Texas Senator Kelly Hancock (R-North Richland Hills) and Rep. Tom Oliverson, MD (R-Spring) asked stakeholders to submit legislative recommendations for the 2021 Texas Legislature.
Some of TOA's recommendations include:
- Require the health plans to include their medical policies on their web page.
- Create a timeline for prior authorization decisions.
- Create an electronic prior authorization program so that staff members are not placed on a telephone hold for hours at a time.
Federal Proposal
The Centers for Medicare and Medicaid Services (CMS) proposed a new prior authorization rule on December 10 that would affect Medicaid, Children's Health Insurance Program, and Qualified Health Plan payers. However, qualified health plan issuers in the marketplace and Medicare Advantage plans would be excluded, and that disappointed stakeholders such as the American Hospital Association.
"The proposed rule is a welcome step toward helping clinicians spend their limited time on patient care," Ashley Thompson, senior vice president of public policy analysis and development for AHA, said in a statement. "We urge the agency to reconsider and hold Medicare Advantage plans accountable to the same standards."
The proposed rule would:
- Cap the amount of time it takes for payers to issue decisions on prior authorizations to 72 hours for urgent requests and seven days for non-urgent ones.
- Require payers to include a specific reason when denying a prior authorization request -- regardless of how it was submitted -- and to publicly report data about their prior authorization process.
- Medicaid, Children's Health Insurance Program and Qualified Health Plan payers would be required to develop a platform for payer-to-provider data sharing of claims and encounter data, with the desired outcome to allow physicians to know in advance what prior authorization paperwork they need and integrate the platform with a provider’s electronic health record so they can send and receive responses electronically.
The New 2019 Prior Authorization Law
The Texas Department of Insurance (TDI) proposed a rule to implement Texas' new prior authorization law, SB 1742, which was passed by the 2019 Texas Legislature.
Click here to read the proposed rule, which governs health plans that are regulated by the state of Texas. (ERISA plans are regulated by the federal government.)
If you have taken the effort to view the prior authorization requirements on the health plans' websites as a result of the new law, let TOA know by replying to this e-mail. We would like to hear your feedback.
Some of the key champions who made this happen include Rep. Greg Bonnen, MD (R-Friendswood), Sen. Charles Schwertner, MD (R-Georgetown), Sen. Dawn Buckingham, MD (R-Lakeway), Rep. Julie Johnson (D-Dallas), and Sen. Jose Mendendez (D-San Antonio).
Some of the key provisions include:
(1) An HMO or a preferred provider benefit plan must make the requirements and information about the preauthorization process readily accessible to enrollees, physicians, health care providers, and the general public by posting the requirements and information on the HMO's or the preferred provider benefit plan's public internet website.
(2) The preauthorization requirements and information described by paragraph (1) of this section must:
(A) be posted: (i) conspicuously in a location on the public internet website that does not require the user to login or input personal information to view the information; except as provided by paragraph (3) or (4) of this subsection; (ii) in a format that is easily searchable; and (iii) in a format that uses design and accessibility standards defined in Section 508 of the U.S. Rehabilitation Act;
(B) except for the screening criteria under subparagraph (D)(iii) of this paragraph, be written: TITLE 28. INSURANCE Proposed Sections Part I. Texas Department of Insurance Page 31 of 36 Chapter 19. Licensing and Regulation of Insurance Professionals (i) using plain language standards, such as the Federal Plain Language Guidelines found on www.PlainLanguage.gov; and (ii) in language that aims to reach a 6th to 8th grade reading level, if the information is for enrollees and the public;
(C) include a detailed description of the preauthorization process and procedure; and
(D) include an accurate and current list of medical or health care services for which the HMO or the preferred provider benefit plan requires preauthorization that includes the following information specific to each service:
(i) the effective date of the preauthorization requirement;
(ii) a list or description of any supporting documentation that the HMO or preferred provider benefit plan requires from the physician or health care provider ordering or requesting the service to approve a request for that service;
(iii) the applicable screening criteria, which may include Current Procedural Terminology codes and International Classification of Diseases codes; and
(iv) statistics regarding the HMO's or the preferred provider benefit plan's preauthorization approval and denial rates for the service in the preceding calendar year, including statistics in the following categories:
(I) physician or health care provider type and specialty, if any;
(II) indication offered;
(III) reasons for request denial;
(IV) denials overturned on internal appeal;
(V) denials overturned by an independent review organization; and TITLE 28. INSURANCE Proposed Sections Part I. Texas Department of Insurance Page 32 of 36 Chapter 19. Licensing and Regulation of Insurance Professionals (VI) total annual preauthorization requests, approvals, and denials for the service.
