SB1380 - Relating to health benefit plan preauthorization requirements for participating physicians and providers providing certain health care services.

      By: Paxton, et al. S.B. No. 1380     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, 2026.          SECTION 3.  This Act takes effect September 1, 2025.