Texas 2019 - 86th Regular

Texas House Bill HB2520 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	~~86R21994~~ JES-F
	1	+	86R12010 JES-F
2	2		By: J. Johnson of Dallas H.B. No. 2520
3		-	Substitute the following for H.B. No. 2520:
4		-	By: Lucio III C.S.H.B. No. 2520
5	3
6	4
7	5		A BILL TO BE ENTITLED
8	6		AN ACT
9	7		relating to disclosures by certain health benefit plans to
10	8		enrollees regarding certain preauthorized medical care and health
11	9		care services.
12	10		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	11		SECTION 1. Subchapter F, Chapter 843, Insurance Code, is
14	12		amended by adding Section 843.2025 to read as follows:
15	13		Sec. 843.2025. DISCLOSURES CONCERNING CERTAIN
16	14		PREAUTHORIZED SERVICES. (a) In this section:
17		-	(1) "Elective" means non-emergent, medically
18		-	necessary, and able to be scheduled at least 24 hours in advance.
19		-	(2) "Facility-based provider" means a physician or
20		-	provider who provides a health care service to a patient of a
21		-	licensed medical facility and bills for the service provided.
22		-	(3) "Licensed medical facility" means:
	15	+	(1) "Elective health care service" means a covered
	16	+	health care service that is scheduled in advance.
	17	+	(2) "Licensed medical facility" means:
23	18		(A) a hospital licensed under Chapter 241, Health
24	19		and Safety Code;
25	20		(B) an ambulatory surgical center licensed under
26	21		Chapter 243, Health and Safety Code; or
27	22		(C) a birthing center licensed under Chapter 244,
28	23		Health and Safety Code.
29		-	(4) "Preauthorization" has the meaning assigned by
	24	+	(3) "Preauthorization" has the meaning assigned by
30	25		Section 843.348.
31		-	(b) A health maintenance organization that preauthorizes an
32		-	enrollee's health care service shall provide a disclosure to the
33		-	enrollee at the time the health maintenance organization issues a
34		-	determination preauthorizing the service if the service:
35		-	(1) will be provided at a licensed medical facility;
36		-	(2) is elective; and
37		-	(3) must be preauthorized as a condition of payment by
38		-	the health maintenance organization for the service.
39		-	(c) The disclosure provided to an enrollee under Subsection
40		-	(b) must include:
	26	+	(b) If a health maintenance organization preauthorizes an
	27	+	elective health care service to be provided at a licensed medical
	28	+	facility, the health maintenance organization shall, within a
	29	+	reasonable period before the date the health care service is
	30	+	scheduled to be performed, provide to the enrollee:
41	31		(1) a statement of the name and network status of any
42		-	facility-based provider that the health maintenance organization
43		-	reasonably expects will provide and bill for the preauthorized
44		-	service or any anesthesia, pathology, or radiology services
45		-	associated with the preauthorized service;
	32	+	facility-based physician or provider that the health maintenance
	33	+	organization reasonably expects will provide and charge for the
	34	+	preauthorized service;
46	35		(2) an estimate of:
47		-	(A) the payment that the health maintenance
48		-	organization will make for the preauthorized service and any
49		-	anesthesia, pathology, or radiology services associated with the
	36	+	(A) the payment that will be made for the
50	37		preauthorized service; and
51		-	(B) the enrollee's financial responsibility,
52		-	including any copayment or other out-of-pocket amount, for the
53		-	preauthorized service and any anesthesia, pathology, or radiology
54		-	services associated with the preauthorized service;
	38	+	(B) the enrollee's financial responsibility for
	39	+	the preauthorized service, including any copayment or other
	40	+	out-of-pocket amount for which the enrollee is responsible;
55	41		(3) a statement that the actual charges and payment
56		-	for the preauthorized service and the enrollee's financial
57		-	responsibility for the service may vary from the estimate provided
58		-	by the health maintenance organization based on the enrollee's
59		-	actual medical condition and other factors associated with the
60		-	performance of the service;
61		-	(4) a statement substantially similar to the
62		-	following: "This notice may not reflect all the physicians and
63		-	health care providers who may be involved in and bill for your care.
64		-	Despite your health maintenance organization's best efforts to
65		-	disclose all physicians and health care providers who we reasonably
66		-	expect to participate in your care, circumstances, including
67		-	facility scheduling, staff changes, or complications, or other
68		-	factors associated with your care, may result in different or
69		-	additional physicians or health care providers providing and
70		-	billing for care provided to you."; and
71		-	(5) a statement that the enrollee may be personally
	42	+	for the health care service and the enrollee's financial
	43	+	responsibility for the health care service may vary from the
	44	+	estimate provided by the health maintenance organization based on
	45	+	the enrollee's medical condition and other factors associated with
	46	+	the performance of the health care service; and
	47	+	(4) a statement that the enrollee may be personally
72	48		liable for the amount charged for health care services provided to
73	49		the enrollee depending on the enrollee's health benefit plan
74	50		coverage.
75		-	(d) A general statement that some facility-based ~~providers~~
76		-	may be out-of-network does not satisfy the ~~requirement in~~
77		-	Subsection (~~c)(1~~).
	51	+	(c) A general statement that some facility-based physicians
	52	+	or providers may be out-of-network does not satisfy the notice
	53	+	requirement of Subsection (b).
78	54		SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is
79	55		amended by adding Section 1301.1355 to read as follows:
80	56		Sec. 1301.1355. DISCLOSURES CONCERNING CERTAIN
81	57		PREAUTHORIZED SERVICES. (a) In this section:
82		-	(1) "Elective" means non-emergent, medically
83		-	necessary, and able to be scheduled at least 24 hours in advance.
84		-	(2) "Facility-based provider" means a physician or
85		-	health care provider who provides a medical care or health care
86		-	service to a patient of a licensed medical facility and bills for
87		-	the service provided.
88		-	(3) "Licensed medical facility" means:
	58	+	(1) "Elective medical care or health care service"
	59	+	means a covered medical care or health care service that is
	60	+	scheduled in advance.
	61	+	(2) "Licensed medical facility" means:
89	62		(A) a hospital licensed under Chapter 241, Health
90	63		and Safety Code;
91	64		(B) an ambulatory surgical center licensed under
92	65		Chapter 243, Health and Safety Code; or
93	66		(C) a birthing center licensed under Chapter 244,
94	67		Health and Safety Code.
95		-	(b) An insurer that preauthorizes an insured's medical care
96		-	or health care service shall provide a disclosure to the insured at
97		-	the time the insurer issues a determination preauthorizing the
98		-	service if the service:
99		-	(1) will be provided at a licensed medical facility;
100		-	(2) is elective; and
101		-	(3) must be preauthorized as a condition of payment by
102		-	the insurer for the service.
103		-	(c) The disclosure provided to an insured under Subsection
104		-	(b) must include:
	68	+	(b) If an insurer preauthorizes an elective medical care or
	69	+	health care service to be provided at a licensed medical facility,
	70	+	the insurer shall, within a reasonable period before the date the
	71	+	medical care or health care service is scheduled to be performed,
	72	+	provide to the insured:
105	73		(1) a statement of the name and network status of any
106		-	facility-based provider that the insurer reasonably expects will
107		-	provide and bill for the preauthorized service or any anesthesia,
108		-	pathology, or radiology services associated with the preauthorized
	74	+	facility-based physician or health care provider that the insurer
	75	+	reasonably expects will provide and charge for the preauthorized
109	76		service;
110	77		(2) an estimate of:
111		-	(A) the payment that the insurer will make for
112		-	the preauthorized service and any anesthesia, pathology, or
113		-	radiology services associated with the preauthorized service; and
114		-	(B) the insured's financial responsibility,
115		-	including any copayment or other out-of-pocket amount, for the
116		-	preauthorized service and any anesthesia, pathology, or radiology
117		-	services associated with the preauthorized service;
	78	+	(A) the payment that will be made for the
	79	+	preauthorized service; and
	80	+	(B) the insured's financial responsibility for
	81	+	the preauthorized service, including any copayment, coinsurance,
	82	+	deductible, or other out-of-pocket amount for which the insured is
	83	+	responsible;
118	84		(3) a statement that the actual charges and payment
119		-	for the preauthorized service and the insured's financial
120		-	responsibility for the service may vary from the estimate provided
121		-	by the insurer based on the insured's actual medical condition and
122		-	other factors associated with the performance of the service;
123		-	(4) a statement substantially similar to the
124		-	following: "This notice may not reflect all the physicians and
125		-	health care providers who may be involved in and bill for your care.
126		-	Despite your insurer's best efforts to disclose all physicians and
127		-	health care providers who we reasonably expect to participate in
128		-	your care, circumstances, including facility scheduling, staff
129		-	changes, or complications, or other factors associated with your
130		-	care, may result in different or additional physicians or health
131		-	care providers providing and billing for care provided to you.";
132		-	and
133		-	(5) a statement that the insured may be personally
	85	+	for the medical care or health care service and the insured's
	86	+	financial responsibility for the medical care or health care
	87	+	service may vary from the estimate provided by the insurer based on
	88	+	the insured's medical condition and other factors associated with
	89	+	the performance of the medical care or health care service; and
	90	+	(4) a statement that the insured may be personally
134	91		liable for the amount charged for medical care or health care
135	92		services provided to the insured depending on the insured's health
136	93		benefit plan coverage.
137		-	(d) A general statement that some facility-based physicians
	94	+	(c) A general statement that some facility-based physicians
138	95		or health care providers may be out-of-network does not satisfy the
139		-	requirement in Subsection (~~c)(1~~).
	96	+	notice requirement of Subsection (b).
140	97		SECTION 3. The changes in law made by this Act apply only to
141	98		a health benefit plan that is delivered, issued for delivery, or
142	99		renewed on or after January 1, 2020.
143	100		SECTION 4. This Act takes effect January 1, 2020.