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A BILL TO BE ENTITLED
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AN ACT
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relating to pricing for health care services and supplies and |
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reimbursement for those services or supplies under certain health |
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benefit plans; imposing penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 8, Insurance Code, is amended |
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by adding Chapter 1225 to read as follows: |
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CHAPTER 1225. PRICING FOR HEALTH CARE SERVICES AND SUPPLIES; |
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REIMBURSEMENT RATES |
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Sec. 1225.001. DEFINITION. In this chapter, "health care |
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provider" includes a physician, health care practitioner, and |
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health care facility. |
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Sec. 1225.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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does not apply to the provision of a health care service or supply |
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to a: |
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(1) patient for which a health care provider has |
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accepted assignment for the health care service or supply from |
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Medicaid or Medicare or any other federal, state, or local |
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government-sponsored indigent health care program; |
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(2) financially or medically indigent person who |
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qualifies for indigent health care services based on: |
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(A) a sliding fee scale; or |
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(B) a written charity care policy established by |
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a health care provider; or |
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(3) person who is not covered by a health benefit plan |
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that provides benefits for the services and qualifies for services |
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for the uninsured based on a written policy established by a health |
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care provider. |
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(b) This chapter does not apply to payments made for a |
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health care service or supply on a capitation basis. |
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(c) This chapter does not permit the establishment of health |
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care provider policies or contracts that violate any other state or |
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federal law. |
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Sec. 1225.003. PRICING INFORMATION; AVAILABILITY. (a) |
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Each health care provider shall compile a list of the price charged |
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by the provider for each service or supply provided by the health |
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care provider. If the health care provider bundles together prices |
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for multiple services or supplies provided by the provider during |
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one treatment by or visit to the provider, the provider shall |
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include any price bundles used by the provider in the list compiled |
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under this subsection. |
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(b) A health care provider shall provide a copy of the price |
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list described by Subsection (a) to any patient of the health care |
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provider who requests a copy of the list. |
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Sec. 1225.004. POSTING REQUIRED. (a) Each health care |
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provider shall post in any general waiting area maintained by the |
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provider, including any waiting areas of off-site or on-site |
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registration, a clear and conspicuous notice that advises patients |
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of the availability of the price list described by Section |
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1225.003. |
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(b) If a health care provider maintains an Internet website, |
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the provider shall post the price list described by Section |
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1225.003 on the provider's website. |
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Sec. 1225.005. OVERPAYMENT; REFUNDS. (a) A health care |
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provider that receives payment for a health care service or supply |
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provided to a patient by the provider that exceeds the price of |
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those products or services published in the price list described by |
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Section 1225.003 shall, not later than the 30th day after the date |
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the overpayment is discovered by the provider, refund to the payor |
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the amount of the overpayment. This section does not apply to an |
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overpayment subject to Section 843.350 or 1301.132. |
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(b) The health care provider shall refund the overpayment |
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described by Subsection (a) by: |
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(1) crediting the patient's account to pay a copayment |
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amount, deductible, or other charge that the patient owes to the |
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provider; or |
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(2) funding an established qualified account of the |
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patient such as a savings account or medical reimbursement account |
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dedicated to the payment of a future medical expense. |
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Sec. 1225.006. DISCIPLINARY ACTIONS AND ADMINISTRATIVE |
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PENALTY. A violation of this chapter is grounds for disciplinary |
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action or the imposition of an administrative penalty by the entity |
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that licenses the health care provider that violates this chapter. |
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Sec. 1225.007. FRAUDULENT INSURANCE ACT. An offense under |
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this chapter is a fraudulent insurance act under Chapter 701. |
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Sec. 1225.008. CHARGING DIFFERENT PRICES; OFFENSE. (a) A |
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health care provider commits an offense if the provider knowingly |
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charges different prices for providing the same health care service |
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or supply. |
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(b) It is a defense to prosecution under this section that |
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the health care provider refunded the overpayment as required by |
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Section 843.350, 1225.005, or 1301.132, as applicable. |
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(c) An offense under this section is a Class B misdemeanor. |
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Sec. 1225.009. ESTABLISHMENT OF RATES. (a) The department |
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shall analyze reimbursement payments made by health benefit plan |
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issuers to a health care provider for specific health care services |
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or supplies in each health service region established by the |
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Department of State Health Services under Section 121.007, Health |
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and Safety Code. |
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(b) For each region analyzed under Subsection (a), and for |
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each health care service or supply, the commissioner shall |
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determine the 25th quartile of the reimbursement payment. |
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(c) The amount determined for each health care service or |
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supply for each region by the department under Subsection (b) is the |
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maximum amount that a health benefit plan issuer may reimburse a |
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health care provider for the health care service or supply. |
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Sec. 1225.010. EXCEPTION. For good cause shown, the |
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commissioner may by rule except from the maximum reimbursement rate |
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established under Section 1225.009 a payment made: |
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(1) to a tertiary care facility as defined by Section |
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46.001, Health and Safety Code; or |
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(2) for tertiary medical services as defined by |
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Section 46.001, Health and Safety Code, or a supply related to those |
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services. |
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SECTION 2. A health care provider shall compile the price |
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list and post the notice required by Chapter 1225, Insurance Code, |
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as added by this Act, not later than January 1, 2010. |
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SECTION 3. This Act applies only to an insurance policy, |
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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. A policy, |
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contract, or evidence of coverage delivered, issued for delivery, |
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or renewed before January 1, 2010, is governed by the law as it |
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existed immediately before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 4. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2009. |