|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to health services provided to health benefit plan |
|
enrollees by certain out-of-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 1458 to read as follows: |
|
CHAPTER 1458. DISCLOSURE OF OUT-OF-NETWORK PROVIDER STATUS; |
|
BALANCE BILLING |
|
Sec. 1458.001. DEFINITIONS. In this chapter: |
|
(1) "Enrollee" means an individual who is eligible to |
|
receive health care services under a managed care plan. |
|
(2) "Health care provider" means: |
|
(A) an individual who is licensed to provide |
|
health care services; or |
|
(B) a hospital, emergency clinic, outpatient |
|
clinic, or other facility providing health care services. |
|
(3) "Managed care plan" 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 health |
|
benefit plan issued by: |
|
(A) a health maintenance organization; |
|
(B) a preferred provider benefit plan issuer; or |
|
(C) any other entity that issues a health benefit |
|
plan, including an insurance company. |
|
(4) "Out-of-network provider" means a health care |
|
provider who is not a participating provider. |
|
(5) "Participating provider" means a health care |
|
provider who has contracted with a health benefit plan issuer to |
|
provide services to enrollees. |
|
Sec. 1458.002. NOTICE OF PROVIDER STATUS AND BALANCE |
|
BILLING. (a) A participating provider shall provide written notice |
|
to an enrollee as required by this chapter if the participating |
|
provider: |
|
(1) refers an enrollee to an out-of-network provider; |
|
(2) is a health care facility that has granted |
|
clinical privileges to a surgeon, a radiologist, an |
|
anesthesiologist, a pathologist, or another physician who: |
|
(A) is an out-of-network provider; and |
|
(B) is to provide services to the enrollee as a |
|
patient of the facility; or |
|
(3) otherwise arranges for health care services for |
|
the enrollee through an out-of-network provider. |
|
(b) The notice required by this section must substantially |
|
comply with requirements adopted under Section 1458.004 and must |
|
disclose that the out-of-network provider: |
|
(1) is not a participating provider for the enrollee's |
|
managed care plan; and |
|
(2) may charge the enrollee the balance of the |
|
provider's fee for services received by the enrollee that is not |
|
fully paid or reimbursed by the enrollee's managed care plan. |
|
(c) The notice must include a signature line for the |
|
enrollee to sign to acknowledge that the enrollee has received the |
|
notice. |
|
(d) An out-of-network provider may elect to provide the |
|
notice required by this section. |
|
(e) A health care provider that provides notice under this |
|
section shall maintain a copy of the notice, signed by the enrollee, |
|
in the provider's records. |
|
Sec. 1458.003. TIME OF NOTICE. The notice required by this |
|
chapter: |
|
(1) must be provided to an enrollee before services |
|
are provided to the enrollee by an out-of-network provider; and |
|
(2) must be provided, to the extent practicable, |
|
sufficiently in advance of the time the services are to be provided |
|
to allow the enrollee to select a participating provider to provide |
|
the services. |
|
Sec. 1458.004. FORM OF NOTICE. The commissioner by rule |
|
shall adopt a form for the notice required by this chapter. |
|
Sec. 1458.005. BALANCE BILLING PROHIBITED IF NOTICE NOT |
|
PROVIDED. If notice is not provided as required by this chapter, the |
|
out-of-network provider may not charge the enrollee for any portion |
|
of that provider's fee that is not paid or reimbursed by the |
|
enrollee's managed care plan. |
|
Sec. 1458.006. EMERGENCY. A health care provider is not |
|
required to provide the notice required by this chapter, and |
|
Section 1458.005 does not apply, if the enrollee's treating |
|
physician reasonably determines, in the physician's medical |
|
judgment, that an emergency exists and there is insufficient time |
|
to provide that notice. |
|
Sec. 1458.007. RULES. The commissioner may adopt rules as |
|
necessary to implement this chapter. |
|
SECTION 2. This Act applies only to a managed care plan that |
|
is delivered, issued for delivery, or renewed on or after January 1, |
|
2008. A managed care plan that is delivered, issued for delivery, or |
|
renewed before January 1, 2008, is governed by the law as it existed |
|
immediately before the effective date of this Act, and that law is |
|
continued in effect for that purpose. |
|
SECTION 3. This Act takes effect September 1, 2007. |