HB2641 - Relating to health benefit plan preauthorization requirements for physicians and providers providing certain health care services.

  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 A [Text truncated for display. 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