Texas 2021 - 87th Regular

Texas House Bill HB1145 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	87R994 SCL-D
2	2	By: Johnson of Dallas H.B. No. 1145
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to utilization review requirements for a health care
8	8	service provided by a network physician or provider.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter J, Chapter 843, Insurance Code, is
11	11	amended by adding Section 843.355 to read as follows:
12	12	Sec. 843.355. UTILIZATION REVIEW FOR PARTICIPATING
13	13	PHYSICIAN OR PROVIDER PROHIBITED. A health maintenance
14	14	organization may not require utilization review, including a
15	15	preauthorization determination that a health care service is
16	16	medically necessary and appropriate, of a health care service
17	17	provided to an enrollee by a participating physician or provider.
18	18	SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is
19	19	amended by adding Section 1301.1345 to read as follows:
20	20	Sec. 1301.1345. UTILIZATION REVIEW FOR PREFERRED PHYSICIAN
21	21	OR PROVIDER PROHIBITED. (a) In this section, "utilization review"
22	22	has the meaning assigned by Section 4201.002.
23	23	(b) An insurer may not require utilization review,
24	24	including preauthorization, of a medical care or health care
25	25	service provided to an insured by a preferred physician or
26	26	provider.
27	27	SECTION 3. The heading to Section 1301.135, Insurance Code,
28	28	is amended to read as follows:
29	29	Sec. 1301.135. PREAUTHORIZATION OF MEDICAL AND HEALTH CARE
30	30	SERVICES FOR NONPREFERRED PHYSICIAN OR PROVIDER.
31	31	SECTION 4. Sections 1301.135(d) and (f), Insurance Code,
32	32	are amended to read as follows:
33	33	(d) If [the] proposed medical care or health care services
34	34	involve inpatient care and the insurer requires preauthorization as
35	35	a condition of payment of a nonpreferred provider, the insurer
36	36	shall review the request and issue a length of stay for the
37	37	admission into a health care facility based on the recommendation
38	38	of the patient's nonpreferred [physician or health care] provider
39	39	and the insurer's written medically accepted screening criteria and
40	40	review procedures. If the proposed medical or health care services
41	41	are to be provided to a patient who is an inpatient in a health care
42	42	facility at the time the services are proposed, the insurer shall
43	43	review the request and issue a determination indicating whether
44	44	proposed services are preauthorized within 24 hours of the request
45	45	by the nonpreferred physician or provider.
46	46	(f) If an insurer has preauthorized medical care or health
47	47	care services, the insurer may not deny or reduce payment to the
48	48	nonpreferred physician or health care provider for those services
49	49	based on medical necessity or appropriateness of care unless the
50	50	nonpreferred physician or provider has materially misrepresented
51	51	the proposed medical or health care services or has substantially
52	52	failed to perform the proposed medical or health care services.
53	53	SECTION 5. Section 1301.1351(d), Insurance Code, is amended
54	54	to read as follows:
55	55	(d) If a requirement or information described by Subsection
56	56	(a) is licensed, proprietary, or copyrighted material that the
57	57	insurer has received from a third party with which the insurer has
58	58	contracted, to comply with a posting requirement described by
59	59	Subsection (b), the insurer may, instead of making that information
60	60	publicly available on the insurer's Internet website, provide the
61	61	material to a nonpreferred [physician or health care] provider who
62	62	submits a preauthorization request using a nonpublic secured
63	63	Internet website link or other protected, nonpublic electronic
64	64	means.
65	65	SECTION 6. The following provisions of the Insurance Code
66	66	are repealed:
67	67	(1) Section 843.348;
68	68	(2) Section 843.3481;
69	69	(3) Section 843.3482;
70	70	(4) Section 843.3483; and
71	71	(5) Sections 1301.135(a), (b), and (c).
72	72	SECTION 7. The changes in law made by this Act apply only to
73	73	a health benefit plan delivered, issued for delivery, or renewed on
74	74	or after January 1, 2022. A health benefit plan delivered, issued
75	75	for delivery, or renewed before January 1, 2022, is governed by the
76	76	law as it existed immediately before the effective date of this Act,
77	77	and that law is continued in effect for that purpose.
78	78	SECTION 8. This Act takes effect September 1, 2021.