Texas 2025 - 89th Regular

Texas House Bill HB2641 Compare Versions

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

Old	New	Differences
1	1	89R6317 SCF-F
2	2	By: Lalani H.B. No. 2641
3	3
4	4
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to health benefit plan preauthorization requirements for
10	10	physicians and providers providing certain health care services.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Chapter 4201, Insurance Code, is amended by
13	13	adding Subchapter O to read as follows:
14	14	SUBCHAPTER O. PROHIBITED PREAUTHORIZATION REQUIREMENTS FOR
15	15	PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES
16	16	Sec. 4201.701. DEFINITIONS. In this subchapter:
17	17	(1) "Chronic health condition" means a health
18	18	condition that:
19	19	(A) is expected to last one or more years;
20	20	(B) requires ongoing health care services to
21	21	manage the condition or prevent an adverse health event; or
22	22	(C) limits one or more of the following daily
23	23	activities:
24	24	(i) bathing;
25	25	(ii) personal hygiene;
26	26	(iii) eating;
27	27	(iv) toileting;
28	28	(v) dressing;
29	29	(vi) bed mobility; or
30	30	(vii) walking or locomotion.
31	31	(2) "Emergency care" and "health care services" have
32	32	the meanings assigned by Section 843.002.
33	33	(3) "Intervention-necessary care" means health care
34	34	services, other than emergency care:
35	35	(A) that are typically provided in a physician's
36	36	office or other outpatient setting;
37	37	(B) that are provided to treat an acute injury,
38	38	illness, or condition that is severe or painful enough to lead a
39	39	prudent layperson possessing an average knowledge of medicine and
40	40	health who is experiencing the injury, illness, or condition to
41	41	believe that the injury, illness, or condition will seriously
42	42	deteriorate if the person does not receive treatment within a
43	43	reasonable amount of time; and
44	44	(C) without which there is a risk that the
45	45	individual experiencing the injury, illness, or condition will:
46	46	(i) acquire an irreversible injury,
47	47	illness, or condition; or
48	48	(ii) require emergency care or another
49	49	inpatient health care service.
50	50	(4) "Physician" has the meaning assigned by Section
51	51	843.002.
52	52	(5) "Preauthorization" means a determination by a
53	53	health maintenance organization, insurer, or person contracting
54	54	with a health maintenance organization or insurer that health care
55	55	services proposed to be provided to a patient are medically
56	56	necessary and appropriate.
57	57	(6) "Provider" has the meaning assigned by Section
58	58	843.002.
59	59	Sec. 4201.702. APPLICABILITY OF SUBCHAPTER. This
60	60	subchapter applies only to:
61	61	(1) a health benefit plan offered by a health
62	62	maintenance organization operating under Chapter 843, except that
63	63	this subchapter does not apply to:
64	64	(A) the child health plan program under Chapter
65	65	62, Health and Safety Code, or the health benefits plan for children
66	66	under Chapter 63, Health and Safety Code; or
67	67	(B) the state Medicaid program, including the
68	68	Medicaid managed care program operated under Chapter 540,
69	69	Government Code;
70	70	(2) a preferred provider benefit plan or exclusive
71	71	provider benefit plan offered by an insurer under Chapter 1301; and
72	72	(3) a person who contracts with a health maintenance
73	73	organization or insurer to issue preauthorization determinations
74	74	or perform the functions described by this subchapter for a health
75	75	benefit plan to which this subchapter applies.
76	76	Sec. 4201.703. CONSTRUCTION OF SUBCHAPTER. This subchapter
77	77	may be construed to:
78	78	(1) authorize a physician or provider to provide a
79	79	health care service outside the scope of the physician's or
80	80	provider's applicable license issued under Title 3, Occupations
81	81	Code; or
82	82	(2) require a health maintenance organization or
83	83	insurer to pay for a health care service described by Subdivision
84	84	(1) that is performed in violation of the laws of this state.
85	85	Sec. 4201.704. PROHIBITED PREAUTHORIZATION REQUIREMENTS
86	86	FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE
87	87	SERVICES. (a) A health maintenance organization or insurer may not
88	88	require a physician or provider to obtain preauthorization for the
89	89	following health care services:
90	90	(1) emergency care;
91	91	(2) intervention-necessary care provided by an
92	92	individual licensed to practice medicine in this state;
93	93	(3) primary care provided by an individual licensed to
94	94	practice medicine in this state;
95	95	(4) outpatient mental health care treatment or
96	96	outpatient substance use disorder treatment, except for the
97	97	provision of prescription drugs or intravenous infusions;
98	98	(5) antineoplastic cancer treatments provided in
99	99	accordance with National Comprehensive Cancer Network guidelines,
100	100	except for the provision of prescription drugs or intravenous
101	101	infusions;
102	102	(6) intravitreal prescription drugs and health care
103	103	services provided in accordance with National Eye Institute
104	104	guidelines to treat macular degeneration, diabetic retinopathy, or
105	105	another eye injury, condition, or illness that may lead to vision
106	106	loss;
107	107	(7) health care services with an "A" or "B"
108	108	recommendation from the United States Preventative Services Task
109	109	Force;
110	110	(8) preventative health care services described by 42
111	111	C.F.R. Section 147.130;
112	112	(9) pediatric hospice services provided by a person
113	113	licensed under Chapter 142, Health and Safety Code;
114	114	(10) health care services provided under a neonatal
115	115	abstinence syndrome program operated by a physician specializing in
116	116	pediatric pain or pediatric palliative care; or
117	117	(11) health care services provided under a
118	118	risk-sharing or capitation arrangement.
119	119	(b) An approved preauthorization request for a chronic
120	120	health condition does not expire unless the standard treatment for
121	121	that condition changes.
122	122	Sec. 4201.705. EFFECT OF PROHIBITED PREAUTHORIZATION
123	123	REQUIREMENTS. (a) A health maintenance organization or insurer
124	124	may not deny or reduce payment to a physician or provider for a
125	125	health care service for which the physician or provider is not
126	126	required to obtain preauthorization under Section 4201.704 unless
127	127	the physician or provider:
128	128	(1) knowingly and materially misrepresented the
129	129	health care service or the nature of an acute injury, condition, or
130	130	illness in a request for payment submitted to the health
131	131	maintenance organization or insurer with the specific intent to
132	132	deceive and obtain an unlawful payment from the health maintenance
133	133	organization or insurer; or
134	134	(2) failed to substantially perform the health care
135	135	service.
136	136	(b) A health maintenance organization or an insurer may not
137	137	conduct a retrospective review of a health care service for which
138	138	the physician or provider is not required to obtain
139	139	preauthorization under Section 4201.704 unless the health
140	140	maintenance organization or insurer has a reasonable cause to
141	141	suspect a basis for denial exists under Subsection (a).
142	142	(c) For a retrospective review described by Subsection (b),
143	143	nothing in this subchapter may be construed to modify or otherwise
144	144	affect:
145	145	(1) the requirements under or application of Section
146	146	4201.305, including any timeframes specified by that section; or
147	147	(2) any other applicable law, except to prescribe the
148	148	only circumstances under which:
149	149	(A) a retrospective utilization review may occur
150	150	as specified by Subsection (b); or
151	151	(B) payment may be denied or reduced as specified
152	152	by Subsection (a).
153	153	(d) If a physician or provider submits a preauthorization
154	154	request for a health care service for which the physician or
155	155	provider is not required to obtain preauthorization under Section
156	156	4201.704, the health maintenance organization or insurer must
157	157	promptly provide a written notice to the physician or provider that
158	158	includes:
159	159	(1) a statement that the health maintenance
160	160	organization or insurer may not require preauthorization for that
161	161	health care service; and
162	162	(2) a notification of the health maintenance
163	163	organization's or insurer's payment requirements.
164	164	SECTION 2. Subchapter O, Chapter 4201, Insurance Code, as
165	165	added by this Act, applies only to a request for preauthorization
166	166	under a health benefit plan that is delivered, issued for delivery,
167	167	or renewed on or after January 1, 2026.
168	168	SECTION 3. This Act takes effect September 1, 2025.