86R12010 JES-F
By: Menéndez S.B. No. 1740
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 health care service" means a covered
health care service that is scheduled in advance.
(2) "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.
(3) "Preauthorization" has the meaning assigned by
Section 843.348.
(b) If a health maintenance organization preauthorizes an
elective health care service to be provided at a licensed medical
facility, the health maintenance organization shall, within a
reasonable period before the date the health care service is
scheduled to be performed, provide to the enrollee:
(1) a statement of the name and network status of any
facility-based physician or provider that the health maintenance
organization reasonably expects will provide and charge for the
preauthorized service;
(2) an estimate of:
(A) the payment that will be made for the
preauthorized service; and
(B) the enrollee's financial responsibility for
the preauthorized service, including any copayment or other
out-of-pocket amount for which the enrollee is responsible;
(3) a statement that the actual charges and payment
for the health care service and the enrollee's financial
responsibility for the health care service may vary from the
estimate provided by the health maintenance organization based on
the enrollee's medical condition and other factors associated with
the performance of the health care service; and
(4) 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.
(c) A general statement that some facility-based physicians
or providers may be out-of-network does not satisfy the notice
requirement of Subsection (b).
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 medical care or health care service"
means a covered medical care or health care service that is
scheduled in advance.
(2) "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) If an insurer preauthorizes an elective medical care or
health care service to be provided at a licensed medical facility,
the insurer shall, within a reasonable period before the date the
medical care or health care service is scheduled to be performed,
provide to the insured:
(1) a statement of the name and network status of any
facility-based physician or health care provider that the insurer
reasonably expects will provide and charge for the preauthorized
service;
(2) an estimate of:
(A) the payment that will be made for the
preauthorized service; and
(B) the insured's financial responsibility for
the preauthorized service, including any copayment, coinsurance,
deductible, or other out-of-pocket amount for which the insured is
responsible;
(3) a statement that the actual charges and payment
for the medical care or health care service and the insured's
financial responsibility for the medical care or health care
service may vary from the estimate provided by the insurer based on
the insured's medical condition and other factors associated with
the performance of the medical care or health care service; and
(4) 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.
(c) A general statement that some facility-based physicians
or health care providers may be out-of-network does not satisfy the
notice requirement of Subsection (b).
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.