79(R) SB 698 - House Committee Report version


                                                                                



By:  Van de Putte                                                 S.B. No. 698

Substitute the following for S.B. No. 698:                                    

By:  Smithee                                                  C.S.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, 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:
		(1)  in any materials sent to the enrollee in 
conjunction with issuance or renewal of the plan's insurance policy 
or evidence of coverage;
		(2)  in an explanation of payment summary provided to 
the enrollee;  
		(3)  in 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 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.  REQUIRED DISCLOSURE:  FACILITY-BASED 
PHYSICIANS.  If a facility-based physician bills a patient who is 
covered by a health benefit 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 benefit 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 may file 
complaints with the Texas State Board of Medical Examiners and 
includes the Texas State Board of Medical Examiners mailing address 
and complaint telephone number; and
		(6)  for billing statements that total 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 the 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 ADMINISTRATIVE 
PENALTY.  (a)  The commissioner may take disciplinary action 
against a licensee that violates this chapter, in accordance with 
Chapter 84.  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 Section 154.058, Occupations Code, 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.
	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.