Texas 2021 - 87th Regular

Texas Senate Bill SB1883 Compare Versions

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

Old	New	Differences
1	1	By: Buckingham S.B. No. 1883
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to preauthorization and utilization review for certain
7	7	health benefit plans.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Subchapter J, Chapter 843, Insurance Code is
10	10	amended by adding Section 843.3483 to read as follows:
11	11	Sec. 843.3483. EXEMPTION FROM PREAUTHORIZATION
12	12	REQUIREMENTS. (a) A health maintenance organization that uses a
13	13	preauthorization process for health care services may not require a
14	14	physician or provider to obtain preauthorization for a particular
15	15	health care service if, in the preceding calendar year, the
16	16	physician or provider had at least eighty percent of the
17	17	physician's or provider's preauthorization requests approved by the
18	18	health maintenance organization for that health care service.
19	19	(b) Each exemption from preauthorization requirements
20	20	described by Subsection (a) shall last for one calendar year and is
21	21	only available for a health care service for which the physician or
22	22	provider submitted at least five preauthorization requests in the
23	23	preceding calendar year.
24	24	(c) A health maintenance organization shall notify each
25	25	physician or provider who qualifies for an exemption from
26	26	preauthorization requirements under Subsection (a) of the
27	27	physician's or provider's exempt status, including the health care
28	28	services for which the exemption applies and the exemption start
29	29	and end date.
30	30	(d) If a physician or provider submits a preauthorization
31	31	request for a health care service for which an exemption applies
32	32	under Subsection (a), the health maintenance organization shall
33	33	promptly notify the physician or provider of the applicable
34	34	exemption, the calendar year and health care services for which the
35	35	exemption applies, and the health maintenance organization payment
36	36	requirements under Subsection (e).
37	37	(e) If a preauthorization exemption applies to a health care
38	38	service under Subsection (a), a health maintenance organization may
39	39	not deny or reduce payment to the physician or provider for the
40	40	health care service based on medical necessity or appropriateness
41	41	of care.
42	42	SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code is
43	43	amended by adding Section 1301.1354 to read as follows:
44	44	Sec. 1301.1354. EXEMPTION FROM PREAUTHORIZATION
45	45	REQUIREMENTS. (a) An insurer that uses a preauthorization process
46	46	for medical care or health care services may not require a physician
47	47	or health care provider to obtain preauthorization for a particular
48	48	medical care or health care service if, in the preceding calendar
49	49	year, the physician or health care provider had at least eighty
50	50	percent of the physician's or health care provider's
51	51	preauthorization requests approved by the insurer for that medical
52	52	care or health care service.
53	53	(b) Each exemption from preauthorization requirements
54	54	described by Subsection (a) shall last for one calendar year and is
55	55	only available for a medical care or health care service for which
56	56	the physician or health care provider submitted at least five
57	57	preauthorization requests in the preceding calendar year.
58	58	(c) An insurer shall notify each physician or health care
59	59	provider who qualifies for an exemption from preauthorization
60	60	requirements under Subsection (a) of the physician's or health care
61	61	provider's exempt status, including the medical care or health care
62	62	services for which the exemption applies and the exemption start
63	63	and end date.
64	64	(d) If a physician or health care provider submits a
65	65	preauthorization request for a medical care or health care service
66	66	for which an exemption applies under Subsection (a), the insurer
67	67	shall promptly notify the physician or health care provider of the
68	68	applicable exemption, the calendar year and medical care or health
69	69	care services for which the exemption applies, and the insurer
70	70	payment requirements under Subsection (e).
71	71	(e) If a preauthorization exemption applies to a medical
72	72	care or health care service under Subsection (a), an insurer may not
73	73	deny or reduce payment to the physician or health care provider for
74	74	the medical care or health care service based on medical necessity
75	75	or appropriateness of care.
76	76	SECTION 3. Section 4201.206, Insurance Code, is amended to
77	77	read as follows:
78	78	Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
79	79	ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
80	80	notice requirements of Subchapter G, before an adverse
81	81	determination is issued by a utilization review agent who questions
82	82	the medical necessity, the appropriateness, or the experimental or
83	83	investigational nature of a health care service, the agent shall
84	84	provide the health care provider who ordered, requested, provided,
85	85	or is to provide the service a reasonable opportunity to discuss
86	86	with a physician licensed to practice medicine in this state the
87	87	patient's treatment plan and the clinical basis for the agent's
88	88	determination.
89	89	(b) If the health care service described by Subsection (a)
90	90	was ordered, requested, or provided, or is to be provided by a
91	91	physician, the opportunity described by that subsection must be
92	92	with a physician licensed to practice medicine in this state who is
93	93	of the same or similar specialty as that physician.
94	94	SECTION 4. The changes in law made by this Act to Section
95	95	4201.206, Insurance Code, apply only to utilization review
96	96	requested on or after the effective date of this Act. Utilization
97	97	review requested before the effective date of this Act is governed
98	98	by the law as it existed immediately before the effective date of
99	99	this Act, and that law is continued in effect for that purpose.
100	100	SECTION 5. This Act takes effect September 1, 2021.