Amend CSSB 1738 (committee printing) as follows:
(1) On page 5, line 19, through page 11, line 11, delete
SECTIONS 3 through 13 and insert new SECTIONS 3, 4 and 5 as follows
and renumber accordingly:
"SECTION 3. Section 1271.055(b), Insurance Code, is amended
as follows:
(b) If medically necessary covered services are not
available through network physicians or providers, the health
maintenance organization, on the request of a network physician or
provider and within a reasonable period, shall:
(1) allow referral to a non-network physician or
provider; and
(2) [fully] reimburse the non-network physician or
provider at the usual and customary rate or at an agreed rate.
SECTION 4. Section 1272.301(a)(1), Insurance Code, is
amended as follows:
(a) A contract between a health maintenance organization
and a limited provider network or delegated entity must provide
that:
(1) if medically necessary covered services are not
available through network physicians or providers, the limited
provider network or delegated entity, on the request of a network
physician or provider, shall:
(A) allow a referral to a non-network physician
or provider; and
(B) [fully] reimburse the non-network physician
or provider at the usual and customary or an agreed rate; and
SECTION 5. Subtitle F, Title 8, Insurance Code, as
effective April 1, 2005, is amended by adding Chapter 1456 to read
as follows:
CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS
Sec. 1456.001. DEFINITIONS. In this chapter:
(1) "Balance billing" means the practice of charging
an enrollee in a health benefit plan that uses a provider network to
recover from the enrollee the balance of a non-network health care
provider's fee for service received by the enrollee from the health
care provider that is not fully reimbursed by the enrollee's health
benefit plan.
(2) "Enrollee" means an individual who is eligible to
receive health care services through a health benefit plan.
(3) "Facility based physician" means a radiologist, an
anesthesiologist, a pathologist, or an emergency department
physician:
(A) to whom the facility has granted clinical
privileges; and
(B) who provides services to patients of the
facility under those clinical privileges.
(4) "Health care facility" means a hospital, emergency
clinic, outpatient clinic, or other facility providing health care
services.
(5) "Health care practitioner" means an individual who
is licensed to provide and provides health care services.
(6) "Health care provider" means a health care
facility or health care practitioner.
(7) "Provider network" means a health benefit plan
under which health care services are provided to enrollees through
contracts with health care providers and that requires those
enrollees to use health care providers participating in the plan
and procedures covered by the plan. The term includes a network
operated by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) another entity that issues a health benefit
plan, including an insurance company.
Sec. 1456.002. APPLICABILITY OF CHAPTER. This chapter
applies to any health benefit plan that:
(1) 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 an individual or group evidence of coverage that is offered by:
(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 health maintenance organization operating
under Chapter 843;
(F) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; or
(H) an entity not authorized under this code or
another insurance law of this state that contracts directly for
health care services on a risk-sharing basis, including a
capitation basis; or
(2) provides health and accident coverage through a
risk pool created under Chapter 172, Local Government Code,
notwithstanding Section 172.014, Local Government Code, or any
other law.
Sec. 1456.003. REQUIRED DISCLOSURE: HEALTH BENEFIT PLAN.
(a) Each health benefit plan that provides health care through a
provider network shall provide notice to its enrollees that:
(1) a facility-based physician or other health care
practitioner may not be included in the health benefit plan's
provider network; and
(2) a health care practitioner described by
Subdivision (1) may balance bill the enrollee for amounts not paid
by the health benefit plan.
(b) The health benefit plan shall provide the disclosure in
writing to each enrollee in:
(1) any materials sent to the enrollee in conjunction
with issuance or renewal of the plan's insurance policy or evidence
of coverage;
(2) an explanation of payment summary provided to the
enrollee;
(3) any other analogous document that describes the
enrollee's benefits under the plan; or
(4) conspicuously displayed on any website that an
enrollee is reasonably expected to access.
Sec. 1456.004. REQUIRED DISCLOSURE: HEALTH CARE FACILITY.
(a) Each health care facility that has entered into a contract with
a health benefit plan to serve as a provider in the health benefit
plan's provider network shall provide notice to enrollees receiving
health care services at the facility that:
(1) a facility-based physician or other heath care
practitioner may not be included in the health benefit plan's
provider network; and
(2) a health care practitioner described by
Subdivision (1) may balance bill the enrollee for amounts not paid
by the health benefit plan.
(b) The health care facility shall provide the disclosure in
writing at the time the enrollee is first admitted to the facility
or first receives services at the facility.
Sec. 1456.005. REQUIRED DISCLOSURE: FACILITY BASED
PHYSICIANS. (a) If a facility based physician bills a patient who
is covered by a health benefits plan, as described in Section
1456.002, that does not have a contract with the facility based
physician, the facility based physician shall send a billing
statement that:
(1) contains an itemized listing of the services and
supplies provided along with the dates the services and supplies
were provided;
(2) contains a conspicuous plain language explanation
that:
(A) the facility based physician is not within
the health plan health delivery network; and
(B) the health benefit plan has paid the usual
and customary rate, as determined by the health benefits plan,
which is below the facility based physician billed amount;
(3) contains a telephone number to call to discuss the
statement, provide an explanation of any acronyms, abbreviations,
and numbers used on the statement, or discuss any payment issues;
(4) contains a statement that the patient may call to
discuss alternative payment arrangements;
(5) contains a notice that the patient my file
complaints with the Texas State Board of Medical Examiners and
include the Texas State Board of Medical Examiners mailing address
and complaint telephone number; and
(6) for billing statements that total to an amount
greater than $200, over any applicable copayments or deductibles,
states, in plain language, that if the patient finalizes a payment
plan agreement within 45 days of receiving the first billing
statement and substantially complies with the agreement, the
facility based physician may not furnish adverse information to a
consumer reporting agency regarding an amount owed by a patient for
the receipt of medical treatment for one calendar year from the
first statement date. A patient may be considered by the facility
based physician to be out of substantial compliance with the
payment plan agreement if payments are not made in compliance with
the agreement for a period of 90 days.
Sec. 1456.006. DISCIPLINARY ACTION AND ADMINSTRATIVE
PENALTY. (a) The commissioner may take disciplinary action against
a licensee that violates this chapter in accordance with Chapter
84, Texas Insurance Code. A health care provider that violates this
chapter is subject to disciplinary action by the appropriate
regulatory agency.
(b) A violation of this chapter by a health care provider or
facility based physician is grounds for disciplinary action and
imposition of an administrative penalty by the appropriate
regulatory agency that issued a license, certification, or
registration to the health care provider or facility based
physician who committed the violation.
(c) The regulatory agency shall:
(1) notify a health care provider or facility based
physician of a finding by the regulatory agency that the health care
provider or facility based physician is violating or has violated
this chapter or a rule adopted under this chapter; and
(2) provide the health care provider or facility based
physician with an opportunity to correct the violation.
(d) The complaints brought under this section are not
considered to require a determination of medical competency, and
therefore Occupations Code Sec. 154.058 shall not apply.
Sec. 1456.007. COMMISSIONER RULES; FORM OF DISCLOSURE. The
commissioner by rule may prescribe specific requirements for the
disclosure required under Sections 1456.003 and 1456.004. The form
of the disclosure must be substantially as follows:
NOTICE
ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN PROVIDED TO YOU AT
A HEALTH CARE FACILITY THAT IS A MEMBER OF THE PROVIDER NETWORK USED
BY YOUR HEALTH BENEFIT PLAN, OTHER PROFESSIONAL SERVICES MAY BE OR
HAVE BEEN PROVIDED AT OR THROUGH THE FACILITY BY HEALTH CARE
PROVIDERS WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE
RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE
PROFESSIONAL SERVICES THAT ARE NOT COVERED BY YOUR HEALTH BENEFIT
PLAN."
(2) On page 11, line 44 through page 12, line 27, delete
SECTIONS 15 and 16 and renumber accordingly.
(3) On page 12, line 38 through page 12, line 44, delete
SECTION 19 and renumber accordingly.
(4) On page 12, line 60 through 64, delete SECTION 22 and
replace with the following:
"SECTION 22. This Act takes effect September 1, 2005."