86R21994 JES-F
By: J. Johnson of Dallas H.B. No. 2520
Substitute the following for H.B. No. 2520:
By: Lucio III C.S.H.B. No. 2520
A BILL TO BE ENTITLED
AN ACT
relating to disclosures by certain health benefit plans to
enrollees regarding certain preauthorized medical care and health
care services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter F, Chapter 843, Insurance Code, is
amended by adding Section 843.2025 to read as follows:
Sec. 843.2025. DISCLOSURES CONCERNING CERTAIN
PREAUTHORIZED SERVICES. (a) In this section:
(1) "Elective" means non-emergent, medically
necessary, and able to be scheduled at least 24 hours in advance.
(2) "Facility-based provider" means a physician or
provider who provides a health care service to a patient of a
licensed medical facility and bills for the service provided.
(3) "Licensed medical facility" means:
(A) a hospital licensed under Chapter 241, Health
and Safety Code;
(B) an ambulatory surgical center licensed under
Chapter 243, Health and Safety Code; or
(C) a birthing center licensed under Chapter 244,
Health and Safety Code.
(4) "Preauthorization" has the meaning assigned by
Section 843.348.
(b) A health maintenance organization that preauthorizes an
enrollee's health care service shall provide a disclosure to the
enrollee at the time the health maintenance organization issues a
determination preauthorizing the service if the service:
(1) will be provided at a licensed medical facility;
(2) is elective; and
(3) must be preauthorized as a condition of payment by
the health maintenance organization for the service.
(c) The disclosure provided to an enrollee under Subsection
(b) must include:
(1) a statement of the name and network status of any
facility-based provider that the health maintenance organization
reasonably expects will provide and bill for the preauthorized
service or any anesthesia, pathology, or radiology services
associated with the preauthorized service;
(2) an estimate of:
(A) the payment that the health maintenance
organization will make for the preauthorized service and any
anesthesia, pathology, or radiology services associated with the
preauthorized service; and
(B) the enrollee's financial responsibility,
including any copayment or other out-of-pocket amount, for the
preauthorized service and any anesthesia, pathology, or radiology
services associated with the preauthorized service;
(3) a statement that the actual charges and payment
for the preauthorized service and the enrollee's financial
responsibility for the service may vary from the estimate provided
by the health maintenance organization based on the enrollee's
actual medical condition and other factors associated with the
performance of the service;
(4) a statement substantially similar to the
following: "This notice may not reflect all the physicians and
health care providers who may be involved in and bill for your care.
Despite your health maintenance organization's best efforts to
disclose all physicians and health care providers who we reasonably
expect to participate in your care, circumstances, including
facility scheduling, staff changes, or complications, or other
factors associated with your care, may result in different or
additional physicians or health care providers providing and
billing for care provided to you."; and
(5) a statement that the enrollee may be personally
liable for the amount charged for health care services provided to
the enrollee depending on the enrollee's health benefit plan
coverage.
(d) A general statement that some facility-based providers
may be out-of-network does not satisfy the requirement in
Subsection (c)(1).
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Section 1301.1355 to read as follows:
Sec. 1301.1355. DISCLOSURES CONCERNING CERTAIN
PREAUTHORIZED SERVICES. (a) In this section:
(1) "Elective" means non-emergent, medically
necessary, and able to be scheduled at least 24 hours in advance.
(2) "Facility-based provider" means a physician or
health care provider who provides a medical care or health care
service to a patient of a licensed medical facility and bills for
the service provided.
(3) "Licensed medical facility" means:
(A) a hospital licensed under Chapter 241, Health
and Safety Code;
(B) an ambulatory surgical center licensed under
Chapter 243, Health and Safety Code; or
(C) a birthing center licensed under Chapter 244,
Health and Safety Code.
(b) An insurer that preauthorizes an insured's medical care
or health care service shall provide a disclosure to the insured at
the time the insurer issues a determination preauthorizing the
service if the service:
(1) will be provided at a licensed medical facility;
(2) is elective; and
(3) must be preauthorized as a condition of payment by
the insurer for the service.
(c) The disclosure provided to an insured under Subsection
(b) must include:
(1) a statement of the name and network status of any
facility-based provider that the insurer reasonably expects will
provide and bill for the preauthorized service or any anesthesia,
pathology, or radiology services associated with the preauthorized
service;
(2) an estimate of:
(A) the payment that the insurer will make for
the preauthorized service and any anesthesia, pathology, or
radiology services associated with the preauthorized service; and
(B) the insured's financial responsibility,
including any copayment or other out-of-pocket amount, for the
preauthorized service and any anesthesia, pathology, or radiology
services associated with the preauthorized service;
(3) a statement that the actual charges and payment
for the preauthorized service and the insured's financial
responsibility for the service may vary from the estimate provided
by the insurer based on the insured's actual medical condition and
other factors associated with the performance of the service;
(4) a statement substantially similar to the
following: "This notice may not reflect all the physicians and
health care providers who may be involved in and bill for your care.
Despite your insurer's best efforts to disclose all physicians and
health care providers who we reasonably expect to participate in
your care, circumstances, including facility scheduling, staff
changes, or complications, or other factors associated with your
care, may result in different or additional physicians or health
care providers providing and billing for care provided to you.";
and
(5) a statement that the insured may be personally
liable for the amount charged for medical care or health care
services provided to the insured depending on the insured's health
benefit plan coverage.
(d) A general statement that some facility-based physicians
or health care providers may be out-of-network does not satisfy the
requirement in Subsection (c)(1).
SECTION 3. The changes in law made by this Act apply only to
a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2020.
SECTION 4. This Act takes effect January 1, 2020.