Texas 2021 - 87th Regular

Texas House Bill HB4012 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
	1	+	87R19495 JES-F
1	2		By: Bonnen H.B. No. 4012
	3	+	Substitute the following for H.B. No. 4012:
	4	+	By: Oliverson C.S.H.B. No. 4012
2	5
3	6
4	7		A BILL TO BE ENTITLED
5	8		AN ACT
6		-	relating to ~~an explanation of benefits provided~~ by certain health
7		-	~~benefit plans to~~ enrollees regarding certain preauthorized medical
8		-	~~care and health~~ care services.
	9	+	relating to disclosures by certain health benefit plans to
	10	+	enrollees regarding certain preauthorized medical care and health
	11	+	care services.
9	12		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	13		SECTION 1. Subchapter F, Chapter 843, Insurance Code, is
11	14		amended by adding Section 843.2025 to read as follows:
12		-	Sec. 843.2025. ~~EXPLANATION OF BENEFITS FOR~~ CERTAIN
	15	+	Sec. 843.2025. DISCLOSURES CONCERNING CERTAIN
13	16		PREAUTHORIZED SERVICES. (a) In this section:
14	17		(1) "Elective" means non-emergent and able to be
15	18		scheduled at least 24 hours in advance.
16		-	(2) "Licensed medical facility" means:
	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:
17	23		(A) a hospital licensed under Chapter 241, Health
18	24		and Safety Code;
19	25		(B) an ambulatory surgical center licensed under
20	26		Chapter 243, Health and Safety Code; or
21	27		(C) a birthing center licensed under Chapter 244,
22	28		Health and Safety Code.
23		-	(3) "Preauthorization" has the meaning assigned by
	29	+	(4) "Preauthorization" has the meaning assigned by
24	30		Section 843.348.
25		-	(b) This section does not apply to coverage under:
26		-	(1) the child health plan program under Chapter 62,
27		-	Health and Safety Code, or the health benefits plan for children
28		-	under Chapter 63, Health and Safety Code; or
29		-	(2) the state Medicaid program, including a Medicaid
30		-	managed care program operated under Chapter 533, Government Code.
31		-	(c) A health maintenance organization that preauthorizes an
32		-	enrollee's health care service shall provide an explanation of
33		-	benefits to the enrollee at the time the health maintenance
34		-	organization issues a determination preauthorizing the service if
35		-	the service:
	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:
36	35		(1) will be provided at a licensed medical facility;
37	36		(2) is elective; and
38	37		(3) must be preauthorized as a condition of payment by
39	38		the health maintenance organization for the service.
	39	+	(c) The disclosure provided to an enrollee under Subsection
	40	+	(b) must include:
	41	+	(1) a statement of the name and network status of the
	42	+	licensed medical facility and any facility-based provider that the
	43	+	health maintenance organization reasonably expects will provide
	44	+	and bill for the preauthorized service or any services associated
	45	+	with the preauthorized service;
	46	+	(2) an itemized estimate of:
	47	+	(A) the payments that the health maintenance
	48	+	organization will make to the licensed medical facility and to each
	49	+	facility-based provider for the preauthorized service and for any
	50	+	services associated with the preauthorized service; and
	51	+	(B) the enrollee's financial responsibility,
	52	+	including any copayment, coinsurance, deductible, or other
	53	+	out-of-pocket amount, for the preauthorized service and any
	54	+	services associated with the preauthorized service;
	55	+	(3) a statement that the actual charges and payment
	56	+	for the services and the enrollee's financial responsibility for
	57	+	the services may vary from the estimate provided by the health
	58	+	maintenance organization based on the enrollee's actual medical
	59	+	condition and other factors associated with the performance of the
	60	+	services;
	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
	72	+	liable for the amount charged for health care services provided to
	73	+	the enrollee depending on the enrollee's health benefit plan
	74	+	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).
40	78		SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is
41	79		amended by adding Section 1301.1355 to read as follows:
42		-	Sec. 1301.1355. ~~EXPLANATION OF BENEFITS FOR~~ CERTAIN
	80	+	Sec. 1301.1355. DISCLOSURES CONCERNING CERTAIN
43	81		PREAUTHORIZED SERVICES. (a) In this section:
44	82		(1) "Elective" means non-emergent and able to be
45	83		scheduled at least 24 hours in advance.
46		-	(2) "Licensed medical facility" means:
	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:
47	89		(A) a hospital licensed under Chapter 241, Health
48	90		and Safety Code;
49	91		(B) an ambulatory surgical center licensed under
50	92		Chapter 243, Health and Safety Code; or
51	93		(C) a birthing center licensed under Chapter 244,
52	94		Health and Safety Code.
53	95		(b) An insurer that preauthorizes an insured's medical care
54		-	or health care service shall provide ~~an explanation of benefits~~ to
55		-	~~the insured at~~ the time the insurer issues a determination
56		-	~~preauthorizing the~~ service if the service:
	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:
57	99		(1) will be provided at a licensed medical facility;
58	100		(2) is elective; and
59	101		(3) must be preauthorized as a condition of payment by
60	102		the insurer for the service.
	103	+	(c) The disclosure provided to an insured under Subsection
	104	+	(b) must include:
	105	+	(1) a statement of the name and network status of the
	106	+	licensed medical facility and any facility-based provider that the
	107	+	insurer reasonably expects will provide and bill for the
	108	+	preauthorized service or any services associated with the
	109	+	preauthorized service;
	110	+	(2) an itemized estimate of:
	111	+	(A) the payments that the insurer will make to
	112	+	the licensed medical facility and to each facility-based provider
	113	+	for the preauthorized service and for any services associated with
	114	+	the preauthorized service; and
	115	+	(B) the insured's financial responsibility,
	116	+	including any copayment, coinsurance, deductible, or other
	117	+	out-of-pocket amount, for the preauthorized service and any
	118	+	services associated with the preauthorized service;
	119	+	(3) a statement that the actual charges and payment
	120	+	for the services and the insured's financial responsibility for the
	121	+	services may vary from the estimate provided by the insurer based on
	122	+	the insured's actual medical condition and other factors associated
	123	+	with the performance of the services;
	124	+	(4) a statement substantially similar to the
	125	+	following: "This notice may not reflect all the physicians and
	126	+	health care providers who may be involved in and bill for your care.
	127	+	Despite your insurer's best efforts to disclose all physicians and
	128	+	health care providers who we reasonably expect to participate in
	129	+	your care, circumstances, including facility scheduling, staff
	130	+	changes, or complications, or other factors associated with your
	131	+	care, may result in different or additional physicians or health
	132	+	care providers providing and billing for care provided to you.";
	133	+	and
	134	+	(5) a statement that the insured may be personally
	135	+	liable for the amount charged for medical care or health care
	136	+	services provided to the insured depending on the insured's health
	137	+	benefit plan coverage.
	138	+	(d) A general statement that some facility-based providers
	139	+	may be out-of-network does not satisfy the requirement in
	140	+	Subsection (c)(1).
61	141		SECTION 3. The changes in law made by this Act apply only to
62	142		a health benefit plan that is delivered, issued for delivery, or
63	143		renewed on or after January 1, 2022.
64	144		SECTION 4. This Act takes effect January 1, 2022.