S.B. No. 1216
 
 
 
 
AN ACT
  relating to the creation of a standard request form for prior
  authorization of medical care or health care services.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle A, Title 8, Insurance Code, is amended
  by adding Chapter 1217 to read as follows:
  CHAPTER 1217.  STANDARD REQUEST FORM FOR PRIOR AUTHORIZATION OF
  HEALTH CARE SERVICES
         Sec. 1217.001.  DEFINITIONS. In this chapter:
               (1)  "Health benefit plan issuer" means an entity
  authorized under this code or another insurance law of this state
  that delivers or issues for delivery a health benefit plan or other
  coverage that is covered under this chapter as described by Section
  1217.002.  The term includes:
                     (A)  an insurance company;
                     (B)  a group hospital service corporation
  operating under Chapter 842;
                     (C)  a fraternal benefit society operating under
  Chapter 885;
                     (D)  a stipulated premium company operating under
  Chapter 884;
                     (E)  a reciprocal exchange operating under
  Chapter 942;
                     (F)  a health maintenance organization operating
  under Chapter 843;
                     (G)  a multiple employer welfare arrangement that
  holds a certificate of authority under Chapter 846; or
                     (H)  an approved nonprofit health corporation
  that holds a certificate of authority under Chapter 844.
               (2)  "Health care services" includes medical or health
  care treatments, consultations, procedures, drugs, supplies,
  imaging and diagnostic services, inpatient and outpatient care,
  medical devices, and durable medical equipment.  The term does not
  include prescription drugs as defined by Section 551.003,
  Occupations Code.
         Sec. 1217.002.  APPLICABILITY OF CHAPTER. (a)  This chapter
  applies only to a health benefit plan that provides benefits for
  medical or surgical expenses incurred as a result of a health
  condition, accident, or sickness, including an individual, group,
  blanket, or franchise insurance policy or insurance agreement, a
  group hospital service contract, or a small or large employer group
  contract or similar coverage document that is offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a fraternal benefit society operating under
  Chapter 885;
               (4)  a stipulated premium company operating under
  Chapter 884;
               (5)  a reciprocal exchange operating under Chapter 942;
               (6)  a health maintenance organization operating under
  Chapter 843;
               (7)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846; or
               (8)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844.
         (b)  This chapter applies to group health coverage made
  available by a school district in accordance with Section 22.004,
  Education Code.
         (c)  Notwithstanding any provision in Chapter 1551, 1575,
  1579, or 1601 or any other law, this chapter applies to:
               (1)  a basic coverage plan under Chapter 1551;
               (2)  a basic plan under Chapter 1575;
               (3)  a primary care coverage plan under Chapter 1579;
  and
               (4)  basic coverage under Chapter 1601.
         (d)  Notwithstanding any other law, this chapter applies to
  coverage under:
               (1)  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; and
               (2)  a Medicaid managed care program operated under
  Chapter 533, Government Code, or a Medicaid program operated under
  Chapter 32, Human Resources Code.
         Sec. 1217.003.  EXCEPTION. This chapter does not apply to:
               (1)  a health benefit plan that provides coverage:
                     (A)  only for a specified disease or for another
  single benefit;
                     (B)  only for accidental death or dismemberment;
                     (C)  only for wages or payments in lieu of wages
  for a period during which an employee is absent from work because of
  sickness or injury;
                     (D)  as a supplement to a liability insurance
  policy;
                     (E)  for credit insurance;
                     (F)  only for dental or vision care;
                     (G)  only for hospital expenses; or
                     (H)  only for indemnity for hospital confinement;
               (2)  a Medicare supplemental policy as defined by
  Section 1882, Social Security Act (42 U.S.C. Section 1395ss);
               (3)  medical payment insurance coverage provided under
  a motor vehicle insurance policy;
               (4)  a long-term care insurance policy, including a
  nursing home fixed indemnity policy, unless the commissioner
  determines that the policy provides benefit coverage so
  comprehensive that the policy is a health benefit plan as described
  by Section 1217.002; or
               (5)  a workers' compensation insurance policy.
         Sec. 1217.004.  STANDARD FORM.  (a)  The commissioner by
  rule shall:
               (1)  prescribe a single, standard form for requesting
  prior authorization of health care services;
               (2)  require a health benefit plan issuer or the agent
  of the health benefit plan issuer that manages or administers
  health care services benefits to use the form for any prior
  authorization required by the plan of health care services; and
               (3)  require that the department and a health benefit
  plan issuer or the agent of the health benefit plan issuer that
  manages or administers health care services benefits make the form
  available in paper form and electronically on the website of:
                     (A)  the department;
                     (B)  the health benefit plan issuer; and
                     (C)  the agent of the health benefit plan issuer.
         (b)  Not later than the second anniversary of the date
  national standards for electronic prior authorization of benefits
  are adopted, a health benefit plan issuer or the agent of the health
  benefit plan issuer that manages or administers health care
  services benefits shall exchange prior authorization requests
  electronically with a physician or health care provider who has
  electronic capability and who initiates a request electronically.  
  For requests initiated on paper, a health benefit plan issuer or the
  agent of the health benefit plan issuer that manages or administers
  health care services benefits shall accept prior authorization
  requests using the standard paper form developed pursuant to this
  chapter.
         (c)  In prescribing a form under this section, the
  commissioner shall:
               (1)  develop the form with input from the advisory
  committee on uniform prior authorization forms for health care
  services benefits established under Section 1217.005; and
               (2)  take into consideration:
                     (A)  any form for requesting prior authorization
  of health care services benefits that is widely used in this state
  or any form currently used by the department;
                     (B)  request forms for prior authorization of
  health care services benefits established by the federal Centers
  for Medicare and Medicaid Services; and
                     (C)  national standards, or draft standards,
  pertaining to electronic prior authorization of benefits.
         Sec. 1217.005.  ADVISORY COMMITTEE ON UNIFORM PRIOR 
  AUTHORIZATION FORMS. (a)  The commissioner shall appoint a
  committee to advise the commissioner on the technical, operational,
  and practical aspects of developing the single, standard prior
  authorization form required under Section 1217.004 for requesting
  prior authorization of health care services, including:
               (1)  requirements for the health benefit plan issuer or
  agent of the health benefit plan issuer to acknowledge receipt of
  the standard form;
               (2)  timelines under which the health benefit plan
  issuer or agent of the health benefit plan issuer must acknowledge
  receipt of the standard form; and
               (3)  implications, including administrative penalties,
  for the failure of a health benefit plan issuer or agent of a health
  benefit plan issuer to:
                     (A)  timely acknowledge receipt of the standard
  form; or
                     (B)  use or accept the form.
         (b)  The commissioner shall consult the advisory committee
  with respect to any rule relating to a subject described by Section
  1217.004 before adopting the rule and may consult the committee as
  needed with respect to a subsequent amendment of an adopted rule.
         (c)  The advisory committee shall be composed of an equal
  number of members from each of the following groups of
  stakeholders:
               (1)  physicians;
               (2)  health care providers other than physicians;
               (3)  hospitals;
               (4)  representatives of health benefit plans; and
               (5)  Health and Human Services Commission
  representatives.
         (d)  A physician may not serve on the advisory committee as a
  physician member under Subsection (c)(1) if the physician is or has
  been employed by or consults or has consulted for an insurance
  company.
         (e)  A member of the advisory committee serves without
  compensation.
         (f)  Section 39.003(a) of this code and Chapter 2110,
  Government Code, do not apply to the advisory committee.
         Sec. 1217.006.  FAILURE TO PRESCRIBE STANDARD FORM. Nothing
  in this chapter may be construed as authorizing the commissioner to
  decline to prescribe the form required by Section 1217.004.
         Sec. 1217.007.  CONSTRUCTION WITH OTHER LAW. Nothing in
  this chapter may be construed as permitting a health benefit plan
  issuer or an agent of a health benefit plan issuer to require prior
  authorization of health care services benefits when otherwise
  prohibited by law.
         SECTION 2.  Not later than January 1, 2015, the commissioner
  of insurance by rule shall prescribe a standard form under Section
  1217.004, Insurance Code, as added by this Act.
         SECTION 3.  The change in law made by this Act applies only
  to a request for prior authorization of health care services made on
  or after September 1, 2015.  A request for prior authorization of
  health care services made before September 1, 2015, under a health
  benefit plan delivered, issued for delivery, or renewed before that
  date is governed by the law in effect immediately before the
  effective date of this Act, and that law is continued in effect for
  that purpose.
         SECTION 4.  This Act takes effect September 1, 2013.
 
 
 
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
         I hereby certify that S.B. No. 1216 passed the Senate on
  May 2, 2013, by the following vote: Yeas 30, Nays 1; and that the
  Senate concurred in House amendments on May 24, 2013, by the
  following vote: Yeas 31, Nays 0.
 
 
  ______________________________
  Secretary of the Senate    
 
         I hereby certify that S.B. No. 1216 passed the House, with
  amendments, on May 22, 2013, by the following vote: Yeas 142,
  Nays 6, one present not voting.
 
 
  ______________________________
  Chief Clerk of the House   
 
 
 
  Approved:
 
  ______________________________ 
              Date
 
 
  ______________________________ 
            Governor