Lalani Preauthorization Bill Exempts Cancer Care, Except Drugs And Infusions

The text as introduced · 1,154 words

89R6317 SCF-F

By: Lalani
H.B. No. 2641

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.