HB4681 - Relating to disclosures of preauthorization requirements and explanations of benefits for medical and health care services and supplies covered by health maintenance organizations and preferred provider benefit plans; imposing administrative penalties.

  89R5923 RDS-F     By: Oliverson H.B. No. 4681       A BILL TO BE ENTITLED   AN ACT   relating to disclosures of preauthorization requirements and   explanations of benefits for medical and health care services and   supplies covered by health maintenance organizations and preferred   provider benefit plans; imposing administrative penalties.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subchapter D, Chapter 843, Insurance Code, is   amended by adding Section 843.114 to read as follows:           Sec.   843.114.     EXPLANATION OF BENEFITS. A health   maintenance organization shall provide a written explanation of   benefits to an enrollee for a health care service or supply   submitted by a physician or health care provider to the health   maintenance organization for payment.   The explanation must   include:                 (1)     a plain-language description of the health care   service or supply that adequately identifies for the enrollee the   health care service or supply received by the enrollee from the   physician or provider; and                 (2)     a plain-language description of each identifying   code, including a denial code, provided in the explanation of   benefits that adequately informs and defines the identifying code   for the enrollee.          SECTION 2.  Section 843.3481, Insurance Code, is amended by   amending Subsections (a) and (b) and adding Subsection (e) to read   as follows:          (a)  A health maintenance organization that uses a   preauthorization process for health care services shall display in   a prominent location on or through a dedicated link that is   prominently displayed on the home page of the health maintenance   organization's Internet website all [ make the ] requirements and   information about the preauthorization process [ readily accessible   to enrollees, physicians, providers, and the general public by   posting the requirements and information on the health maintenance   organization's Internet website ].          (b)  The preauthorization requirements and information   described by Subsection (a) [ must ]:                (1)   must  be [ posted ]:                       (A)  available free of charge;                       (B)     formatted in a manner that is digitally   searchable and prescribed by the commissioner;                       (C)     accessible to a common commercial operator of   an Internet search engine as reasonably necessary for the search   engine to:                             (i)     index the requirements and information;   and                             (ii)     display the requirements and   information as a result in a response to a search query initiated by   a user of the search engine; and                       (D)   [ (A)     except as provided by Subsection (c) or   (d), conspicuously in a location on the Internet website that does   not require the use of a log-in or other input of personal   information to view the information; and                      [ (B)     in a format that is easily searchable and   accessible;                [ (2)     except for the screening criteria under   Subdivision (4)(C), be ] written in plain language that is easily   understandable by enrollees, physicians, providers, and the   general public;                 (2)  may not require an individual to:                       (A)  establish a user account or password;                       (B)  submit personal identifying information; or                       (C)     overcome any other impediment to accessing   the requirements and information, including a requirement that the   individual enter a code to access the requirements and information;                (3)   must include a detailed description of the   preauthorization process and procedure; and                (4)   must include an accurate and current list of the   health care services for which the health maintenance organization   requires preauthorization that includes the following information   specific to each service:                      (A)  the effective date of the preauthorization   requirement;                      (B)  a list or description of any supporting   documentation that the health maintenance organization requires   from the physician or provider ordering or requesting the service   to approve a request for that service;                      (C)  the applicable screening criteria, which may   include Current Procedural Terminology codes and International   Classification of Diseases codes; and                      (D)  statistics regarding preauthorization   approval and denial rates for the service in the preceding calendar   year, including statistics in the following categories:                            (i)  physician or provider type and   specialty, if any;                            (ii)  indication offered;                            (iii)  reasons for request denial , which may   not be in the form of alphanumeric codes ;                            (iv)   initial denials;                             (v)   denials overturned on internal appeal;                             (vi) [ (v) ]  denials overturned by an   independent review organization;                             (vii)     approvals and denials of expedited   preauthorization requests;                             (viii)   [ and                            [ (vi) ]  total annual preauthorization   requests, approvals, and denials for the service ; and                             (ix)     average and median times that elapsed   between the submission of a preauthorization request and a decision   by the health maintenance organization, sorted by standard   preauthorization requests and expedited preauthorization requests .           (e)     The provisions of this section may not be waived by   contract.          SECTION 3.  Section 843.3482, Insurance Code, is amended to   read as follows:          Sec. 843.3482.  CHANGES TO PREAUTHORIZATION REQUIREMENTS.     (a)  Except as provided by Subsection (b), not later than the 60th   business day before the date a new or amended preauthorization   requirement takes effect, a health maintenance organization that   uses a preauthorization process for health care services shall , in   accordance with Section 843.3481:                 (1)   provide written notice of the new or amended   preauthorization requirement and the date and time the requirement   goes into effect to each enrollee and each participating physician   and provider in the health maintenance organization's network who   provides a health care service subject to the requirement; and                 (2)   disclose the new or amended requirement and the   date and time the requirement goes into effect in the health   maintenance organization's newsletter or network bulletin, if any,   and on the health maintenance organization's Internet website.          (b)  For a change in a preauthorization requirement or   process that removes a service from the list of health care services   requiring preauthorization or amends a preauthorization   requirement in a way that is less burdensome to enrollees or   participating physicians or providers, a health maintenance   organization shall , in accordance with Section 843.3481:                 (1)   provide written notice of the change in the   preauthorization requirement and the date and time the change goes   into effect to each enrollee and each participating physician and   provider in the health maintenance organization's network who   provides the health care service; and                 (2)   disclose the change and the date and time the   change goes into effect in the health maintenance organization's   newsletter or network bulletin, if any, and on the health   maintenance organization's Internet website [ not later than the   fifth day before the date the change takes effect ].          (c)  Not later than the fifth day before the date a new or   amended preauthorization requirement takes effect, a health   maintenance organization shall update its Internet website to   disclose the change to the health maintenance organization's   preauthorization requirements or process and the date and time the   change is effective in accordance with Section 843.3481 .           (d)     A new or amended preauthorization requirement imposed   by a health maintenance organization must take effect on a business   day.           (e)     The provisions of this section may not be waived by   contract.          SECTION 4.  Subchapter J, Chapter 843, Insurance Code, is   amended by adding Section 843.3484 to read as follows:           Sec.   843.3484.     ADDITIONAL ENFORCEMENT FOR PREAUTHORIZATION   VIOLATION. (a) In addition to any other penalty or remedy provided   by law and if the commissioner determines that a health maintenance   organization has violated Section 843.348, 843.3481, or 843.3482,   the commissioner shall issue a notice of the violation to the health   maintenance organization and order the health maintenance   organization to submit a corrective action plan to the department.   The notice must:                 (1)     indicate the form and manner in which the   corrective action plan must be submitted to the department; and                 (2)     clearly state the date by which the health   maintenance organization must submit the plan.           (b)     A health maintenance organization that receives a   notice under [Text truncated for display. Full text available on Congress.gov.]