Texas House Bill HB4681

Texas 2025 - 89th Regular

• Filed: 3/12/25

Caption

Relating to disclosures of preauthorization requirements and explanations of benefits for medical and health care services and supplies covered by health maintenance organizations and preferred provider benefit plans; imposing administrative penalties.

Impact

The implications of HB 4681 are significant, as it aims to enhance transparency and accountability within the health insurance industry. By requiring HMOs and insurers to furnish detailed explanations of benefits and preauthorization rules, the legislation seeks to protect the rights of consumers and medical providers alike. Should these organizations fail to comply with the regulations set forth in the bill, they would face administrative penalties that scale according to their total revenue. This provision is designed to ensure that the regulations are taken seriously and that organizations are incentivized to follow them closely.

Summary

House Bill 4681 addresses the disclosure of preauthorization requirements and explanations of benefits by health maintenance organizations (HMOs) and preferred provider benefit plans. The bill mandates that these organizations provide clear and timely information regarding their preauthorization processes. Specifically, it requires that changes to preauthorization requirements be published on their websites no later than five days before they take effect, allowing insured individuals and medical providers to be adequately informed about the requirements they must meet to receive medical services. Moreover, it enforces adhering to standard formats that ensure these disclosures are easily accessible and understandable.

Contention

Notably, there may be points of contention around the administrative penalties imposed for non-compliance. Critics may argue that the financial penalties could disproportionately affect smaller health maintenance organizations, making them less competitive within the healthcare industry. Furthermore, discussions among industry stakeholders, including insurers, healthcare providers, and patient advocacy groups, may bring about debates on how best to balance the interests of protecting patients while maintaining a viable insurance market.

Texas Constitutional Statutes Affected

Insurance Code

• Chapter 843. Health Maintenance Organizations
  • Section: New Section
  • Section: 3481
  • Section: 3482

• Chapter 1301. Preferred Provider Benefit Plans
  • Section: New Section
  • Section: 1351
  • Section: 1352