Bill Text: TX SB1380 | 2025-2026 | 89th Legislature | Engrossed
Bill Title: Relating to health benefit plan preauthorization requirements for participating physicians and providers providing certain health care services.
Sponsorship: Bipartisan Bill
Status: (Engrossed - Dead) 2025-05-25 - Referred to Insurance [SB1380 Detail]
Download: Texas-2025-SB1380-Engrossed.html
| By: Paxton, et al. | S.B. No. 1380 | |
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| 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, 2026. | ||
| SECTION 3. This Act takes effect September 1, 2025. | ||
