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A BILL TO BE ENTITLED
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AN ACT
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relating to out-of-pocket expense credits for payments made |
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directly to a physician or health care provider by an enrollee of a |
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governmental employee health benefit plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle H, Title 8, Insurance Code, is amended |
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by adding Chapter 1582 to read as follows: |
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CHAPTER 1582. PROVISIONS APPLICABLE TO STATE AND LOCAL EMPLOYEE |
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HEALTH BENEFITS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1582.001. APPLICABILITY OF CHAPTER. This chapter |
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applies only to a health benefit plan that is: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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(4) a plan providing basic coverage under Chapter |
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1601; |
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(5) county employee group health benefits provided |
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under Chapter 157, Local Government Code; or |
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(6) health and accident coverage provided by a risk |
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pool created under Chapter 172, Local Government Code. |
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SUBCHAPTER B. OUT-OF-POCKET EXPENSES |
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Sec. 1582.051. OUT-OF-POCKET EXPENSE CREDIT. (a) The |
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issuer or administrator of a health benefit plan to which this |
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chapter applies shall credit toward an enrollee's deductible and |
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annual maximum out-of-pocket expenses an amount the enrollee pays |
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directly to any physician or health care provider for a medically |
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necessary covered medical or health care service or supply if a |
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claim for the service or supply is not submitted to the issuer or |
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administrator and the amount paid by the enrollee to the physician |
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or health care provider is less than the average discounted rate for |
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the service or supply paid to an equivalently licensed or |
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authorized preferred provider under the enrollee's health benefit |
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plan. |
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(b) The health benefit plan issuer or administrator shall: |
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(1) establish a procedure by which an enrollee may |
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claim a credit under Subsection (a); and |
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(2) identify documentation necessary to support a |
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claim for a credit under Subsection (a). |
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(c) Information about the procedure and documentation |
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described by Subsection (b) must be readily accessible to an |
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enrollee on the issuer's or administrator's Internet website. |
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SECTION 2. The changes in law made by this Act apply only to |
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a health benefit plan delivered, issued for delivery, or renewed, |
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or a plan year that commences, on or after January 1, 2026. |
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SECTION 3. This Act takes affect September 1, 2025. |