87R19495 JES-F
By: Bonnen H.B. No. 4012
Substitute the following for H.B. No. 4012:
By: Oliverson C.S.H.B. No. 4012
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 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 the
licensed medical facility and any facility-based provider that the
health maintenance organization reasonably expects will provide
and bill for the preauthorized service or any services associated
with the preauthorized service;
(2) an itemized estimate of:
(A) the payments that the health maintenance
organization will make to the licensed medical facility and to each
facility-based provider for the preauthorized service and for any
services associated with the preauthorized service; and
(B) the enrollee's financial responsibility,
including any copayment, coinsurance, deductible, or other
out-of-pocket amount, for the preauthorized service and any
services associated with the preauthorized service;
(3) a statement that the actual charges and payment
for the services and the enrollee's financial responsibility for
the services 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
services;
(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 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 the
licensed medical facility and any facility-based provider that the
insurer reasonably expects will provide and bill for the
preauthorized service or any services associated with the
preauthorized service;
(2) an itemized estimate of:
(A) the payments that the insurer will make to
the licensed medical facility and to each facility-based provider
for the preauthorized service and for any services associated with
the preauthorized service; and
(B) the insured's financial responsibility,
including any copayment, coinsurance, deductible, or other
out-of-pocket amount, for the preauthorized service and any
services associated with the preauthorized service;
(3) a statement that the actual charges and payment
for the services and the insured's financial responsibility for the
services 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 services;
(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 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, 2022.
SECTION 4. This Act takes effect January 1, 2022.