By: Van de Putte S.B. No. 698
A BILL TO BE ENTITLED
AN ACT
relating to required disclosures to health benefit plan enrollees
regarding professional services provided by certain non-network
health care providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. 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 services received by the enrollee from the
health care provider that are 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) "Health care facility" means a hospital, emergency
clinic, outpatient clinic, or other facility providing health care
services.
(4) "Health care practitioner" means an individual who
is licensed to provide and provides health care services.
(5) "Health care provider" means a health care
facility or health care practitioner.
(6) "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; or
(3) any other analogous document that describes the
enrollee's benefits under the plan.
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 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 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. 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.
SECTION 2. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2005.