80R8035 AJA-F

By: Taylor H.B. No. 2199

A BILL TO BE ENTITLED

AN ACT

relating to payment of physicians and health care providers for care provided to persons covered by certain health benefit plans.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle C, Title 8, Insurance Code, is amended by adding Chapter 1275 to read as follows: CHAPTER 1275. PAYMENT OF PHYSICIANS AND PROVIDERS FOR SERVICES PROVIDED TO PERSONS COVERED BY CERTAIN MANAGED CARE PLANS

Sec. 1275.001. DEFINITIONS. In this chapter:

(1) "Anesthesia" means medical services that involve anesthesia as that term is used by the 2005 edition of the American Medical Association's Current Procedural Terminology (Professional Edition).

(2) "Emergency medicine" means medical services that involve emergency department services as that term is used by the 2005 edition of the American Medical Association's Current Procedural Terminology (Professional Edition).

(3) "Exclusive arrangement" means a formal contract or informal arrangement between a physician and a health care facility under which only the physician, alone or with other physicians selected or designated by the facility, may provide a facility-based physician service at the facility.

(4) "Facility-based physician service" means a service:

(A) the performance of which requires a license to practice medicine in this state;

(B) involving one or more of the medical specialties of radiology, anesthesia, pathology, emergency medicine, or neonatology; and

(C) provided to a patient of a health care facility.

(5) "Health benefit plan issuer" means:

(A) a health insurer that issues a preferred provider benefit plan under Chapter 1301; or

(B) a health maintenance organization operating under Chapter 843.

(6) "Health care facility" means a hospital, skilled nursing facility, or ambulatory surgical center licensed by this state.

(7) "Member" means an individual insured by a preferred provider benefit plan under Chapter 1301, including a covered dependent, or an enrollee, as that term is defined by Section 843.002.

(8) "Neonatology" means neonatal critical care as that term is used by the 2005 edition of the American Medical Association's Current Procedural Terminology (Professional Edition).

(9) "Nonparticipating physician" means a physician who, with respect to a health benefit plan, is not part of the network of providers with whom the health benefit plan issuer has contracted to provide medical care or health care to members of the health benefit plan.

(10) "Nonparticipating provider" means a provider who, with respect to a health benefit plan, is not part of the network of providers with whom the health benefit plan issuer has contracted to provide health care to members of the health benefit plan.

(11) "Pathology" means medical services that involve anatomic pathology as that term is used by the 2005 edition of the American Medical Association's Current Procedural Terminology (Professional Edition).

(12) "Physician" has the meaning assigned by Section 843.002.

(13) "Provider" has the meaning assigned by Section 843.002.

(14) "Radiology" means medical services that involve one or more of the following services, as those terms are used by the 2005 edition of the American Medical Association's Current Procedural Terminology (Professional Edition):

(A) diagnostic radiology (diagnostic imaging);

(B) diagnostic ultrasound;

(C) radiation oncology; or

(D) nuclear medicine.

Sec. 1275.002. SERVICES PROVIDED UNDER EXCLUSIVE ARRANGEMENT. (a) If a member offers to assign to a nonparticipating physician the member's right to benefits from the member's health benefit plan issuer, the nonparticipating physician may not charge the member or the member's representative any amount for any facility-based physician service provided under an exclusive arrangement, other than amounts for copayments, coinsurance, or deductibles as provided by the member's policy or contract with the health benefit plan issuer.

(b) If a member does not offer to assign or refuses to assign to a nonparticipating physician the member's right to benefits from the member's health benefit plan issuer, the nonparticipating physician may charge the member for the facility-based physician service provided under an exclusive arrangement.

(c) A health benefit plan issuer's liability to a nonparticipating physician for a facility-based physician service provided under an exclusive arrangement is limited to the health benefit plan issuer's obligation under the issuer's policy or contract with the member.

Sec. 1275.003. SERVICES PROVIDED BY NONPARTICIPATING PHYSICIAN OR PROVIDER. (a) A nonparticipating physician or provider may require a member to assign the member's benefits from the member's health benefit plan issuer to the nonparticipating physician or provider.

(b) If a nonparticipating physician or provider accepts a member's assignment of the member's benefits, the nonparticipating physician or provider may not charge the member or the member's representative any amount for a physician or provider service, other than amounts for copayments, coinsurance, or deductibles under the member's policy or contract with the health benefit plan issuer.

(c) A health benefit plan issuer's liability to a nonparticipating physician or provider who has accepted an assignment of benefits from a member for a physician or provider service is limited to the issuer's obligation under the issuer's policy or contract with the member.

(d) Except as provided by Section 1275.002, if a nonparticipating physician or provider does not require a member to assign the member's benefits or otherwise accept the member's assignment of benefits, the nonparticipating physician or provider may charge the member or the member's representative for the physician or provider service.

SECTION 2. The change in law made by this Act applies only to professional services provided by a physician or health care provider on or after the effective date of this Act. Services provided before the effective date of this Act are governed by the law in effect immediately before that date, and that law is continued in effect for that purpose.

SECTION 3. This Act takes effect September 1, 2007.