chapter 942;
(F) a health maintenance organization operating
under Chapter 843;
(G) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846; or
(H) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844.
(2) "Health care services" includes medical or health
care treatments, consultations, procedures, drugs, supplies,
imaging and diagnostic services, inpatient and outpatient care,
medical devices, and durable medical equipment. The term does not
include prescription drugs as defined by Section 551.003,
Occupations Code.
Sec. 1217.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or a small or large employer group
contract or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium company operating under
Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This chapter applies to group health coverage made
available by a school district in accordance with Section 22.004,
Education Code.
(c) Notwithstanding Section 172.014, Local Government Code,
or any other law, this chapter applies to health and accident
coverage provided by a risk pool created under Chapter 172, Local
Government Code.
(d) Notwithstanding any provision in Chapter 1551, 1575,
1579, or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) basic coverage under Chapter 1601.
(e) Notwithstanding any other law, this chapter applies to
coverage under:
(1) the child health plan program under Chapter 62,
Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; and
(2) a Medicaid managed care program operated under
Chapter 533, Government Code, or a Medicaid program operated under
Chapter 32, Human Resources Code.
Sec. 1217.003. EXCEPTION. This chapter does not apply to:
(1) a health benefit plan that provides coverage:
(A) only for a specified disease or for another
single benefit;
(B) only for accidental death or dismemberment;
(C) only for wages or payments in lieu of wages
for a period during which an employee is absent from work because of
sickness or injury;
(D) as a supplement to a liability insurance
policy;
(E) for credit insurance;
(F) only for dental or vision care;
(G) only for hospital expenses; or
(H) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by
Section 1882, Social Security Act (42 U.S.C. Section 1395ss);
(3) medical payment insurance coverage provided under
a motor vehicle insurance policy; or
(4) a long-term care insurance policy, including a
nursing home fixed indemnity policy, unless the commissioner
determines that the policy provides benefit coverage so
comprehensive that the policy is a health benefit plan as described
by Section 1217.002.
Sec. 1217.004. STANDARD FORM. (a) The commissioner by
rule shall:
(1) prescribe a single, standard form for requesting
prior authorization of health care services;
(2) require a health benefit plan issuer or the agent
of the health benefit plan issuer that manages or administers
health care services benefits to use the form for any prior
authorization required by the plan of health care services; and
(3) require that the department and a health benefit
plan issuer or the agent of the health benefit plan issuer that
manages or administers health care services benefits make the form
available in paper form and electronically on the website of:
(A) the department;
(B) the health benefit plan issuer; and
(C) the agent of the health benefit plan issuer.
(b) Not later than the second anniversary of the date
national standards for electronic prior authorization of benefits
are adopted, a health benefit plan issuer or the agent of the health
benefit plan issuer that manages or administers health care
services benefits shall exchange prior authorization requests
electronically with a physician or health care provider who has
electronic capability and who initiates a request electronically.
For requests initiated on paper, a health benefit plan issuer or the
agent of the health benefit plan issuer that manages or administers
health care services benefits shall accept prior authorization
requests using the standard paper form developed pursuant to this
chapter.
(c) In prescribing a form under this section, the
commissioner shall:
(1) develop the form with input from the advisory
committee on uniform prior authorization forms for health care
services benefits established under Section 1217.005; and
(2) take into consideration:
(A) any form for requesting prior authorization
of health care services benefits that is widely used in this state
or any form currently used by the department;
(B) request forms for prior authorization of
health care services benefits established by the federal Centers
for Medicare and Medicaid Services; and
(C) national standards, or draft standards,
pertaining to electronic prior authorization of benefits.
Sec. 1217.005. ADVISORY COMMITTEE ON UNIFORM PRIOR
AUTHORIZATION FORMS. (a) The commissioner shall appoint a
committee to advise the commissioner on the technical, operational,
and practical aspects of developing the single, standard prior
authorization form required under Section 1217.004 for requesting
prior authorization of health care services, including:
(1) requirements for the health benefit plan issuer or
agent of the health benefit plan issuer to acknowledge receipt of
the standard form;
(2) timelines under which the health benefit plan
issuer or agent of the health benefit plan issuer must acknowledge
receipt of the standard form; and
(3) implications, including administrative penalties,
for the failure of a health benefit plan issuer or agent of a health
benefit plan issuer to:
(A) timely acknowledge receipt of the standard
form; or
(B) use or accept the form.
(b) The commissioner shall consult the advisory committee
with respect to any rule relating to a subject described by Section
1217.004 before adopting the rule and may consult the committee as
needed with respect to a subsequent amendment of an adopted rule.
(c) The advisory committee shall be composed of an equal
number of members from each of the following groups of
stakeholders:
(1) physicians;
(2) health care providers other than physicians;
(3) hospitals;
(4) medical representatives of health benefit plans;
and
(5) Health and Human Services Commission
representatives.
(d) A physician may not serve on the advisory committee as a
physician member under Subsection (c)(1) if the physician is or has
been employed by or consults or has consulted for an insurance
company.
(e) A member of the advisory committee serves without
compensation.
(f) Section 39.003(a) of this code and Chapter 2110,
Government Code, do not apply to the advisory committee.
Sec. 1217.006. FAILURE TO PRESCRIBE STANDARD FORM. Nothing
in this chapter may be construed as authorizing the commissioner to
decline to prescribe the form required by Section 1217.004.
Sec. 1217.007. CONSTRUCTION WITH OTHER LAW. Nothing in
this chapter may be construed as permitting a health benefit plan
issuer or an agent of a health benefit plan issuer to require prior
authorization of health care services benefits when otherwise
prohibited by law.
SECTION 2. Not later than January 1, 2015, the commissioner
of insurance by rule shall prescribe a standard form under Section
1217.004, Insurance Code, as added by this Act.
SECTION 3. The change in law made by this Act applies only
to a request for prior authorization of health care services made on
or after September 1, 2015. A request for prior authorization of
health care services made before September 1, 2015, 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 4. This Act takes effect September 1, 2013.