84R13565 SCL-F
By: Klick H.B. No. 3919
A BILL TO BE ENTITLED
AN ACT
relating to prior authorization from a health benefit plan issuer
to obtain health care services under the health benefit plan.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 32.072(a), Human Resources Code, is
amended to read as follows:
(a) Notwithstanding any other law, a recipient of medical
assistance is entitled to:
(1) select an ophthalmologist or therapeutic
optometrist who is a medical assistance provider to provide eye
health care services, other than surgery, that are within the scope
of:
(A) services provided under the medical
assistance program; and
(B) the professional specialty practice for
which the ophthalmologist or therapeutic optometrist is licensed
and credentialed; and
(2) have direct access to the selected ophthalmologist
or therapeutic optometrist for the provision of the nonsurgical
services without any requirement by the patient or ophthalmologist
or therapeutic optometrist to obtain:
(A) a referral from a primary care physician or
other gatekeeper or health care coordinator; or
(B) any other prior authorization or
precertification.
SECTION 2. Subchapter I, Chapter 843, Insurance Code, is
amended by adding Section 843.324 to read as follows:
Sec. 843.324. PRIOR AUTHORIZATION FOR COVERED BENEFIT
PROHIBITED. Notwithstanding any other law, a health maintenance
organization may not require a physician or provider to obtain
prior authorization from the health maintenance organization for
the health maintenance organization to pay for a covered benefit
provided to an enrollee.
SECTION 3. Chapter 1217, Insurance Code, is amended by
adding Section 1217.008 to read as follows:
Sec. 1217.008. PRIOR AUTHORIZATION STUDY. (a) The
department shall conduct a study of:
(1) the use and effect of prior authorization in this
state from a health benefit plan issuer to pay for a covered benefit
for an enrollee; and
(2) the circumstances that give rise to prior
authorization from a health benefit plan issuer.
(b) The commissioner shall implement the results of the
study by adopting rules regulating, limiting, or prohibiting prior
authorization practices.
SECTION 4. Subchapter B, Chapter 1301, Insurance Code, is
amended by adding Section 1301.070 to read as follows:
Sec. 1301.070. PRIOR AUTHORIZATION FOR COVERED BENEFIT
PROHIBITED. Notwithstanding any other law, an insurer may not
require a physician or health care provider to obtain prior
authorization from the insurer for the insurer to pay for a covered
benefit provided to an enrollee.
SECTION 5. The Texas Department of Insurance shall prepare
a report of the results of the study conducted under Section
1217.008, Insurance Code, as added by this Act. Not later than
December 1, 2016, the department shall provide the report to the
governor, lieutenant governor, speaker of the house of
representatives, and chairs of the house and senate standing
committees with primary jurisdiction over insurance.
SECTION 6. The changes in law made by this Act apply only to
a health benefit plan delivered, issued for delivery, or renewed on
or after January 1, 2016. A health benefit plan delivered, issued
for delivery, or renewed before January 1, 2016, 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 7. This Act takes effect September 1, 2015.