BILL ANALYSIS
BACKGROUND AND PURPOSE
In recent years, health care costs have consistently increased. The rising cost of health care has been a prevalent point of discussion and debate for employers, providers, health plans, and patients. A major point of this discussion is the potential for inaccurate information and the absence of transparency in the costs of health care services. The disclosure of this information may help patients to make appropriate and cost-effective health choices.
S.B. 1731 creates a "Consumer Guide to Health Care" on the Department of State Health Services' Internet website to provide certain information to the general public. This bill also requires that physicians and hospitals create and maintain consistent billing policies, that these policies be posted for disclosure to the patient, and to inform patents about the possibility of an out-of-network physician or provider working in an in-network facility and any potentially resultant costs to the patient. This bill requires the Texas Department of Insurance to create a new data collection program to collect certain reimbursement rates that health plans pay to insurers and to organize this information in a specific fashion. The bill directs the Texas Department of Insurance to work with the network adequacy study group to develop the data collection and evaluate the information collected.
Rulemaking authority is expressly granted to the executive commissioner of the Health and Human Services Commission in SECTION 1 of this bill.
Rulemaking authority is expressly granted to the Texas Medical Board in SECTION 5 of this bill.
Rulemaking authority is expressly granted to the commissioner of insurance in SECTION 7, SECTION 10, SECTION 17 and SECTION 18 of this bill.
It is the committee's opinion that rulemaking authority is expressly granted to the Department of State Health Services in SECTION 16 of this bill.
It is the committee's opinion that rulemaking authority is expressly granted to the Texas Medical Board in SECTION 16 of this bill.
It is the committee's opinion that rulemaking authority is expressly granted to the Texas Department of Insurance in SECTION 16 of this bill.
ANALYSIS
SECTION 1. Amends Subtitle G, Title 4, Health and Safety Code, by adding Chapter 324, as follows:
CHAPTER 324. CONSUMER ACCESS TO HEALTH CARE INFORMATION
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 324.001. DEFINITIONS. Defines "average charge," "billed charge," "costs," "consumer," "department," "executive commissioner," and "facility."
Sec. 324.002. RULES. Requires the executive commissioner of the Health and Human Services Commission (HHSC) to adopt and enforce rules to further the purposes of this chapter.
[Reserves Sections 324.003-324.050 for expansion.]
SUBCHAPTER B. CONSUMER GUIDE TO HEALTH CARE
Sec. 324.051. DEPARTMENT WEBSITE. (a) Provides that the Department of State Health Services (DSHS) shall make a consumer guide to health care (guide) available on its Internet website. Requires DSHS to include information in its guide concerning facility pricing practices and the correlation between certain prices, including variation on prices relating to certain aspects of a person's medical condition and resultant treatment.
(b) Sets forth certain information required to be included in the guide by DSHS.
(c) Provides that DSHS shall include in the guide an Internet link for consumers to access quality of care data from certain websites and a disclaimer noting that those linked websites are not provided by this state or an agency of this state.
(d) Authorizes DSHS to accept gifts and grants to fund the guide. Prohibits DSHS from identifying, recognizing, or acknowledging in any format any such donors or grantors.
[Reserves Sections 324.052-324.100 for expansion.]
SUBCHAPTER C. BILLING OF FACILITY SERVICES AND SUPPLIES
Sec. 324.101. FACILITY POLICIES. (a) Provides that each facility shall develop, implement, and enforce written policies for the billing of facility health care services and supplies (services and supplies). Sets forth certain provisions that these policies are required to address.
(b) Provides that a hospital that provides services in an emergency department of the hospital or as a result of an emergent direct admission shall provide certain written disclosure before discharging the patient from the emergency department or hospital, as appropriate.
(c) Provides that each facility shall post a clear and conspicuous notice of the availability of certain policies in the general waiting area and in the waiting areas of certain offices.
(d) Provides that the facility shall provide an estimate of the facility's charges for certain admissions and procedures on request and before the scheduling of either an admission, procedure, or service. The estimate must be provided not later than the 10th business day after the date on which the estimate was requested. Sets forth certain issues on which the facility must advise the consumer requesting the estimate.
(e) Provides that a facility shall provide to the consumer an itemized statement of the billed services if the consumer requests this statement not later than the first anniversary of the date the person is discharged from the facility. Provides that the facility shall provide the statement to the consumer within 10 days of the consumer's request.
(f) Provides that a facility shall provide an itemized statement of billed services to a third-party payor who is actually or potentially responsible for paying all or part of the billed services provided to a patient and who has received a claim for payment of those services. To be entitled to receive a statement, the third-party payor must request the statement from the facility and must have received a claim for payment. The request must be made not later than one year after the date on which the payor received the claim for payment. The facility shall provide the statement to the payor not later than the 30th day after the date on which the payor requests the statement. If a third-party payor receives a claim for payment of part but not all of the billed services, the third-party payor may request an itemized statement of only the billed services for which payment is claimed or to which any deduction or copayment applies.
(g) Requires that a facility in violation of this section be subject to enforcement action by the appropriate licensing agency.
(h) Provides that if a consumer or a third-party payor requests more than two copies of the statement, the facility may charge a reasonable fee for the third and subsequent copies provided. The fee may not exceed a certain sum.
(i) Provides that if a consumer overpays a facility, the facility is required to refund the amount of the overpayment not later than the 30th day after the date the facility determines that an overpayment has been made. This subsection does not apply to an overpayment subject to Section 1301.132 or 843.350, Insurance Code.
Sec. 324.102. COMPLAINT PROCESS. Provides that a facility shall establish and implement a procedure for handling consumer complaints. The facility shall make a good faith effort to resolve a complaint in an informal manner based on its complaint procedures. Provides that the facility shall advise the consumer that a complaint may be filed with the Department of State Health Services and to provide the consumer with certain contact information for Department of State Health Services when the complaint cannot be resolved in an informal manner.
Sec. 324.103. CONSUMER WAIVER PROHIBITED. Prohibits the waiving, voiding, or nullification of the provisions of this chapter by a contract or an agreement between a facility and a consumer.
SECTION 2. Amends Section 108.002(10), Health and Safety Code, to redefine "health care facility."
SECTION 3. Amends Section 108.009(k), Health and Safety Code, to require the Texas Health Care Information Council (council) to prioritize data collection efforts on inpatient and outpatient surgical and radiological procedures from hospitals, ambulatory surgical centers, and free-standing radiology centers.
SECTION 4. Subsection (h), Section 311.002, Health and Safety Code, amends what the term "hospital" includes and makes conforming changes.
SECTION 5. Amends Chapter 101, Occupations Code, by adding Subchapter H, redesignating Section 101.202, Occupations Code, as Section 101.351, transferring it to Subsection H, and further amending that section, and adding Section 101.352, as follows:
SUBCHAPTER H. BILLING
Sec. 101.351. FAILURE TO PROVIDE BILLING INFORMATION. (a) Provides that this section does not apply to a physician subject to Section 101.352, Occupations Code.
Sec. 101.352. BILLING POLICIES AND INFORMATION; PHYSICIANS. (a) Requires a physician to develop, implement, and enforce written policies for the billing of health care services and supplies (services and supplies). Sets forth certain issues which the policies are required to address.
(b) Requires each physician, who maintains a waiting area, to post a clear and conspicuous notice of the availability of the policies required by Subsection (a) in the general waiting area and in the waiting areas of certain offices in which patients are reasonably expected to seek service.
(c) Requires the physician to provide an estimate of the charges for any health care services or supplies on request of a patient who is seeking the provision of services on an out-of-network basis or who does not have coverage under certain programs. The estimate must be provided not later than the 10th business day after the date the request was made. Sets forth certain issues on which the physician must advise the consumer requesting the estimate.
(d) For services provided in an emergency department of a hospital or as a result of an emergent direct admission, the physician is required to provide the estimate of charges required by Subsection (c) before discharging the patient from the emergency department or hospital, as appropriate.
(e) Requires a physician to provide to the consumer an itemized statement of the billed services if the consumer requests this statement not later than the first anniversary of the date the services or supplies were provided. Requires a physician to provide the statement to the consumer within 10 days of the consumer's request.
(f) Authorizes a physician to charge a reasonable fee for the third and subsequent copies of a statement if the consumer requests more than two. Requires the Texas Medical Board (board) by rule to set the permissible fee that a physician is authorized to charge for the copying, processing, and delivering a copy of the statement.
(g) Requires a physician to provide, upon request and in plain language, a written explanation for services or supplies previously made on a bill or statement for the patient.
(h) Requires a physician to refund a consumer's overpayment to the consumer within 30 days after the physician's determination that an overpayment has been made. Provides that this subsection does not apply to an overpayment related to a preferred provider benefit plan or a health maintenance organization, subject to Section 1301.132 or 843.350, Insurance Code, respectively.
(i) Defines "physician" for purposes of this section.
SECTION 6. Amends Section 154.002, Occupations Code, by adding Subsection (c), to require the Texas Medical Board (board) to make a consumer guide to health care (guide) available on its Internet website. Requires the board to include information in its guide concerning the billing and reimbursement of health care services provided by physicians and variations in the costs of those services due to certain factors.
SECTION 7. Amends Chapter 38, Insurance Code, by adding Subchapter H, as follows:
SUBCHAPTER H. HEALTH CARE REIMBURSEMENT RATE INFORMATION
Sec. 38.351. PURPOSE OF SUBCHAPTER. Provides that the purpose of this subchapter is to authorize the Texas Department of Insurance (TDI) to collect data concerning health benefit plan reimbursement rates in a uniform format and to disseminate, on an aggregate basis for geographical regions of this state, information concerning health care reimbursement rates that are derived from the data.
Sec. 38.352. DEFINITION. Defines "group health benefit plan."
Sec. 38.353. APPLICABILITY OF SUBCHAPTER. (a) Applies this subchapter only to certain issuers of a group health benefit plan.
(b) Applies this subchapter to specific plans and types of coverage provided under Chapters 1551 (Texas Employees Group Benefits Act), 1575 (Texas Public School Employees Group Benefits Program), 1579 (Texas School Employees Uniform Group Health Coverage), and 1601 (Uniform Insurance Benefits Act for Employees of the University of Texas System and the Texas A&M University System), Insurance Code, notwithstanding any provisions of those chapters.
(c) Applies this subchapter to a small employer health benefit plan provided under Chapter 1501 (Health Insurance Portability and Availability Act), Insurance Code, except as provided by Subsection (d).
(d) Sets forth certain health benefit plans to which this subchapter does not apply.
(e) Authorizes the commissioner of insurance (commissioner) by rule to exclude a type of health benefit plan from the requirements of this subchapter if the commissioner finds that data collected in relation to the plan would not be relevant in accomplishing the purposes of this subchapter.
Sec. 38.354. RULES. Authorizes the commissioner to adopt rules as provided by Subchapter A (Rules), Chapter 36, Insurance Code, to implement this subchapter.
Sec. 38.355. DATA CALL; STANDARDIZED FORMAT. (a) Requires each health benefit plan issuer (issuer) to submit to TDI, at the time and in the form and manner required by TDI, aggregate reimbursement rates organized by region and paid by the issuer for health care services identified by TDI.
(b) Requires TDI to require that data submitted under this section (data) be submitted in a standardized format, established by rule, to permit comparison of health care costs. Requires TDI to develop the data submission requirements in a manner that provides for the submission of specific health care related figures, to the extent feasible.
(c) Requires TDI to specify the period for which reimbursement rates are required to be filed under this section.
(d) Authorizes TDI to contract with a private third party to obtain data. Authorizes TDI, under such a contract, to determine the aggregate data to be collected and published under Section 38.357 if consistent with the purposes of this subchapter described in Section 38.351. Requires TDI to prohibit the third party contractor from selling, leasing, or publishing the obtained data.
Sec. 38.356. CONFIDENTIALITY OF DATA. Provides that data collected under this subchapter (data) is confidential and not subject to disclosure under Chapter 552 (Public Information), Government Code, except as provided by Section 38.357, Insurance Code.
Sec. 38.357. PUBLICATION OF AGGREGATE HEALTH CARE REIMBURSEMENT RATE INFORMATION. Requires TDI to provide to the Department of State Health Services for publication, for identified regions of this state, aggregate health care reimbursement rate information derived from collected data. Prohibits the published information from revealing the name of any health care provider or issuer. Authorizes TDI to make the information available thorough TDI's website.
Sec. 38.358. PENALTIES. Provides that an issuer that fails to submit data as required in accordance with this subchapter is subject to an administrative penalty under Chapter 84 (Administrative Penalties), Insurance Code. Provides that each day the issuer fails to submit the data as required is a separate violation for purposes of penalty assessment.
SECTION 8. Amends Section 843.155, Insurance Code, by amending Subsection (b) and adding Subsection (d), as follows:
(b) Requires a statement of certain enumerated information to be included in an annual report required to be filed by a health maintenance organization under this section (HMO report). Makes conforming changes.
(d) Requires the HMO report to be made publicly available on TDI's Internet website in a user-friendly format that allows consumers to make direct comparisons of the financial and other data reported by a health maintenance organization under this section.
SECTION 9. Amends Subchapter A, Chapter 1301, Insurance Code, by adding Section 1301.009, as follows:
Sec. 1301.009. ANNUAL REPORT. (a) Requires an insurer to file a report with the commissioner relating to the preferred provider benefit plan offered under this chapter (Preferred Provider Benefit Plans) and covering the preceding calendar year, not later than March 1 of each year.
(b) Requires the report to be verified by at least two principal officers, to be in a form prescribed by the commissioner, and to include certain information.
(c) Requires the report to be made publicly available on TDI's Internet website in a user-friendly format that allows consumers to make direct comparisons of the financial and other data reported by insurers under this section.
(d) Provides that an insurer providing group coverage of $10 million or less in premiums or individual coverage of $2 million or less in premiums is not required to report a statement of certain information required under Subsection (b)(3)(C).
SECTION 10. Amends Subtitle F, Title 8, Insurance Code, by adding Chapter 1456, as follows:
Chapter 1456. DISCLOSURE OF PROVIDER STATUS
Sec. 1456.001. DEFINITIONS. Defines "balance billing," "enrollee," "facility-based physician," "health care facility," "health care practitioner," and "provider network."
Sec. 1456.002. APPLICABILITY OF CHAPTER. (a) Applies this chapter to any health benefits plan that provides benefits for medical or surgical expenses incurred as a result of certain health conditions, accidents, or sicknesses, including policies, agreements, or contracts offered by certain entities, or that provides health and accident coverage through a risk pool created under Chapter 172 (Texas Political Subdivisions Uniform Group Benefits Program), Local Government Code, notwithstanding Section 172.014 (Application of Certain Laws), Local Government Code, or any other law.
(b) Applies this chapter to a person to whom a health benefit plan contracts to process or pay claims, to obtain the services of physicians or other providers to provide health care services to enrollees, or to issue verifications or preauthorizations.
(c) Provides that this chapter does not apply to Medicaid managed care programs operated under Chapter 533, Government Code; Medicaid programs operated under Chapter 32, Human Resources Code; or the state child health plan operated under Chapter 62 or 63, Health and Safety Code.
Sec. 1456.003. REQUIRED DISCLOSURE; HEALTH BENEFIT PLAN. (a) Requires each health benefit plan that provides health care through a provider network to provide notice to enrollees that a facility-based physician (physician) or other health care practitioner (practitioner) may not be included in the health benefit plan's provider network (provider network) and that said practitioner is authorized to balance bill the enrollee for amounts not paid by the health benefit plan.
(b) Sets forth certain areas in which the health benefit plan is required to provide the disclosure in writing to each enrollee.
(c) Requires a plan to clearly identify any facilities within the provider network in which physicians do not participate in the plan's provider network. Requires facilities identified in such a way to be identified in a separate and conspicuous manner in any provider network directory or website directory.
(d) Requires any explanation of benefits sent to an enrollee that contains a remark code indicating that a payment made to a non-network physician has been paid at the plan's allowable or usual and customary amount to also include the number for TDI's consumer protection division for complaints regarding payment.
Sec. 1456.004. REQUIRED DISCLOSURE; FACILITY-BASED PHYSICIANS. (a) Requires a physician who bills a patient covered by a health benefit plan described in Section 1456.002, Insurance Code, that does not have a contract with the physician, to send a billing statement including certain information. Sets forth the certain information to be contained in the billing statement.
(b) Provides that a patient may be considered to be out of substantial compliance with the payment plan agreement between the patient and physician if payments are not made in compliance with the agreement for a period of 90 days.
Sec. 1456.005. DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY. (a) Authorizes the commissioner to take disciplinary action against a licensee that violates this chapter in accordance with Chapter 84, Insurance Code.
(b) Provides that a violation of this chapter by a physician is grounds for disciplinary action and imposition of an administrative penalty by the Texas Medical Board.
(c) Requires the Texas Medical Board to notify the physician of the board's finding that the physician is violating or has violated this chapter or a rule adopted under this chapter and to provide the physician with an opportunity to correct the violation.
Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. Authorizes the commissioner by rule to prescribe specific requirements for the disclosure required under Section 1456.003, Insurance Code. Sets forth the required substantial language of the disclosure.
Sec. 1456.0065. STUDY OF NETWORK ADEQUACY AND CONTRACTS OF HEALTH PLANS. (a) Defines "commissioner" and "health benefit plan."
(b) Requires the commissioner to appoint an advisory committee (committee) to study facility-based provider network adequacy of health benefit plans.
(c) Sets forth the committee's required composition.
(d) Requires the committee to advise the commissioner periodically of its findings, no later than December 1, 2008.
(e) Provides that committee members serve without compensation.
(f) Provides that the committee is abolished and this section expires January 1, 2009.
Sec. 1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. Requires a health benefit plan that must comply with this chapter under Section 1456.002 to provide an estimate of payments that will be made for any service or supply on request of an enrollee and to also specify certain amounts for which the enrollee is responsible. Requires the estimate to be provided not later than the 10th business day after the date on which the estimate was requested. Sets forth certain issues on which the health benefit plan is required to advise the consumer requesting the estimate.
SECTION 11. Amends Section 843.201, Insurance Code, by adding Subsection (d), to require a health maintenance organization (HMO) to provide information regarding whether a physician or provider is in the HMO's network, whether the proposed health services are covered by the health plan, and what the enrollee's personal responsibility will be for payment of applicable copayment or deductible amounts, on the enrollee's request.
SECTION 12. Amends Subchapter F, Chapter 843, Insurance Code, by adding Section 843.211, as follows:
Sec. 843.211. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION. Applies Subchapter F (Relations with Enrollees and Group Contract Holders), Chapter 843, Insurance Code, to a person to whom an HMO contracts to process or pay claims, to obtain the services of physicians or providers to provide health care services to enrollees, or to issue verifications or preauthorizations.
SECTION 13. Amends Section 1301.158, Insurance Code, by adding Subsection (d), to require an insurer to provide to an insured on request certain information relating to the presence of a physician or provider in the insurer's network and any resultant affects on the payment to be made for services rendered.
SECTION 14. Amends Subchapter D, Chapter 1301, Insurance Code, by adding Section 1301.163, as follows:
Sec. 1301.163. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH INSURER. Applies this subchapter to a person to whom an insurer contracts to process or pay claims, to obtain the services of physicians or providers to provide health care services to enrollees, or to issue verifications or preauthorizations.
SECTION 15. This bill applies to an insurance policy, certificate, or contract or an evidence of coverage delivered, issued for delivery, or renewed on or after the effective date of this bill. A policy, certificate, or contract or evidence of coverage delivered, issued for delivery, or renewed before the effective date of this bill is governed by the law as it existed immediately before the effective date of this bill, and that law is continued in effect for that purpose.
SECTION 16. Except as provided by Section 17 of this bill, the Department of State Health Services, Texas Medical Board, and Texas Department of Insurance shall adopt rules as necessary to implement this bill not later than May 1, 2008.
SECTION 17. Not later than December 31, 2007, the commissioner of insurance shall adopt rules as necessary to implement Subchapter H, Chapter 38, Insurance Code, as added by this bill. The rules must require that each health benefit plan issuer subject to that subchapter make the initial submission of data under that subchapter not later than the 60th day after the effective date of the rules.
SECTION 18. (a) The commissioner of insurance by rule shall require each health benefit plan issuer subject to Chapter 1456, Insurance Code, as added by this bill, to submit information to the Texas Department of Insurance concerning the use of non-network providers by health benefit plan enrollees and the payments made to those providers. The information collected must cover a 12-month period specified by the commissioner of insurance. The commissioner of insurance shall work with the network adequacy study group to develop the data collection and evaluate the information collected.
(b) A health benefit plan issuer that fails to submit data as required in accordance with this section is subject to an administrative penalty under Chapter 84, Insurance Code. For purposes of penalty assessment, each day the health benefit plan issuer fails to submit the data as required is a separate violation.
EFFECTIVE DATE
September 1, 2007.
SECTION 1. Amends Subtitle
G, Title 4, Health and Safety Code, by adding Chapter 324, as follows:
CHAPTER 324. CONSUMER ACCESS TO HEALTH CARE INFORMATION
SUBCHAPTER A. GENERAL
PROVISIONS
Sec.
324.001. DEFINITIONS. Defines "average charge," "billed
charge," "costs," "consumer," "department,"
"executive commissioner," and "facility."
Sec.
324.002. RULES. Requires the executive commissioner of the Health and Human
Services Commission (HHSC) to adopt and enforce rules to further the purposes
of this chapter.
[Reserves Sections
324.003-324.050 for expansion.]
SUBCHAPTER B. CONSUMER GUIDE
TO HEALTH CARE
Sec.
324.051. DEPARTMENT WEBSITE. (a) Requires the Department of State Health
Services (DSHS) to make a consumer guide to health care (guide) available on
its Internet website. Requires DSHS to include information in its guide
concerning facility pricing practices and the correlation between certain
prices, including variation on prices relating to certain aspects of a person's
medical condition and resultant treatment.
(b) Sets
forth certain information required to be included in the guide by DSHS.
(c)
Requires DSHS to include in the guide an Internet link for consumers to access
quality of care data from certain websites and a disclaimer noting that those
linked websites .are not provided by this state or an
agency of this state.
(d)
Authorizes DSHS to accept gifts and grants to fund the guide. Prohibits DSHS
from identifying, recognizing, or acknowledging in any format any such donors
or grantors.
[Reserves Sections
324.052-324.100 for expansion.]
SUBCHAPTER C. BILLING OF
FACILITY SERVICES AND SUPPLIES
Sec.
324.101. FACILITY POLICIES. (a) Requires each facility to develop,
implement, and enforce written policies for the billing of facility health care
services and supplies (services and supplies). Sets forth certain provisions
that these policies are required to address.
(b)
Requires a hospital that provides services in an emergency department of the
hospital or as a result of an emergent direct admission to provide the written
disclosure required under Subsection (a)(6) before discharging the patient from
the emergency department or hospital, as appropriate.
(c)
Requires each facility to post a clear and conspicuous notice of the
availability of the policies required by Subsection (a) in the general waiting
area and in the waiting areas of certain offices.
(d)
Requires the facility to provide an estimate of the facility's charges for any
elective inpatient admission (admission) or nonemergency outpatient surgical
procedure (procedure) or other service on request and before the scheduling of
either an admission, procedure, or service. Requires the estimate to be
provided not later than the 10th business day after the date on which the
estimate was requested. Sets forth certain issues on which the facility is
required to advise the consumer requesting the estimate.
(e)
Requires a facility to provide to the consumer an itemized statement of the
billed services if the consumer requests this statement not later than the
first anniversary of the date the person is discharged from the facility.
Requires the facility to provide the statement to the consumer within 10 days
of the consumer's request.
(f) A
facility must provide an itemized statement of billed services to a third-party
payor who is actually or potentially responsible for paying all or part of the
billed services provided to a patient and who has received a claim for payment
of those services. To be entitled to receive a statement, the third-party
payor must request the statement from the facility and must have received a
claim for payment. The request must be made not later than one year after the
date on which the payor received the claim for payment. The facility shall
provide the statement to the payor not later than the 30th day after the date
on which the payor requests the statement. If a third-party payor receives a
claim for payment of part but not all of the billed services, the third-party
payor may request an itemized statement of only the billed services for which
payment is claimed or to which any deduction or copayment applies.
(g) A
facility in violation of this section is subject to enforcement action by the
appropriate licensing agency.
(h) If
a consumer or a third-party payor requests more than two copies of the
statement, the facility may charge a reasonable fee for the third and
subsequent copies provided. The fee may not exceed a certain sum.
(i) If
a consumer overpays a facility, the facility must refund the amount of the
overpayment not later than the 30th day after the date the facility determines
that an overpayment has been made. This subsection does not apply to an
overpayment subject to Section 1301.132 or 843.350, Insurance Code.
Sec.
324.102. COMPLAINT PROCESS. Requires a facility to establish and implement a
procedure for handling consumer complaints. Requires the facility to make a
good faith effort to resolve a complaint in an informal manner based on its
complaint procedures. Requires the facility to advise the consumer that a
complaint may be filed with the Department of State Health Services and to
provide the consumer with certain contact information for Department of State
Health Services when the complaint cannot be resolved in an informal manner.
Sec.
324.103. CONSUMER WAIVER PROHIBITED. Prohibits the waiving, voiding, or
nullification of the provisions of this chapter by a contract or an agreement
between a facility and a consumer.
SECTION 2. Amends Section
108.002(10), Health and Safety Code, to redefine "health care
facility."
SECTION 3. Amends Section
108.009(k), Health and Safety Code, to require the Texas Health Care
Information Council (council) to prioritize data collection efforts on
inpatient and outpatient surgical and radiological procedures from hospitals,
ambulatory surgical centers, and free-standing radiology centers.
SECTION 4. Subsection
(h), Section 311.002, Health and Safety Code, amends what the term
"hospital" includes and makes conforming changes.
SECTION 5. Amends Chapter
101, Occupations Code, by adding Subchapter H, redesignating Section 101.202,
Occupations Code, as Section 101.351, transferring it to Subsection H, and
further amending that section, and adding Section 101.352, as follows:
SUBCHAPTER
H. BILLING
Sec.
101.351. FAILURE TO PROVIDE BILLING INFORMATION. (a) Provides that this
section does not apply to a physician subject to Section 101.352, Occupations
Code.
Sec.
101.352. BILLING POLICIES AND INFORMATION; PHYSICIANS. (a) Requires a
physician to develop, implement, and enforce written policies for the billing
of health care services and supplies (services and supplies). Sets forth
certain issues which the policies are required to address.
(b)
Requires each physician, who maintains a waiting area, to post a clear and
conspicuous notice of the availability of the policies required by Subsection
(a) in the general waiting area and in the waiting areas of certain offices in
which patients are reasonably expected to seek service.
(c)
Requires the physician to provide an estimate of the charges for any health
care services or supplies on request of a patient who is seeking the provision
of services on an out-of-network basis or who does not have coverage under
certain programs. Requires the estimate to be provided not later than the 10th
business day after the date the request was made. Sets forth certain issues on
which the physician is required to advise the consumer requesting the estimate.
(d) For
services provided in an emergency department of a hospital or as a result of an
emergent direct admission, the physician must provide the estimate of charges
required by Subsection (c) before discharging the patient from the emergency
department or hospital, as appropriate.
(e)
Requires a physician to provide to the consumer an itemized statement of the
billed services if the consumer requests this statement not later than the
first anniversary of the date the services or supplies were provided. Requires
a physician to provide the statement to the consumer within 10 days of the
consumer's request.
(f)
Authorizes a physician to charge a reasonable fee for the third and subsequent
copies of a statement if the consumer requests more than two. Requires the
Texas Medical Board (board) by rule to set the permissible fee that a physician
is authorized to charge for the copying, processing, and delivering a copy of
the statement.
(g) Requires
a physician to provide, upon request and in plain language, a written
explanation for services or supplies previously made on a bill or statement for
the patient.
(h)
Requires a physician to refund a consumer's overpayment to the consumer within
30 days after the physician's determination that an overpayment has been made.
Provides that this subsection does not apply to an overpayment related to a
preferred provider benefit plan or a health maintenance organization, subject
to Section 1301.132 or 843.350, Insurance Code, respectively.
(i)
Defines "physician" for purposes of this section.
SECTION 6. Amends Section
154.002, Occupations Code, by adding Subsection (c), to require the Texas
Medical Board (board) to make a consumer guide to health care (guide) available
on its Internet website. Requires the board to include information in its
guide concerning the billing and reimbursement of health care services provided
by physicians and variations in the costs of those services due to certain
factors.
SECTION 7. Amends Chapter
38, Insurance Code, by adding Subchapter H, as follows:
SUBCHAPTER H. HEALTH CARE
REIMBURSEMENT RATE INFORMATION
Sec.
38.351. PURPOSE OF SUBCHAPTER. Provides that the purpose of this subchapter
is to authorize the Texas Department of Insurance (TDI) to collect data
concerning health benefit plan reimbursement rates in a uniform format and to
disseminate, on an aggregate basis for geographical regions of this state,
information concerning health care reimbursement rates that are derived from
the data.
Sec.
38.352. DEFINITION. Defines "group health benefit plan."
Sec.
38.353. APPLICABILITY OF SUBCHAPTER. (a) Applies this subchapter only to
certain issuers of a group health benefit plan.
(b)
Applies this subchapter to specific plans and types of coverage provided under
Chapters 1551 (Texas Employees Group Benefits Act), 1575 (Texas Public School
Employees Group Benefits Program), 1579 (Texas School Employees Uniform Group
Health Coverage), and 1601 (Uniform Insurance Benefits Act for Employees of the
University of Texas System and the Texas A&M University System), Insurance
Code, notwithstanding any provisions of those chapters.
(c)
Applies this subchapter to a small employer health benefit plan provided under
Chapter 1501 (Health Insurance Portability and Availability Act), Insurance
Code, except as provided by Subsection (d).
(d) Sets
forth certain health benefit plans to which this subchapter does not apply.
(e)
Authorizes the commissioner of insurance (commissioner) by rule to exclude a
type of health benefit plan from the requirements of this subchapter if the
commissioner finds that data collected in relation to the plan would not be
relevant in accomplishing the purposes of this subchapter.
Sec. 38.354.
RULES. Authorizes the commissioner to adopt rules as provided by Subchapter A
(Rules), Chapter 36, Insurance Code, to implement this subchapter.
Sec.
38.355. DATA CALL; STANDARDIZED FORMAT. (a) Requires each health benefit
plan issuer (issuer) to submit to TDI, at the time and in the form and manner
required by TDI, aggregate reimbursement rates organized by region and paid by
the issuer for health care services identified by TDI.
(b)
Requires TDI to require that data submitted under this section (data) be
submitted in a standardized format, established by rule, to permit comparison
of health care costs. Requires TDI to develop the data submission requirements
in a manner that provides for the submission of specific health care related figures,
to the extent feasible.
(c)
Requires TDI to specify the period for which reimbursement rates are required
to be filed under this section.
(d)
Authorizes TDI to contract with a private third party to obtain data.
Authorizes TDI, under such a contract, to determine the aggregate data to be
collected and published under Section 38.357 if consistent with the purposes of
this subchapter described in Section 38.351. Requires TDI to prohibit the
third party contractor from selling, leasing, or publishing the obtained data.
Sec.
38.356. CONFIDENTIALITY OF DATA. Provides that data collected under this
subchapter (data) is confidential and not subject to disclosure under Chapter
552 (Public Information), Government Code, except as provided by Section
38.357, Insurance Code.
Sec.
38.357. PUBLICATION OF AGGREGATE HEALTH CARE REIMBURSEMENT RATE INFORMATION.
Requires TDI to provide to the Department of State Health Services for
publication, for identified regions of this state, aggregate health care
reimbursement rate information derived from collected data. Prohibits the
published information from revealing the name of any health care provider or
issuer. Authorizes TDI to make the information available thorough TDI's
website.
Sec.
38.358. PENALTIES. Provides that an issuer that fails to submit data as
required in accordance with this subchapter is subject to an administrative
penalty under Chapter 84 (Administrative Penalties), Insurance Code. Provides
that each day the issuer fails to submit the data as required is a separate
violation for purposes of penalty assessment.
SECTION 8. Amends Section
843.155, Insurance Code, by amending Subsection (b) and adding Subsection (d),
as follows:
(b)
Requires a statement of certain enumerated information to be included in an
annual report required to be filed by a health maintenance organization under
this section (HMO report). Makes conforming changes.
(d)
Requires the HMO report to be made publicly available on TDI's Internet website
in a user-friendly format that allows consumers to make direct comparisons of
the financial and other data reported by a health maintenance organization
under this section.
SECTION 9. Amends Subchapter
A, Chapter 1301, Insurance Code, by adding Section 1301.009, as follows:
Sec.
1301.009. ANNUAL REPORT. (a) Requires an insurer to file a report with the
commissioner relating to the preferred provider benefit plan offered under this
chapter (Preferred Provider Benefit Plans) and covering the preceding calendar
year, not later than March 1 of each year.
(b)
Requires the report to be verified by at least two principal officers, to be in
a form prescribed by the commissioner, and to include certain information.
(c)
Requires the report to be made publicly available on TDI's Internet website in
a user-friendly format that allows consumers to make direct comparisons of the
financial and other data reported by insurers under this section.
(d)
Provides that an insurer providing group coverage of $10 million or less in
premiums or individual coverage of $2 million or less in premiums is not
required to report a statement of certain information required under Subsection
(b)(3)(C).
SECTION 10. Amends Subtitle
F, Title 8, Insurance Code, by adding Chapter 1456, as follows:
Chapter 1456. DISCLOSURE OF
PROVIDER STATUS
Sec.
1456.001. DEFINITIONS. Defines "balance billing,"
"enrollee," "facility-based physician," "health care
facility," "health care practitioner," and "provider
network."
Sec.
1456.002. APPLICABILITY OF CHAPTER. (a) Applies this chapter to any health
benefits plan that provides benefits for medical or surgical expenses incurred
as a result of certain health conditions, accidents, or sicknesses, including
policies, agreements, or contracts offered by certain entities, or that
provides health and accident coverage through a risk pool created under Chapter
172 (Texas Political Subdivisions Uniform Group Benefits Program), Local
Government Code, notwithstanding Section 172.014 (Application of Certain Laws),
Local Government Code, or any other law.
(b)
Applies this chapter to a person to whom a health benefit plan contracts to
process or pay claims, to obtain the services of physicians or other providers
to provide health care services to enrollees, or to issue verifications or
preauthorizations.
(c)
Provides that this chapter does not apply to Medicaid managed care programs
operated under Chapter 533, Government Code; Medicaid programs operated under
Chapter 32, Human Resources Code; or the state child health plan operated under
Chapter 62 or 63, Health and Safety Code.
Sec.
1456.003. REQUIRED DISCLOSURE; HEALTH BENEFIT PLAN. (a) Requires each health
benefit plan that provides health care through a provider network to provide
notice to enrollees that a facility-based physician (physician) or other health
care practitioner (practitioner) may not be included in the health benefit
plan's provider network (provider network) and that said practitioner is
authorized to balance bill the enrollee for amounts not paid by the health
benefit plan.
(b) Sets
forth certain areas in which the health benefit plan is required to provide the
disclosure in writing to each enrollee.
(c)
Requires a plan to clearly identify any facilities within the provider network
in which physicians do not participate in the plan's provider network.
Requires facilities identified in such a way to be identified in a separate and
conspicuous manner in any provider network directory or website directory.
(d)
Requires any explanation of benefits sent to an enrollee that contains a remark
code indicating that a payment made to a non-network physician has been paid at
the plan's allowable or usual and customary amount to also include the number
for TDI's consumer protection division for complaints regarding payment.
Sec.
1456.004. REQUIRED DISCLOSURE; FACILITY-BASED PHYSICIANS. (a) Requires a
physician who bills a patient covered by a health benefit plan described in
Section 1456.002, Insurance Code, that does not have a contract with the
physician, to send a billing statement including certain information. Sets
forth the certain information to be contained in the billing statement.
(b)
Provides that a patient may be considered to be out of substantial compliance
with the payment plan agreement between the patient and physician if payments
are not made in compliance with the agreement for a period of 90 days.
Sec.
1456.005. DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY. (a) Authorizes the
commissioner to take disciplinary action against a licensee that violates this
chapter in accordance with Chapter 84, Insurance Code.
(b)
Provides that a violation of this chapter by a physician is grounds for
disciplinary action and imposition of an administrative penalty by the Texas
Medical Board.
(c)
Requires the Texas Medical Board to notify the physician of the board's finding
that the physician is violating or has violated this chapter or a rule adopted
under this chapter and to provide the physician with an opportunity to correct
the violation.
Sec.
1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. Authorizes the commissioner
by rule to prescribe specific requirements for the disclosure required under
Section 1456.003, Insurance Code. Sets forth the required substantial language
of the disclosure.
Sec.
1456.0065. STUDY OF NETWORK ADEQUACY AND CONTRACTS OF HEALTH PLANS. (a)
Defines "commissioner" and "health benefit plan."
(b)
Requires the commissioner to appoint an advisory committee (committee) to study
facility-based provider network adequacy of health benefit plans.
(c) Sets
forth the committee's required composition.
(d)
Requires the committee to advise the commissioner periodically of its findings,
no later than December 1, 2008.
(e) Provides
that committee members serve without compensation.
(f)
Provides that the committee is abolished and this section expires January 1,
2009.
Sec.
1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. Requires a health benefit plan
that must comply with this chapter under Section 1456.002 to provide an
estimate of payments that will be made for any service or supply on request of
an enrollee and to also specify certain amounts for which the enrollee is
responsible. Requires the estimate to be provided not later than the 10th
business day after the date on which the estimate was requested. Sets forth
certain issues on which the health benefit plan is required to advise the
consumer requesting the estimate.
SECTION 11. Amends Section
843.201, Insurance Code, by adding Subsection (d), to require a health
maintenance organization (HMO) to provide information regarding whether a
physician or provider is in the HMO's network, whether the proposed health
services are covered by the health plan, and what the enrollee's personal
responsibility will be for payment of applicable copayment or deductible
amounts, on the enrollee's request.
SECTION 12. Amends
Subchapter F, Chapter 843, Insurance Code, by adding Section 843.211, as
follows:
Sec.
843.211. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH HEALTH
MAINTENANCE ORGANIZATION. Applies Subchapter F (Relations with Enrollees and
Group Contract Holders), Chapter 843, Insurance Code, to a person to whom an
HMO contracts to process or pay claims, to obtain the services of physicians or
providers to provide health care services to enrollees, or to issue
verifications or preauthorizations.
SECTION 13. Amends Section
1301.158, Insurance Code, by adding Subsection (d), to require an insurer to
provide to an insured on request certain information relating to the presence
of a physician or provider in the insurer's network and any resultant affects
on the payment to be made for services rendered.
SECTION 14. Amends
Subchapter D, Chapter 1301, Insurance Code, by adding Section 1301.163, as
follows:
Sec.
1301.163. APPLICABILITY OF SUBCHAPTER TO ENTITIES CONTRACTING WITH INSURER.
Applies this subchapter to a person to whom an insurer contracts to process or
pay claims, to obtain the services of physicians or providers to provide health
care services to enrollees, or to issue verifications or preauthorizations.
SECTION 15. This
bill applies to an insurance policy, certificate, or contract or an evidence of
coverage delivered, issued for delivery, or renewed on or after the effective
date of this bill. A policy, certificate, or contract or evidence of coverage
delivered, issued for delivery, or renewed before the effective date of this
bill is governed by the law as it existed immediately before the effective date
of this bill, and that law is continued in effect for that purpose.
SECTION 16. Except as provided by
Section 17 of this bill, the Department of State Health Services, Texas Medical
Board, and Texas Department of Insurance shall adopt rules as necessary to
implement this bill not later than May 1, 2008.
SECTION 17. Not later than December
31, 2007, the commissioner of insurance shall adopt rules as necessary to
implement Subchapter H, Chapter 38, Insurance Code, as added by this bill. The
rules must require that each health benefit plan issuer subject to that
subchapter make the initial submission of data under that subchapter not later
than the 60th day after the effective date of the rules.
SECTION 18. (a) The
commissioner of insurance by rule shall require each health benefit plan issuer
subject to Chapter 1456, Insurance Code, as added by this bill, to submit
information to the Texas Department of Insurance concerning the use of
non-network providers by health benefit plan enrollees and the payments made to
those providers. The information collected must cover a 12-month period
specified by the commissioner of insurance. The commissioner of insurance
shall work with the network adequacy study group to develop the data collection
and evaluate the information collected.
(b) A health benefit plan issuer that
fails to submit data as required in accordance with this section is subject to
an administrative penalty under Chapter 84, Insurance Code. For purposes of
penalty assessment, each day the health benefit plan issuer fails to submit the
data as required is a separate violation.