87R8216 RDS-F
By: Oliverson H.B. No. 4531
A BILL TO BE ENTITLED
AN ACT
relating to preauthorization of medical care or health care
services by certain health benefit plan issuers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.348, Insurance Code, is amended by
amending Subsections (a) and (g) and adding Subsection (g-1) to
read as follows:
(a) In this section:
(1) "Preauthorization" [, "preauthorization"] means a
determination by a health maintenance organization that health care
services proposed to be provided to a patient are medically
necessary and appropriate.
(2) "Verification" has the meaning assigned by Section
843.347.
(g) Notwithstanding Section 843.347, if [If] the health
maintenance organization has preauthorized health care services,
the health maintenance organization may not deny or reduce payment
to the physician or provider for those services based on:
(1) medical necessity or appropriateness of care
unless the physician or provider has materially misrepresented the
proposed health care services or has substantially failed to
perform the proposed health care services;
(2) an eligibility or coverage determination if the
proposed health care services are provided to the enrollee before
the 31st day after the date the physician or provider received the
determination that the health care services were preauthorized
unless the physician or provider has materially misrepresented the
proposed health care services or has substantially failed to
perform the proposed health care services;
(3) the fact that a physician or provider did not
request or obtain or was not provided a verification from the health
maintenance organization; or
(4) the health maintenance organization declining or
failing to determine an enrollee's eligibility or make coverage
determinations in the time frame required for the issuance of a
preauthorization determination.
(g-1) If a health maintenance organization determines that
a health care service is preauthorized, the health maintenance
organization shall specify any deductibles, copayments, or
coinsurance for which the enrollee is responsible in its
determination.
SECTION 2. Section 1301.135, Insurance Code, is amended by
amending Subsection (f) and adding Subsections (f-1) and (i) to
read as follows:
(f) Notwithstanding Section 1301.133, if [If] an insurer
has preauthorized medical care or health care services, the insurer
may not deny or reduce payment to the physician or health care
provider for those services based on:
(1) medical necessity or appropriateness of care
unless the physician or provider has materially misrepresented the
proposed medical or health care services or has substantially
failed to perform the proposed medical or health care services;
(2) an eligibility or coverage determination if the
proposed medical care or health care services are provided to the
insured before the 31st day after the date the physician or provider
received the determination that the medical care or health care
services were preauthorized unless the physician or provider has
materially misrepresented the proposed medical care or health care
services or has substantially failed to perform the proposed
medical care or health care services;
(3) the fact that a physician or provider did not
request or obtain or was not provided a verification from the
insurer; or
(4) the insurer declining or failing to determine an
insured's eligibility or make coverage determinations in the time
frame required for the issuance of a preauthorization
determination.
(f-1) If an insurer determines that a medical care or health
care service is preauthorized, the insurer shall specify any
deductibles, copayments, or coinsurance for which the insured is
responsible in its determination.
(i) In this section, "verification" has the meaning
assigned by Section 1301.133.
SECTION 3. The change in law made by this Act applies only
to a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2022. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2022,
is governed by the law as it existed immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.
SECTION 4. This Act takes effect September 1, 2021.