86R23802 JES-F
By: Bonnen of Galveston H.B. No. 2327
Substitute the following for H.B. No. 2327:
By: Lucio III C.S.H.B. No. 2327
A BILL TO BE ENTITLED
AN ACT
relating to preauthorization of certain medical care and 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(b), Insurance Code, is amended
to read as follows:
(b) A health maintenance organization that uses a
preauthorization process for health care services shall provide
each participating physician or provider, not later than the fifth
[10th] business day after the date a request is made, a list of
health care services that [do not] require preauthorization and
information concerning the preauthorization process.
SECTION 2. Subchapter J, Chapter 843, Insurance Code, is
amended by adding Sections 843.3481, 843.3482, 843.3483, and
843.3484 to read as follows:
Sec. 843.3481. POSTING OF PREAUTHORIZATION REQUIREMENTS.
(a) A health maintenance organization that uses a preauthorization
process for health care services shall make the requirements and
information about the preauthorization process readily accessible
to enrollees, physicians, providers, and the general public by
posting the requirements and information on the health maintenance
organization's Internet website.
(b) The preauthorization requirements and information
described by Subsection (a) must:
(1) be posted:
(A) conspicuously in a location on the Internet
website that does not require the use of a log-in or other input of
personal information to view the information; and
(B) in a format that is easily searchable and
accessible;
(2) be written in plain language that is easily
understandable by enrollees, physicians, providers, and the
general public;
(3) include a detailed description of the
preauthorization process and procedure; and
(4) include an accurate and current list of the health
care services for which the health maintenance organization
requires preauthorization that includes the following information
specific to each service:
(A) the effective date of the preauthorization
requirement;
(B) a list or description of any supporting
documentation that the health maintenance organization requires
from the physician or provider providing the service to approve a
request for that service;
(C) the applicable screening criteria using
Current Procedural Terminology codes and International
Classification of Diseases codes; and
(D) statistics regarding preauthorization
approval and denial rates for the service in the preceding year and
for each previous year the preauthorization requirement was in
effect, including statistics in the following categories:
(i) physician or provider type and
specialty, if any;
(ii) indication offered;
(iii) reasons for request denial;
(iv) denials overturned on internal appeal;
(v) denials overturned on external appeal;
and
(vi) total annual preauthorization
requests, approvals, and denials for the service.
Sec. 843.3482. CHANGES TO PREAUTHORIZATION REQUIREMENTS.
(a) Except as provided by Subsection (b), not later than the 60th
day before the date a new or amended preauthorization requirement
takes effect, a health maintenance organization that uses a
preauthorization process for health care services shall provide
each participating physician or provider written notice of the new
or amended preauthorization requirement and disclose the new or
amended requirement in the health maintenance organization's
newsletter or network bulletin, if any.
(b) For a change in a preauthorization requirement or
process that removes a service from the list of health care services
requiring preauthorization or amends a preauthorization
requirement in a way that is less burdensome to enrollees and
participating physicians and providers, a health maintenance
organization shall provide each participating physician or
provider written notice of the change in the preauthorization
requirement and disclose the change in the health maintenance
organization's newsletter or network bulletin, if any, not later
than the fifth day before the date the change takes effect.
(c) Not later than the fifth day before the date a new or
amended preauthorization requirement takes effect, a health
maintenance organization shall update its Internet website to
disclose the change to the health maintenance organization's
preauthorization requirements or process and the date and time the
change is effective.
Sec. 843.3483. REMEDY FOR NONCOMPLIANCE; AUTOMATIC WAIVER.
In addition to any other penalty or remedy provided by law, a health
maintenance organization that uses a preauthorization process for
health care services that violates this subchapter with respect to
a required publication, notice, or response regarding its
preauthorization requirements, including by failing to comply with
any applicable deadline for the publication, notice, or response,
waives the health maintenance organization's preauthorization
requirements with respect to any health care service affected by
the violation.
Sec. 843.3484. EFFECT OF PREAUTHORIZATION WAIVER. A waiver
of preauthorization requirements under Section 843.3483 may not be
construed to:
(1) authorize a physician or provider to provide
health care services outside of the scope of the physician's or
provider's applicable license; or
(2) require the health maintenance organization to pay
for a health care service provided outside of the scope of a
physician's or provider's applicable license.
SECTION 3. Section 1301.135(a), Insurance Code, is amended
to read as follows:
(a) An insurer that uses a preauthorization process for
medical care or [and] health care services shall provide to each
preferred provider, not later than the fifth [10th] business day
after the date a request is made, a list of medical care and health
care services that require preauthorization and information
concerning the preauthorization process.
SECTION 4. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Sections 1301.1351, 1301.1352, 1301.1353, and
1301.1354 to read as follows:
Sec. 1301.1351. POSTING OF PREAUTHORIZATION REQUIREMENTS.
(a) An insurer that uses a preauthorization process for medical
care or health care services shall make the requirements and
information about the preauthorization process readily accessible
to insureds, physicians, health care providers, and the general
public by posting the requirements and information on the insurer's
Internet website.
(b) The preauthorization requirements and information
described by Subsection (a) must:
(1) be posted:
(A) conspicuously in a location on the Internet
website that does not require the use of a log-in or other input of
personal information to view the information; and
(B) in a format that is easily searchable and
accessible;
(2) be written in plain language that is easily
understandable by insureds, physicians, health care providers, and
the general public;
(3) include a detailed description of the
preauthorization process and procedure; and
(4) include an accurate and current list of medical
care and health care services for which the insurer requires
preauthorization that includes the following information specific
to each service:
(A) the effective date of the preauthorization
requirement;
(B) a list or description of any supporting
documentation that the insurer requires from the physician or
health care provider providing the service to approve a request for
the service;
(C) the applicable screening criteria using
Current Procedural Terminology codes and International
Classification of Diseases codes; and
(D) statistics regarding the insurer's
preauthorization approval and denial rates for the medical care or
health care service in the preceding year and for each previous year
the preauthorization requirement was in effect, including
statistics in the following categories:
(i) physician or health care provider
specialty, if any;
(ii) indication offered;
(iii) reasons for request denial;
(iv) denials overturned on internal appeal;
(v) denials overturned on external appeal;
and
(vi) total annual preauthorization
requests, approvals, and denials for the service.
(c) The provisions of this section may not be waived,
voided, or nullified by contract.
Sec. 1301.1352. CHANGES TO PREAUTHORIZATION REQUIREMENTS.
(a) Except as provided by Subsection (b), not later than the 60th
day before the date a new or amended preauthorization requirement
takes effect, an insurer that uses a preauthorization process for
medical care or health care services shall provide to each
preferred provider written notice of the new or amended
preauthorization requirement and disclose the new or amended
requirement in the insurer's newsletter or network bulletin, if
any.
(b) For a change in a preauthorization requirement or
process that removes a service from the list of medical care or
health care services requiring preauthorization or amends a
preauthorization requirement in a way that is less burdensome to
insureds, physicians, and health care providers, an insurer shall
provide each preferred provider written notice of the change in the
preauthorization requirement and disclose the change in the
insurer's newsletter or network bulletin, if any, not later than
the fifth day before the date the change takes effect.
(c) Not later than the fifth day before the date a new or
amended preauthorization requirement takes effect, an insurer
shall update its Internet website to disclose the change to the
insurer's preauthorization requirements or process and the date and
time the change is effective.
(d) The provisions of this section may not be waived,
voided, or nullified by contract.
Sec. 1301.1353. REMEDY FOR NONCOMPLIANCE; AUTOMATIC
WAIVER. (a) In addition to any other penalty or remedy provided by
law, an insurer that uses a preauthorization process for medical
care or health care services that violates this subchapter with
respect to a required publication, notice, or response regarding
its preauthorization requirements, including by failing to comply
with any applicable deadline for the publication, notice, or
response, waives the insurer's preauthorization requirements with
respect to any medical care or health care service affected by the
violation.
(b) The provisions of this section may not be waived,
voided, or nullified by contract.
Sec. 1301.1354. EFFECT OF PREAUTHORIZATION WAIVER. (a) A
waiver of preauthorization requirements under Section 1301.1353
may not be construed to:
(1) authorize a physician or health care provider to
provide medical care or health care services outside of the scope of
the physician's or health care provider's applicable license; or
(2) require the insurer to pay for a medical care or
health care service provided outside of the scope of a physician's
or health care provider's applicable license.
(b) The provisions of this section may not be waived,
voided, or nullified by contract.
SECTION 5. The change in law made by this Act applies only
to a request for preauthorization of medical care or health care
services made on or after January 1, 2020, under a health benefit
plan delivered, issued for delivery, or renewed on or after that
date. A request for preauthorization of medical care or health care
services made before January 1, 2020, or on or after January 1,
2020, under a health benefit plan delivered, issued for delivery,
or renewed before that date 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 6. This Act takes effect September 1, 2019.