BILL ANALYSIS Senate Research Center C.S.S.B. 547 89R23623 DNC-D By: Menndez Health & Human Services 4/23/2025 Committee Report (Substituted) AUTHOR'S / SPONSOR'S STATEMENT OF INTENT In 2021, Texas passed H.B. 3459, which created "gold card exemptions" that allow for physicians or providers to be exempt from a preauthorization requirement that would otherwise apply to them in respect to a particular health care service. This legislation was an important step in addressing the barriers to accessing care caused by preauthorization procedures. Currently, physicians receive notices through mail from insurance companies regarding their "gold card" exemption status; however, these notices are easily missed if a physician or provider works from multiple offices. Further, each exemption notification can look different depending on the insurance company. Overall, physicians have experienced difficulty in knowing when their exemption has taken effect, especially given that the Texas Department of Insurance (TDI) does not maintain this information in one centralized system. Allowing for more oversight and a centralized system would save providers time and ultimately help patients receive the treatment they need. S.B. 547 would require a health benefit plan issuer that uses a preauthorization process to provide notice to TDI of a provider's preauthorization exemption status. It would also require TDI to maintain a centralized database of this information that can be requested by physicians as needed. Committee Substitute: Repeals the existing provider notice requirements to instead use the TDI database created through this bill as the central source for all gold card information. This will remove duplicative efforts and avoid confusion amongst providers. C.S.S.B. 547 amends current law relating to notice from a health benefit plan issuer regarding a physician's or health care provider's preauthorization exemption status. RULEMAKING AUTHORITY This bill does not expressly grant any additional rulemaking authority to a state officer, institution, or agency. SECTION BY SECTION ANALYSIS SECTION 1. Amends Section 4201.659(e), Insurance Code, as follows: (e) Requires the health maintenance organization or insurer, if a physician or provider submits a preauthorization request for a health care service for which the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653 (Exemption From Preauthorization Requirements For Physicians and Providers Providing Certain Health Care Services), to promptly provide a notice to the physician or provider that includes: (1) a statement that the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653; (2) a list of the health care services and health benefit plans to which the exemption applies; (3) a statement of the duration of the exemption, rather than the information described by Subsection (d) (relating to requiring a health maintenance organization or insurer to provide a notice to a physician or provider qualifying for a preauthorization exemption within five days of the determination); and (4) redesignates existing Subdivision (2) as Subdivision (4) and makes no further changes. SECTION 2. Amends Subchapter N, Chapter 4201, Insurance Code, by adding Section 4201.660, as follows: Sec. 4201.660. EXEMPTION STATUS NOTIFICATION TO DEPARTMENT; DATABASE AND REPORT. (a) Requires a health maintenance organization or insurer that uses a preauthorization process for health care services to provide written notice to the Texas Department of Insurance (TDI) of a physician's or provider's preauthorization exemption status under Subchapter N (Exemption From Preauthorization Requirements For Physicians and Providers Providing Certain Health Care Services) not later than the 10th day after the date on which the health maintenance organization or insurer: (1) completes an evaluation of the physician or provider as required by Section 4201.653(b) (relating to the requirement to evaluate a healthcare provider for exemption from preauthorization requirements once every six months) and determines whether the physician or provider qualifies for an exemption; (2) determines that the health maintenance organization or insurer will continue the physician's or provider's exemption under Section 4201.653(c) (relating to a health maintenance organization or insurer's authority to continue a provider's preauthorization exemption without re-evaluating); (3) provides notice to the physician or provider of a determination to rescind the physician's or provider's exemption; or (4) makes an internal appeal determination or receives a determination from an independent review organization under Section 4201.656 (Independent Review of Exemption Determination) affirming or denying the health maintenance organization's or insurer's determination to rescind the physician's or provider's exemption. (b) Requires TDI to establish and maintain a database of preauthorization exemption grants, denials, recissions, and internal appeal and independent review determinations. Requires TDI, on the request of a physician or provider, to provide the physician or provider with information regarding the physician's or provider's preauthorization exemption status with respect to each relevant health maintenance organization or insurer and with respect to each relevant health care service. (c) Requires TDI to collect and compile certain data regarding preauthorization exemption reviews and appeals. (d) Requires TDI to annually prepare a statistical report reflecting the data collected under Subsection (c) and make the report available to the public on request. SECTION 3. Repealer: Section 4201.659(d) (relating to requiring a health maintenance organization or insurer to provide a notice to a physician or provider qualifying for a preauthorization exemption within five days of the determination), Insurance Code. SECTION 4. Makes application of Subchapter N, Chapter 4201 (Utilization Review Agents), Insurance Code, as amended by this Act, prospective. SECTION 5. Effective date: September 1, 2025.
BILL ANALYSIS
Senate Research Center C.S.S.B. 547
89R23623 DNC-D By: Menndez
Health & Human Services
4/23/2025
Committee Report (Substituted)
Senate Research Center
C.S.S.B. 547
89R23623 DNC-D
By: Menndez
Health & Human Services
4/23/2025
Committee Report (Substituted)
AUTHOR'S / SPONSOR'S STATEMENT OF INTENT
In 2021, Texas passed H.B. 3459, which created "gold card exemptions" that allow for physicians or providers to be exempt from a preauthorization requirement that would otherwise apply to them in respect to a particular health care service. This legislation was an important step in addressing the barriers to accessing care caused by preauthorization procedures.
Currently, physicians receive notices through mail from insurance companies regarding their "gold card" exemption status; however, these notices are easily missed if a physician or provider works from multiple offices. Further, each exemption notification can look different depending on the insurance company. Overall, physicians have experienced difficulty in knowing when their exemption has taken effect, especially given that the Texas Department of Insurance (TDI) does not maintain this information in one centralized system. Allowing for more oversight and a centralized system would save providers time and ultimately help patients receive the treatment they need.
S.B. 547 would require a health benefit plan issuer that uses a preauthorization process to provide notice to TDI of a provider's preauthorization exemption status. It would also require TDI to maintain a centralized database of this information that can be requested by physicians as needed.
Committee Substitute:
* Repeals the existing provider notice requirements to instead use the TDI database created through this bill as the central source for all gold card information. This will remove duplicative efforts and avoid confusion amongst providers.
C.S.S.B. 547 amends current law relating to notice from a health benefit plan issuer regarding a physician's or health care provider's preauthorization exemption status.
RULEMAKING AUTHORITY
This bill does not expressly grant any additional rulemaking authority to a state officer, institution, or agency.
SECTION BY SECTION ANALYSIS
SECTION 1. Amends Section 4201.659(e), Insurance Code, as follows:
(e) Requires the health maintenance organization or insurer, if a physician or provider submits a preauthorization request for a health care service for which the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653 (Exemption From Preauthorization Requirements For Physicians and Providers Providing Certain Health Care Services), to promptly provide a notice to the physician or provider that includes:
(1) a statement that the physician or provider qualifies for an exemption from preauthorization requirements under Section 4201.653;
(2) a list of the health care services and health benefit plans to which the exemption applies;
(3) a statement of the duration of the exemption, rather than the information described by Subsection (d) (relating to requiring a health maintenance organization or insurer to provide a notice to a physician or provider qualifying for a preauthorization exemption within five days of the determination); and
(4) redesignates existing Subdivision (2) as Subdivision (4) and makes no further changes.
SECTION 2. Amends Subchapter N, Chapter 4201, Insurance Code, by adding Section 4201.660, as follows:
Sec. 4201.660. EXEMPTION STATUS NOTIFICATION TO DEPARTMENT; DATABASE AND REPORT. (a) Requires a health maintenance organization or insurer that uses a preauthorization process for health care services to provide written notice to the Texas Department of Insurance (TDI) of a physician's or provider's preauthorization exemption status under Subchapter N (Exemption From Preauthorization Requirements For Physicians and Providers Providing Certain Health Care Services) not later than the 10th day after the date on which the health maintenance organization or insurer:
(1) completes an evaluation of the physician or provider as required by Section 4201.653(b) (relating to the requirement to evaluate a healthcare provider for exemption from preauthorization requirements once every six months) and determines whether the physician or provider qualifies for an exemption;
(2) determines that the health maintenance organization or insurer will continue the physician's or provider's exemption under Section 4201.653(c) (relating to a health maintenance organization or insurer's authority to continue a provider's preauthorization exemption without re-evaluating);
(3) provides notice to the physician or provider of a determination to rescind the physician's or provider's exemption; or
(4) makes an internal appeal determination or receives a determination from an independent review organization under Section 4201.656 (Independent Review of Exemption Determination) affirming or denying the health maintenance organization's or insurer's determination to rescind the physician's or provider's exemption.
(b) Requires TDI to establish and maintain a database of preauthorization exemption grants, denials, recissions, and internal appeal and independent review determinations. Requires TDI, on the request of a physician or provider, to provide the physician or provider with information regarding the physician's or provider's preauthorization exemption status with respect to each relevant health maintenance organization or insurer and with respect to each relevant health care service.
(c) Requires TDI to collect and compile certain data regarding preauthorization exemption reviews and appeals.
(d) Requires TDI to annually prepare a statistical report reflecting the data collected under Subsection (c) and make the report available to the public on request.
SECTION 3. Repealer: Section 4201.659(d) (relating to requiring a health maintenance organization or insurer to provide a notice to a physician or provider qualifying for a preauthorization exemption within five days of the determination), Insurance Code.
SECTION 4. Makes application of Subchapter N, Chapter 4201 (Utilization Review Agents), Insurance Code, as amended by this Act, prospective.
SECTION 5. Effective date: September 1, 2025.