Texas 2021 - 87th Regular

Texas House Bill HB4531 Compare Versions

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

Old	New	Differences
1	1	87R8216 RDS-F
2	2	By: Oliverson H.B. No. 4531
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to preauthorization of medical care or health care
8	8	services by certain health benefit plan issuers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 843.348, Insurance Code, is amended by
11	11	amending Subsections (a) and (g) and adding Subsection (g-1) to
12	12	read as follows:
13	13	(a) In this section:
14	14	(1) "Preauthorization" [, "preauthorization"] means a
15	15	determination by a health maintenance organization that health care
16	16	services proposed to be provided to a patient are medically
17	17	necessary and appropriate.
18	18	(2) "Verification" has the meaning assigned by Section
19	19	843.347.
20	20	(g) Notwithstanding Section 843.347, if [If] the health
21	21	maintenance organization has preauthorized health care services,
22	22	the health maintenance organization may not deny or reduce payment
23	23	to the physician or provider for those services based on:
24	24	(1) medical necessity or appropriateness of care
25	25	unless the physician or provider has materially misrepresented the
26	26	proposed health care services or has substantially failed to
27	27	perform the proposed health care services;
28	28	(2) an eligibility or coverage determination if the
29	29	proposed health care services are provided to the enrollee before
30	30	the 31st day after the date the physician or provider received the
31	31	determination that the health care services were preauthorized
32	32	unless the physician or provider has materially misrepresented the
33	33	proposed health care services or has substantially failed to
34	34	perform the proposed health care services;
35	35	(3) the fact that a physician or provider did not
36	36	request or obtain or was not provided a verification from the health
37	37	maintenance organization; or
38	38	(4) the health maintenance organization declining or
39	39	failing to determine an enrollee's eligibility or make coverage
40	40	determinations in the time frame required for the issuance of a
41	41	preauthorization determination.
42	42	(g-1) If a health maintenance organization determines that
43	43	a health care service is preauthorized, the health maintenance
44	44	organization shall specify any deductibles, copayments, or
45	45	coinsurance for which the enrollee is responsible in its
46	46	determination.
47	47	SECTION 2. Section 1301.135, Insurance Code, is amended by
48	48	amending Subsection (f) and adding Subsections (f-1) and (i) to
49	49	read as follows:
50	50	(f) Notwithstanding Section 1301.133, if [If] an insurer
51	51	has preauthorized medical care or health care services, the insurer
52	52	may not deny or reduce payment to the physician or health care
53	53	provider for those services based on:
54	54	(1) medical necessity or appropriateness of care
55	55	unless the physician or provider has materially misrepresented the
56	56	proposed medical or health care services or has substantially
57	57	failed to perform the proposed medical or health care services;
58	58	(2) an eligibility or coverage determination if the
59	59	proposed medical care or health care services are provided to the
60	60	insured before the 31st day after the date the physician or provider
61	61	received the determination that the medical care or health care
62	62	services were preauthorized unless the physician or provider has
63	63	materially misrepresented the proposed medical care or health care
64	64	services or has substantially failed to perform the proposed
65	65	medical care or health care services;
66	66	(3) the fact that a physician or provider did not
67	67	request or obtain or was not provided a verification from the
68	68	insurer; or
69	69	(4) the insurer declining or failing to determine an
70	70	insured's eligibility or make coverage determinations in the time
71	71	frame required for the issuance of a preauthorization
72	72	determination.
73	73	(f-1) If an insurer determines that a medical care or health
74	74	care service is preauthorized, the insurer shall specify any
75	75	deductibles, copayments, or coinsurance for which the insured is
76	76	responsible in its determination.
77	77	(i) In this section, "verification" has the meaning
78	78	assigned by Section 1301.133.
79	79	SECTION 3. The change in law made by this Act applies only
80	80	to a health benefit plan that is delivered, issued for delivery, or
81	81	renewed on or after January 1, 2022. A health benefit plan that is
82	82	delivered, issued for delivery, or renewed before January 1, 2022,
83	83	is governed by the law as it existed immediately before the
84	84	effective date of this Act, and that law is continued in effect for
85	85	that purpose.
86	86	SECTION 4. This Act takes effect September 1, 2021.