Bill Text: TX HB3459 | 2021-2022 | 87th Legislature | Comm Sub

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Relating to preauthorization requirements for certain health care services and utilization review for certain health benefit plans.

Spectrum: Slight Partisan Bill (Republican 2-1)

Status: (Passed) 2021-06-18 - Effective on 9/1/21 [HB3459 Detail]

Download: Texas-2021-HB3459-Comm_Sub.html

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87R16947 RDS-F
By: Bonnen H.B. No. 3459
Substitute the following for H.B. No. 3459:
By: Oliverson C.S.H.B. No. 3459

A BILL TO BE ENTITLED
AN ACT
relating to preauthorization requirements for certain medical and
health care services and utilization review for certain health
benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter J, Chapter 843, Insurance Code, is
amended by adding Section 843.3484 to read as follows:
Sec. 843.3484. EXEMPTION FROM PREAUTHORIZATION
REQUIREMENTS FOR PHYSICIANS AND PROVIDERS PROVIDING CERTAIN HEALTH
CARE SERVICES. (a) A health maintenance organization that uses a
preauthorization process for health care services may not require a
physician or provider to obtain preauthorization for a particular
health care service if, in the preceding calendar year:
(1) the physician or provider submitted not less than
five preauthorization requests for the particular health care
service; and
(2) the health maintenance organization approved not
less than 80 percent of the preauthorization requests submitted by
the physician or provider for the particular health care service.
(b) An exemption from preauthorization requirements under
Subsection (a) lasts for one calendar year.
(c) Not later than January 30 of each calendar year, a
health maintenance organization must provide to a physician or
provider who qualifies for an exemption from preauthorization
requirements under Subsection (a) a notice that includes:
(1) a statement that the physician or provider
qualifies for an exemption from preauthorization requirements
under Subsection (a);
(2) a list of the health care services to which the
exemption applies; and
(3) a statement that the exemption applies only for
the calendar year in which the physician or provider receives the
notice.
(d) If a physician or provider submits a preauthorization
request for a health care service for which the physician or
provider qualifies for an exemption from preauthorization
requirements under Subsection (a), the health maintenance
organization must promptly provide a notice to the physician or
provider that includes:
(1) the information described by Subsection (c); and
(2) a notification of the health maintenance
organization payment requirements described by Subsection (e).
(e) A health maintenance organization may not deny or reduce
payment to a physician or provider for a health care service to
which the physician or provider qualifies for an exemption from
preauthorization requirements under Subsection (a) based on
medical necessity or appropriateness of care.
SECTION 2. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Section 1301.1354 to read as follows:
Sec. 1301.1354. EXEMPTION FROM PREAUTHORIZATION
REQUIREMENTS FOR PHYSICIANS AND HEALTH CARE PROVIDERS PROVIDING
CERTAIN HEALTH CARE SERVICES. (a) An insurer that uses a
preauthorization process for medical care or health care services
may not require a physician or health care provider to obtain
preauthorization for a particular medical or health care service
if, in the preceding calendar year:
(1) the physician or health care provider submitted
not less than five preauthorization requests for the particular
medical or health care service; and
(2) the insurer approved not less than 80 percent of
the preauthorization requests submitted by the physician or health
care provider for the particular medical or health care service.
(b) An exemption from preauthorization requirements under
Subsection (a) lasts for one calendar year.
(c) Not later than January 30 of each calendar year, an
insurer must provide to a physician or health care provider who
qualifies for an exemption from preauthorization requirements
under Subsection (a) a notice that includes:
(1) a statement that the physician or health care
provider qualifies for an exemption from preauthorization
requirements under Subsection (a);
(2) a list of the medical or health care services to
which the exemption applies; and
(3) a statement that the exemption applies only for
the calendar year in which the physician or health care provider
receives the notice.
(d) If a physician or health care provider submits a
preauthorization request for a medical or health care service for
which the physician or health care provider qualifies for an
exemption from preauthorization requirements under Subsection (a),
the insurer must promptly provide a notice to the physician or
health care provider that includes:
(1) the information described by Subsection (c); and
(2) a notification of the insurer payment requirements
described by Subsection (e).
(e) An insurer may not deny or reduce payment to a physician
or health care provider for a medical or health care service to
which the physician or health care provider qualifies for an
exemption from preauthorization requirements under Subsection (a)
based on medical necessity or appropriateness of care.
SECTION 3. Section 4201.206, Insurance Code, is amended to
read as follows:
Sec. 4201.206. OPPORTUNITY TO DISCUSS TREATMENT BEFORE
ADVERSE DETERMINATION. (a) Subject to Subsection (b) and the
notice requirements of Subchapter G, before an adverse
determination is issued by a utilization review agent who questions
the medical necessity, the appropriateness, or the experimental or
investigational nature of a health care service, the agent shall
provide the health care provider who ordered, requested, provided,
or is to provide the service a reasonable opportunity to discuss
with a physician licensed to practice medicine in this state the
patient's treatment plan and the clinical basis for the agent's
determination.
(b) If the health care service described by Subsection (a)
was ordered, requested, or provided, or is to be provided by a
physician, the opportunity described by that subsection must be
with a physician licensed to practice medicine in this state and who
has the same or similar specialty as the physician.
SECTION 4. The changes in law made by this Act to Chapters
843 and 1301, Insurance Code, apply only to a request for
preauthorization of medical care or health care services made on or
after January 1, 2022. A request for preauthorization of medical
care or health care services made before January 1, 2022, is
governed by the law as it existed immediately before the effective
date of this Act, and that law is continued in effect for that
purpose.
SECTION 5. Section 4201.206, Insurance Code, as amended by
this Act, applies only to a utilization review requested on or after
the effective date of this Act. A utilization review requested
before the effective date of this Act is governed by the law as it
existed immediately before the effective date of this Act, and that
law is continued in effect for that purpose.
SECTION 6. This Act takes effect September 1, 2021.