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House Bill 2256 |
House Author: Hancock et al. |
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Effective: 6-19-09 |
Senate Sponsor: Duncan |
House Bill 2256 amends the Insurance Code to establish a mandatory mediation process for settling out-of-network health benefit claims. The bill authorizes an enrollee in a preferred provider benefit plan or a health benefit plan offered under the Texas Employees Group Benefits Act to request mediation of such a claim if the amount for which the enrollee is responsible to a facility-based physician, after certain adjustments, is greater than $1,000, and the claim is for a medical service or supply provided by a facility-based physician in a hospital that is a preferred provider or has a contract with the plan's administrator. The bill provides for a three-step dispute resolution process that includes a teleconference, mediation, and a trial by judge; outlines the procedures for requesting and conducting the mediation; and establishes mediator qualifications. The bill provides for the confidentiality of information by the mediator, specifies the matters that may be considered in mediation, and establishes procedures to be followed if the parties do not reach a resolution. The bill identifies conduct that constitutes bad faith mediation and the resulting penalties, and requires the commissioner of insurance and the Texas Medical Board, as appropriate, to adopt rules regulating the investigation and review of a complaint filed that relates to the settlement of an out-of-network health benefit claim. The bill specifies the issues to be addressed by those rules and establishes requirements for the maintenance of information relating to such complaints and claims. The bill requires an out-of-network facility-based physician who bills a patient covered by a preferred provider benefit plan or a health benefit plan offered under the Texas Employees Group Benefits Act to include notice of the mandatory mediation process in a billing statement sent to the patient, if the amount for which the patient ultimately is responsible exceeds $1,000.
House Bill 2256 requires the commissioner to adopt network adequacy standards that are adapted to local markets in which an insurer offering a preferred provider benefit plan operates and that ensure the availability of, and accessibility to, a full range of contract physicians and health care providers, allowing for departure from those standards under certain conditions.
House Bill 2256 amends the Health and Safety Code to include certain disclosures relating to medical services provided by facility-based physicians in the information that must be addressed by licensed ambulatory surgical centers, birthing centers, and hospitals in their written policies for the billing of health care services.