Annual checks on insurers’ prior-approval practices

The text as introduced · 489 words

89R4361 SCF-F

By: Vo
H.B. No. 1818

A BILL TO BE ENTITLED

AN ACT

relating to examinations of health maintenance organizations and

insurers by the commissioner of insurance regarding compliance with

certain utilization review and preauthorization requirements;

authorizing a fee.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 843.154(f), Insurance Code, is amended

to read as follows:

(f) A health maintenance organization shall pay to the

commissioner a fee in an amount assessed by the commissioner and

paid in accordance with rules adopted by the commissioner for the

expenses of an examination under Section 843.156(a) or (a-1) that:

(1) are incurred by the commissioner or under the

commissioner's authority; and

(2) are directly attributable to that examination,

including the actual salaries and expenses of the examiners

directly attributable to that examination, as determined under

rules adopted by the commissioner.

SECTION 2. Section 843.156, Insurance Code, is amended by

adding Subsections (a-1) and (a-2) to read as follows:

(a-1) The commissioner shall examine a health maintenance

organization to determine the health maintenance organization's

compliance with applicable requirements related to utilization

review, including requirements under this chapter, Chapter 1222,

Chapter 1369, and Chapter 4201 that relate to the preauthorization

of health care services. The commissioner may conduct an

examination under this subsection as often as the commissioner

considers necessary but shall conduct an examination at least once

annually. Documentation provided to the commissioner during an

examination conducted under this subsection is confidential and is

not subject to disclosure as public information under Chapter 552,

Government Code. In this subsection and Subsection (a-2),

"utilization review" has the meaning assigned by Section 4201.002.

(a-2) If in a certain year the commissioner examines or will

examine a health maintenance organization's compliance with

applicable requirements related to utilization review as part of an

examination other than the examination required by Subsection

(a-1), the commissioner is not required to examine the health

maintenance organization under Subsection (a-1) in that year.

SECTION 3. Section 1301.0056, Insurance Code, is amended by

adding Subsections (a-2) and (a-3) to read as follows:

(a-2) The commissioner shall examine an insurer to

determine the insurer's compliance with applicable requirements

related to utilization review, including requirements under this

chapter, Chapter 1222, Chapter 1369, and Chapter 4201 that relate

to the preauthorization of medical care or health care services.

The commissioner may conduct an examination under this subsection

as often as the commissioner considers necessary but shall conduct

an examination at least once annually. In this subsection and

Subsection (a-3), "utilization review" has the meaning assigned by

Section 4201.002.

(a-3) If in a certain year the commissioner examines or will

examine an insurer's compliance with applicable requirements

related to utilization review as part of an examination other than

the examination required by Subsection (a-2), the commissioner is

not required to examine the insurer under Subsection (a-2) in that

year.

SECTION 4. This Act takes effect September 1, 2025.