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A BILL TO BE ENTITLED
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AN ACT
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relating to the disclosure of the calculation of out-of-network |
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payments by the issuers of preferred provider benefit plans and by |
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health maintenance organizations. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter F, Chapter 843, Insurance Code, is |
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amended by adding Section 843.212 to read as follows: |
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Sec. 843.212. CALCULATION OF NONPARTICIPATING PROVIDER |
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PAYMENTS. (a) In this section, "usual charge for out-of-network |
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health care services" means the 99th percentile of the actual |
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charges charged by a physician or provider that does not |
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participate in a health maintenance organization's delivery |
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network for a particular health care service in a particular |
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service area covered by the delivery network, as reported in a |
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benchmarking database maintained by a nonprofit organization that |
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is not affiliated with a health maintenance organization or other |
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health benefit plan issuer, a holding company of a health benefit |
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plan issuer, or a trade association in the field of insurance or |
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health benefits. |
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(b) A health maintenance organization shall disclose to |
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each enrollee and, if applicable, each group contract holder the |
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methodology used by the health maintenance organization to |
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calculate payment under the health plan for health care services |
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provided by a physician or provider that does not participate in the |
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health maintenance organization's delivery network. The |
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disclosure required by this section must: |
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(1) express the payment amount in terms of a |
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percentage of the usual charge for out-of-network health care |
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services that will be paid to the physician or provider; and |
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(2) include examples of the anticipated out-of-pocket |
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payment responsibility for frequently billed health care services |
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provided by physicians or providers that do not participate in the |
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health maintenance organization's delivery network. |
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(c) A health maintenance organization shall, at the request |
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of an enrollee, provide the enrollee with information, in writing |
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or through publication on an Internet website, that allows the |
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enrollee to determine the anticipated out-of-pocket payment |
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responsibility for a specific health care service provided by a |
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physician or provider that does not participate in the health |
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maintenance organization's delivery network based on: |
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(1) the methodology used by the health maintenance |
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organization to calculate payment under the health plan for health |
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care services provided by physicians and providers that do not |
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participate in the health maintenance organization's delivery |
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network; and |
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(2) the usual charge for out-of-network health care |
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services. |
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SECTION 2. Subchapter A, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.010 to read as follows: |
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Sec. 1301.010. CALCULATION OF NONPREFERRED PROVIDER |
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PAYMENTS. (a) In this section, "usual charge for out-of-network |
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health care services" means the 99th percentile of the actual |
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charges charged by a nonpreferred provider for a particular health |
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care service in a particular service area covered by the preferred |
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provider benefit plan, as reported in a benchmarking database |
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maintained by a nonprofit organization that is not affiliated with |
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an insurer or other health benefit plan issuer, a holding company of |
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a health benefit plan issuer, or a trade association in the field of |
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insurance or health benefits. |
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(b) An insurer offering a preferred provider benefit plan |
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shall disclose to each insured and, if applicable, each group |
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policy holder the methodology used by the insurer to calculate |
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payment under the plan for health care services provided by |
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nonpreferred providers. The disclosure required by this section |
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must: |
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(1) express the payment amount in terms of a |
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percentage of the usual charge for out-of-network health care |
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services that will be paid to the provider; and |
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(2) include examples of the anticipated out-of-pocket |
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payment responsibility for frequently billed health care services |
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provided by nonpreferred providers. |
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(c) An insurer offering a preferred provider benefit plan |
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shall, at the request of an insured, provide the insured with |
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information, in writing or through publication on an Internet |
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website, that allows the insured to determine the anticipated |
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out-of-pocket payment responsibility for a specific health care |
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service provided by a nonpreferred provider based on: |
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(1) the methodology used by the insurer to calculate |
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payment under the plan for health care services provided by |
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nonpreferred providers; and |
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(2) the usual charge for out-of-network health care |
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services. |
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SECTION 3. The change in law made by this Act applies only |
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to a health plan contract or health insurance policy that is |
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delivered, issued for delivery, or renewed on or after January 1, |
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2014. A health plan contract or health insurance policy that is |
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delivered, issued for delivery, or renewed before January 1, 2014, |
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is covered by the law in effect immediately before the effective |
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date of this Act, and that law is continued in effect for that |
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purpose. |
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SECTION 4. This Act takes effect September 1, 2013. |