89R6317 SCF-F
By: Paxton S.B. No. 1380
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan preauthorization requirements for
physicians and providers providing certain health care services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 4201, Insurance Code, is amended by
adding Subchapter O to read as follows:
SUBCHAPTER O. PROHIBITED PREAUTHORIZATION REQUIREMENTS FOR
PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES
Sec. 4201.701. DEFINITIONS. In this subchapter:
(1) "Chronic health condition" means a health
condition that:
(A) is expected to last one or more years;
(B) requires ongoing health care services to
manage the condition or prevent an adverse health event; or
(C) limits one or more of the following daily
activities:
(i) bathing;
(ii) personal hygiene;
(iii) eating;
(iv) toileting;
(v) dressing;
(vi) bed mobility; or
(vii) walking or locomotion.
(2) "Emergency care" and "health care services" have
the meanings assigned by Section 843.002.
(3) "Intervention-necessary care" means health care
services, other than emergency care:
(A) that are typically provided in a physician's
office or other outpatient setting;
(B) that are provided to treat an acute injury,
illness, or condition that is severe or painful enough to lead a
prudent layperson possessing an average knowledge of medicine and
health who is experiencing the injury, illness, or condition to
believe that the injury, illness, or condition will seriously
deteriorate if the person does not receive treatment within a
reasonable amount of time; and
(C) without which there is a risk that the
individual experiencing the injury, illness, or condition will:
(i) acquire an irreversible injury,
illness, or condition; or
(ii) require emergency care or another
inpatient health care service.
(4) "Physician" has the meaning assigned by Section
843.002.
(5) "Preauthorization" means a determination by a
health maintenance organization, insurer, or person contracting
with a health maintenance organization or insurer that health care
services proposed to be provided to a patient are medically
necessary and appropriate.
(6) "Provider" has the meaning assigned by Section
843.002.
Sec. 4201.702. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to:
(1) a health benefit plan offered by a health
maintenance organization operating under Chapter 843, except that
this subchapter does not apply to:
(A) the child health plan program under Chapter
62, Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; or
(B) the state Medicaid program, including the
Medicaid managed care program operated under Chapter 540,
Government Code;
(2) a preferred provider benefit plan or exclusive
provider benefit plan offered by an insurer under Chapter 1301; and
(3) a person who contracts with a health maintenance
organization or insurer to issue preauthorization determinations
or perform the functions described by this subchapter for a health
benefit plan to which this subchapter applies.
Sec. 4201.703. CONSTRUCTION OF SUBCHAPTER. This subchapter
may be construed to:
(1) authorize a physician or provider to provide a
health care service outside the scope of the physician's or
provider's applicable license issued under Title 3, Occupations
Code; or
(2) require a health maintenance organization or
insurer to pay for a health care service described by Subdivision
(1) that is performed in violation of the laws of this state.
Sec. 4201.704. PROHIBITED PREAUTHORIZATION REQUIREMENTS
FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE
SERVICES. (a) A health maintenance organization or insurer may not
require a physician or provider to obtain preauthorization for the
following health care services:
(1) emergency care;
(2) intervention-necessary care provided by an
individual licensed to practice medicine in this state;
(3) primary care provided by an individual licensed to
practice medicine in this state;
(4) outpatient mental health care treatment or
outpatient substance use disorder treatment, except for the
provision of prescription drugs or intravenous infusions;
(5) antineoplastic cancer treatments provided in
accordance with National Comprehensive Cancer Network guidelines,
except for the provision of prescription drugs or intravenous
infusions;
(6) intravitreal prescription drugs and health care
services provided in accordance with National Eye Institute
guidelines to treat macular degeneration, diabetic retinopathy, or
another eye injury, condition, or illness that may lead to vision
loss;
(7) health care services with an "A" or "B"
recommendation from the United States Preventative Services Task
Force;
(8) preventative health care services described by 42
C.F.R. Section 147.130;
(9) pediatric hospice services provided by a person
licensed under Chapter 142, Health and Safety Code;
(10) health care services provided under a neonatal
abstinence syndrome program operated by a physician specializing in
pediatric pain or pediatric palliative care; or
(11) health care services provided under a
risk-sharing or capitation arrangement.
(b) An approved preauthorization request for a chronic
health condition does not expire unless the standard treatment for
that condition changes.
Sec. 4201.705. EFFECT OF PROHIBITED PREAUTHORIZATION
REQUIREMENTS. (a) A health maintenance organization or insurer
may not deny or reduce payment to a physician or provider for a
health care service for which the physician or provider is not
required to obtain preauthorization under Section 4201.704 unless
the physician or provider:
(1) knowingly and materially misrepresented the
health care service or the nature of an acute injury, condition, or
illness in a request for payment submitted to the health
maintenance organization or insurer with the specific intent to
deceive and obtain an unlawful payment from the health maintenance
organization or insurer; or
(2) failed to substantially perform the health care
service.
(b) A health maintenance organization or an insurer may not
conduct a retrospective review of a health care service for which
the physician or provider is not required to obtain
preauthorization under Section 4201.704 unless the health
maintenance organization or insurer has a reasonable cause to
suspect a basis for denial exists under Subsection (a).
(c) For a retrospective review described by Subsection (b),
nothing in this subchapter may be construed to modify or otherwise
affect:
(1) the requirements under or application of Section
4201.305, including any timeframes specified by that section; or
(2) any other applicable law, except to prescribe the
only circumstances under which:
(A) a retrospective utilization review may occur
as specified by Subsection (b); or
(B) payment may be denied or reduced as specified
by Subsection (a).
(d) If a physician or provider submits a preauthorization
request for a health care service for which the physician or
provider is not required to obtain preauthorization under Section
4201.704, the health maintenance organization or insurer must
promptly provide a written notice to the physician or provider that
includes:
(1) a statement that the health maintenance
organization or insurer may not require preauthorization for that
health care service; and
(2) a notification of the health maintenance
organization's or insurer's payment requirements.
SECTION 2. Subchapter O, Chapter 4201, Insurance Code, as
added by this Act, applies only to a request for preauthorization
under a health benefit plan that is delivered, issued for delivery,
or renewed on or after January 1, 2026.
SECTION 3. This Act takes effect September 1, 2025.