bill to drop insurer preauthorization for some in-network care

The text as introduced · 1,025 words

90R1635 SCF-F

By: Lalani
H.B. No. 524

A BILL TO BE ENTITLED

AN ACT

relating to health benefit plan preauthorization requirements for

participating 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. PREAUTHORIZATION REQUIREMENTS FOR PARTICIPATING

PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH CARE SERVICES

Sec. 4201.701. DEFINITIONS. In this subchapter:

(1) "Health care services" has the meaning assigned by

Section 843.002.

(2) "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; and

(C) that:

(i) if not provided, would place the

individual receiving the health care services at risk of:

(a) acquiring an irreversible injury,

illness, or condition; or

(b) requiring emergency care or other

health care services provided in an inpatient setting; or

(ii) are provided to an individual with an

injury, illness, or condition that is severe or painful enough to

lead a prudent layperson possessing an average knowledge of

medicine and health to believe that the individual's injury,

illness, or condition is of a nature that failure to obtain

treatment within a reasonable amount of time would result in

serious deterioration of the injury, illness, or condition.

(3) "Physician" has the meaning assigned by Section

843.002.

(4) "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.

(5) "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 not 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 PARTICIPATING PHYSICIANS AND PROVIDERS PROVIDING CERTAIN

HEALTH CARE SERVICES. A health maintenance organization or insurer

may not require a participating 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) outpatient mental health care treatment or

outpatient substance use disorder treatment, except for the

provision of prescription drugs or intravenous infusions;

(4) intravitreal prescription drugs and health care

services provided by an ophthalmologist in accordance with National

Eye Institute guidelines to treat an eye injury, condition, or

illness that may lead to immediate vision loss;

(5) health care services with an "A" or "B"

recommendation from the United States Preventive Services Task

Force;

(6) preventive health care services described by 45

C.F.R. Section 147.130; or

(7) health care services provided under a fully

capitated risk-sharing or capitation arrangement, unless otherwise

agreed to by the participating physician or provider.

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, 2028.

SECTION 3. This Act takes effect September 1, 2027.