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A BILL TO BE ENTITLED
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AN ACT
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relating to certain prohibited practices concerning the payment of |
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copayments and deductibles under health benefit plans; providing a |
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civil penalty and for injunctive relief. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Chapter 552, Insurance Code, is |
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amended to read as follows: |
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CHAPTER 552. ILLEGAL PRICING AND PAYMENT PRACTICES |
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SECTION 2. Sections 552.001, 552.002, and 552.003, |
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Insurance Code, are designated as Subchapter A, Chapter 552, |
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Insurance Code, and a heading is added to Subchapter A to read as |
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follows: |
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SUBCHAPTER A. ILLEGAL PRICING PRACTICES |
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SECTION 3. Section 552.001, Insurance Code, is amended to |
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read as follows: |
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Sec. 552.001. APPLICABILITY OF SUBCHAPTER [CHAPTER]. (a) |
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This subchapter [chapter] does not apply to the provision of a |
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health care service to a: |
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(1) Medicaid or Medicare patient or a patient who is |
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covered by a federal, state, or local government-sponsored indigent |
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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 insurance |
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policy or other health benefit plan that provides benefits for the |
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services and qualifies for services for the uninsured based on a |
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written policy established by a health care provider. |
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(b) This subchapter [chapter] does not permit the |
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establishment of health care provider policies or contracts that |
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violate any other state or federal law. |
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(c) This subchapter [chapter] does not prohibit a health |
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care provider from entering into a contract to provide services |
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covered by a health insurance policy or other health benefit plan |
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with: |
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(1) the issuer of the health insurance policy or other |
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health benefit plan; or |
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(2) a preferred provider organization that contracts |
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with the issuer of the health insurance policy or other health |
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benefit plan. |
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SECTION 4. Chapter 552, Insurance Code, is amended by |
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adding Subchapter B to read as follows: |
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SUBCHAPTER B. ILLEGAL PAYMENT PRACTICES |
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Sec. 552.051. DEFINITIONS. In this subchapter: |
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(1) "Enrollee" means an individual entitled to |
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coverage under a health benefit plan. |
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(2) "Health benefit plan" means a plan that provides |
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benefits for hospital, medical, surgical, or other treatment |
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expenses incurred as a result of a health condition, an accident, or |
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sickness, including an individual, group, blanket, or franchise |
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health insurance policy or insurance agreement, a group hospital |
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service contract, an individual or group evidence of coverage, or |
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any other similar coverage document. The term includes a |
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self-funded plan that is otherwise described by this subdivision. |
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(3) "Health care provider" means an individual or |
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entity that is licensed or otherwise authorized to provide health |
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care services or supplies in this state. The term includes: |
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(A) an individual licensed under or otherwise |
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subject to Title 3, Occupations Code; and |
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(B) a public or private entity licensed under |
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Subtitle B, Title 4, or Subtitle C, Title 7, Health and Safety Code. |
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Sec. 552.052. DUTY TO COLLECT COPAYMENT OR DEDUCTIBLE; |
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CERTAIN WAIVERS PROHIBITED. (a) Except as provided by Subsection |
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(b), a health care provider: |
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(1) shall make a good faith effort to collect any |
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applicable copayment or deductible from each enrollee in a health |
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benefit plan; and |
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(2) based on an enrollee's coverage under a health |
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benefit plan, may not waive, in cash or in kind, all or part of any |
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applicable copayment or deductible under the health benefit plan to |
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induce or encourage the enrollee to purchase, order, use, or lease |
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any facility, service, or supply. |
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(b) A health care provider may waive any applicable |
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copayment or deductible for an enrollee if the enrollee |
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demonstrates special financial need or hardship. |
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Sec. 552.053. CIVIL PENALTY; INJUNCTION. (a) If it |
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appears that an individual or entity has violated or is violating |
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this subchapter, a district or county attorney in the jurisdiction |
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where the violation is alleged to have occurred or may occur may |
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institute a civil suit for: |
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(1) an order enjoining the violation; |
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(2) a permanent or temporary injunction, a temporary |
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restraining order, or other appropriate remedy if the district or |
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county attorney shows that the individual or entity has engaged in |
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or is engaging in a violation; |
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(3) the assessment and recovery of a civil penalty; or |
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(4) both injunctive relief and a civil penalty. |
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(b) A civil penalty may not exceed $25,000 a day for each |
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violation. Each day the violation occurs constitutes a separate |
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violation for the purposes of the assessment of a civil penalty. |
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(c) In determining the amount of the civil penalty, the |
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court hearing the matter shall consider: |
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(1) the individual's or entity's history of previous |
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violations; |
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(2) the seriousness of the violation; |
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(3) the hazard to the health and safety of the public; |
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(4) the demonstrated good faith of the individual or |
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entity charged; and |
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(5) any other matter that justice may require. |
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(d) A civil penalty recovered in a suit instituted by a |
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local government under this subchapter shall be paid to the local |
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government. |
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(e) The district or county attorney, as appropriate, may |
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recover, on behalf of the local government, reasonable expenses |
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incurred in obtaining injunctive relief or a civil penalty under |
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this section, including investigation and court costs, reasonable |
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attorney's fees, witness fees, and other expenses. |
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SECTION 5. The change in law made by this Act applies only |
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to a health benefit plan copayment or deductible relating to a |
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facility, service, or supply provided by a health care provider on |
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or after the effective date of this Act. A health benefit plan |
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copayment or deductible relating to a facility, service, or supply |
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provided before the effective date of this Act is covered by the law |
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in effect on the date the facility, service, or supply is provided, |
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and that law is continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2011. |