85R13312 BEE-D
By: Shaheen H.B. No. 3412
A BILL TO BE ENTITLED
AN ACT
relating to preauthorization by certain health benefit plan issuers
of certain covered benefits under the health benefit plan.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter I, Chapter 843, Insurance Code, is
amended by adding Section 843.324 to read as follows:
Sec. 843.324. PREAUTHORIZATION OF CERTAIN COVERED
BENEFITS; WAIVER. (a) The commissioner by rule shall:
(1) specify covered benefits provided to an enrollee
under a health care plan for which the health maintenance
organization is prohibited from requiring a physician or provider
to obtain preauthorization from the health maintenance
organization in order for the health maintenance organization to
pay for the benefit; and
(2) establish a simple procedure under which a
physician or provider may obtain a waiver of a health maintenance
organization's preauthorization requirement for a covered benefit
under circumstances specified by rule.
(b) Rules adopted under Subsection (a) must provide that the
following covered benefits are not subject to preauthorization or
are subject to a waiver of preauthorization requirements:
(1) if a physician or provider determines that an
enrollee has an immediate need for the covered benefit:
(A) durable medical equipment, including
crutches and wheelchairs; or
(B) diagnostic testing; or
(2) another health care service under circumstances
that take into account:
(A) symptoms displayed by the enrollee;
(B) the relationship between the physician or
provider and the enrollee, including the length of the
relationship; and
(C) the professional experience of the physician
or provider.
SECTION 2. Subchapter B, Chapter 1301, Insurance Code, is
amended by adding Section 1301.070 to read as follows:
Sec. 1301.070. PREAUTHORIZATION OF CERTAIN COVERED
BENEFITS; WAIVER. (a) The commissioner by rule shall:
(1) specify covered benefits provided to an insured
under a preferred provider benefit plan for which the insurer is
prohibited from requiring a physician or health care provider to
obtain preauthorization from the insurer in order for the insurer
to pay for the benefit; and
(2) establish a simple procedure under which a
physician or health care provider may obtain a waiver of an
insurer's preauthorization requirement for a covered benefit under
circumstances specified by rule.
(b) Rules adopted under Subsection (a) must provide that the
following covered benefits are not subject to preauthorization or
are subject to a waiver of preauthorization requirements:
(1) if a physician or health care provider determines
that an insured has an immediate need for the covered benefit:
(A) durable medical equipment, including
crutches and wheelchairs; or
(B) diagnostic testing; or
(2) another health care service under circumstances
that take into account:
(A) symptoms displayed by the insured;
(B) the relationship between the physician or
health care provider and the insured, including the length of the
relationship; and
(C) the professional experience of the physician
or health care provider.
SECTION 3. 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, 2018. A health benefit plan delivered, issued
for delivery, or renewed before January 1, 2018, 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, 2017.