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A BILL TO BE ENTITLED
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AN ACT
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relating to payment of claims of certain out-of-network physicians |
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and health care providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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by adding Chapter 1458 to read as follows: |
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CHAPTER 1458. PAYMENT OF OUT-OF-NETWORK PROVIDER |
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Sec. 1458.001. DEFINITIONS. In this chapter: |
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(1) "Enrollee" means an individual who is eligible to |
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receive health care services under a managed care plan. |
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(2) "Health care provider" means: |
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(A) an individual who is licensed to provide |
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health care services; or |
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(B) a hospital, emergency clinic, outpatient |
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clinic, or other facility providing health care services. |
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(3) "Managed care plan" means a health benefit plan |
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under which health care services are provided to enrollees through |
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contracts with health care providers and that requires those |
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enrollees to use health care providers participating in the plan |
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and procedures covered by the plan. The term includes a health |
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benefit plan issued by: |
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(A) a health maintenance organization; |
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(B) a preferred provider benefit plan issuer; or |
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(C) any other entity that issues a health benefit |
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plan, including an insurance company. |
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(4) "Out-of-network provider" means a health care |
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provider who is not a participating provider. |
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(5) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer to |
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provide services to enrollees. |
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Sec. 1458.002. CONDITION FOR PAYMENT AT IN-NETWORK RATE. A |
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managed care plan must pay an out-of-network health care provider |
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that provides a service to an enrollee at the rate the plan pays a |
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participating provider for the health care service only if the |
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enrollee: |
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(1) makes a reasonable effort to locate and obtain the |
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health care service from a participating provider; and |
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(2) is unable, after that reasonable effort, to locate |
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and obtain the health care service from a participating provider. |
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Sec. 1458.003. RULES. The commissioner shall adopt rules |
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necessary to implement this chapter, including a rule to identify |
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criteria used to determine whether an enrollee made reasonable |
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efforts to locate and obtain adequate health care services from a |
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participating provider. |
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SECTION 2. This Act applies only to an insurance policy or |
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contract or evidence of coverage that is delivered, issued for |
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delivery, or renewed on or after January 1, 2010. An insurance |
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policy or contract or evidence of coverage delivered, issued for |
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delivery, or renewed before January 1, 2010, is governed by the law |
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as it existed immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2009. |