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INTRODUCED
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HOUSE COMMITTEE
SUBSTITUTE
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SECTION 1. Chapter 241,
Health and Safety Code, is amended by adding Subchapter J to read as
follows:
SUBCHAPTER J. NOTICE OF
FACILITY FEES IN CERTAIN FREESTANDING EMERGENCY MEDICAL CARE FACILITIES
Sec. 241.251. APPLICABILITY.
Sec. 241.252. NOTICE OF
FEES. (a) In this section, "provider network" has the meaning
assigned by Section 1456.001, Insurance Code.
(b) A facility described
by Section 241.251 shall post notice that states:
(1) that the facility is
a freestanding emergency medical care facility and not an urgent care center;
(2) either:
(A) that the facility does not participate in a provider network;
or
(B) that the facility participates in a provider network; and
(3) any facility fee charged by the facility, including the
minimum and maximum facility fee amounts charged per visit.
(c) The notice required under Subsection (b)(2)(B) must:
(1) identify the provider network;
(2) identify each physician providing medical care at the facility
who is excluded from the provider network; and
(3) for each physician described by Subdivision (2), state that
the physician may bill separately from the facility for the medical care
provided to a patient and provide the minimum and maximum amounts the
physician charges for each patient visit.
(d) The notices required
by this section must be posted prominently and conspicuously:
(1) at the primary
entrance to the facility;
(2) in each patient
treatment room; and
(3) at each location
within the facility at which a person pays for health care services.
(e) A facility that is required to post notice under this section
and Section 241.183, as added by Chapter 917 (H.B. 1376), Acts of the 83rd
Legislature, Regular Session, 2013, may post the required notices on the
same sign.
Sec. 241.253. REQUIRED
DISCLOSURE FOR CERTAIN ENROLLEES. (a) In this section:
(1)
"Administrator" has the meaning assigned by Section 1467.001,
Insurance Code.
(2) "Enrollee"
has the meaning assigned by Section 1467.001, Insurance Code.
(b) A facility that bills
an enrollee covered by a preferred provider benefit plan or a health
benefit plan under Chapter 1551, Insurance Code, shall make a disclosure to
the enrollee under this section if:
(1) the facility is not a
network provider for the enrollee's plan; and
(2) the facility fee
amount for which the enrollee is responsible is greater than $1,000 after
copayments, deductibles, and coinsurance, including the amount unpaid by
the administrator or insurer.
(c) The disclosure
required under this section must be made in the billing statement provided
to the enrollee and must include information sufficient to notify the
patient of the mandatory mediation process available under Chapter 1467,
Insurance Code.
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SECTION 1. Chapter 241,
Health and Safety Code, is amended by adding Subchapter J to read as
follows:
SUBCHAPTER J. NOTICE OF
FACILITY FEES IN CERTAIN FREESTANDING EMERGENCY MEDICAL CARE FACILITIES
Sec. 241.251.
APPLICABILITY.
Sec. 241.252. NOTICE OF
FEES. (a) In this section, "provider network" has the meaning
assigned by Section 1456.001, Insurance Code.
(b) A facility described
by Section 241.251 shall post notice that states:
(1) that the facility is
a freestanding emergency medical care facility;
(2) that the facility charges rates comparable to a hospital
emergency room and may charge a facility fee;
(3) that a facility or a physician providing medical care at the
facility may not be a participating provider in the patient's health
benefit plan provider network; and
(4) that a physician providing medical care at the facility may
bill separately from the facility for the medical care provided to a
patient.
(c) The notice required
by this section must be posted prominently and conspicuously:
(1) at the primary
entrance to the facility;
(2) in each patient
treatment room; and
(3) at each location
within the facility at which a person pays for health care services.
(d) The notice required by this section must be in legible print
on a sign with dimensions of at least 8.5 inches by 11 inches.
No
equivalent provision.
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SECTION 2. Section 254.001,
Health and Safety Code, is amended.
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SECTION 2. Same as introduced
version.
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SECTION 3. Subchapter D,
Chapter 254, Health and Safety Code, is amended by adding Sections 254.155
and 254.156 to read as follows:
Sec. 254.155. NOTICE OF
FEES. (a) A facility shall post notice that states:
(1) that the facility is
a freestanding emergency medical care facility and not an urgent care center;
(2) either:
(A) that the facility does not participate in a provider network;
or
(B) that the facility participates in a provider network; and
(3) any facility fee charged by the facility, including the
minimum and maximum facility fee amounts charged per visit.
(b) The notice required under Subsection (a)(2)(B) must:
(1) identify the provider network;
(2) identify each physician providing medical care at the facility
who is excluded from the provider network; and
(3) for each physician described by Subdivision (2), state that
the physician may bill separately from the facility for the medical care
provided to a patient and provide the minimum and maximum amounts the
physician charges for each patient visit.
(c) The notices required
by this section must be posted prominently and conspicuously:
(1) at the primary
entrance to the facility;
(2) in each patient
treatment room; and
(3) at each location
within the facility at which a person pays for health care services.
(d) A facility that is required to post notice under this section
may post the required notices on the same sign.
Sec. 254.156. REQUIRED
DISCLOSURE FOR CERTAIN ENROLLEES. (a) In this section:
(1)
"Administrator" has the meaning assigned by Section 1467.001,
Insurance Code.
(2) "Enrollee"
has the meaning assigned by Section 1467.001, Insurance Code.
(b) A facility that bills
an enrollee covered by a preferred provider benefit plan or a health
benefit plan under Chapter 1551, Insurance Code, shall make a disclosure to
the enrollee under this section if:
(1) the facility is not a
network provider for the enrollee's plan; and
(2) the facility fee
amount for which the enrollee is responsible is greater than $1,000 after
copayments, deductibles, and coinsurance, including the amount unpaid by
the administrator or insurer.
(c) The disclosure
required under this section must be made in the billing statement provided
to the enrollee and must include information sufficient to notify the
patient of the mandatory mediation process available under Chapter 1467,
Insurance Code.
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SECTION 3. Subchapter D,
Chapter 254, Health and Safety Code, is amended by adding Section 254.155
to read as follows:
Sec. 254.155. NOTICE OF
FEES. (a) A facility shall post notice that states:
(1) that the facility is
a freestanding emergency medical care facility;
(2) that the facility charges rates comparable to a hospital
emergency room and may charge a facility fee;
(3) that a facility or a physician providing medical care at the
facility may not be a participating provider in the patient's health
benefit plan provider network; and
(4) that a physician providing medical care at the facility may
bill separately from the facility for the medical care provided to a
patient.
(b) The notice required
by this section must be posted prominently and conspicuously:
(1) at the primary
entrance to the facility;
(2) in each patient
treatment room; and
(3) at each location
within the facility at which a person pays for health care services.
(c) The notice required by this section must be in legible print
on a sign with dimensions of at least 8.5 inches by 11 inches.
No
equivalent provision.
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SECTION 4. Section
324.001(7), Health and Safety Code, is amended.
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SECTION 4. Same as introduced
version.
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SECTION 5. Section 1467.001,
Insurance Code, is amended by amending Subdivisions (4), (5), and (7) and
adding Subdivision (4-a) to read as follows:
(4) "Facility-based
physician" means a radiologist, an anesthesiologist, a pathologist, an
emergency department physician, or a neonatologist:
(A) to whom the facility or
freestanding emergency medical care facility has granted clinical
privileges; and
(B) who provides services to
patients of the facility under those clinical privileges.
(4-a) "Freestanding
emergency medical care facility" has the meaning assigned by Section
254.001, Health and Safety Code, and includes a freestanding emergency
medical care facility that is exempt from the licensing requirements of
Chapter 254 under Section 254.052(8).
(5) "Mediation" means
a process in which an impartial mediator facilitates and promotes agreement
between the insurer offering a preferred provider benefit plan or the
administrator and a facility-based physician, a freestanding emergency
medical care facility, or the physician's or facility's
representative to settle a health benefit claim of an enrollee.
(7) "Party" means
an insurer offering a preferred provider benefit plan, an administrator, [or]
a facility-based physician, a freestanding emergency medical care
facility, or the physician's or facility's representative who
participates in a mediation conducted under this chapter. The enrollee is
also considered a party to the mediation.
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No
equivalent provision.
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SECTION 6. Section 1467.003,
Insurance Code, is amended to read as follows:
Sec. 1467.003. RULES. The
commissioner, the Texas Medical Board, the executive commissioner of the
Health and Human Services Commission for the Department of State Health
Services, and the chief administrative law judge shall adopt rules as
necessary to implement their respective powers and duties under this
chapter.
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No
equivalent provision.
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SECTION 7. Section 1467.005,
Insurance Code, is amended to read as follows:
Sec. 1467.005. REFORM. This
chapter may not be construed to prohibit:
(1) an insurer offering a
preferred provider benefit plan or administrator from, at any time,
offering a reformed claim settlement; or
(2) a facility-based
physician or a freestanding emergency medical care facility from, at
any time, offering a reformed charge for medical services or a facility
fee.
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No
equivalent provision.
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SECTION 8. Section 1467.051,
Insurance Code, is amended to read as follows:
Sec. 1467.051. AVAILABILITY
OF MANDATORY MEDIATION; EXCEPTION. (a) An enrollee may request mediation
of a settlement of an out-of-network health benefit claim if:
(1) the amount for which the
enrollee is responsible to a facility-based physician, after copayments,
deductibles, and coinsurance, including the amount unpaid by the
administrator or insurer, is greater than $1,000[;] and
[(2)] the health
benefit claim is for a medical service or supply provided by a
facility-based physician in a hospital that is a preferred provider or that
has a contract with the administrator; or
(2) the amount for which
the enrollee is responsible to a freestanding emergency medical care
facility for a facility fee, after copayments, deductibles, and
coinsurance, including the amount unpaid by the administrator or insurer,
is greater than $1,000.
(b) Except as provided by
Subsections (c) and (d), if an enrollee requests mediation under this
subchapter, the facility-based physician, the freestanding emergency
medical care facility, or the physician's or facility's
representative and the insurer or the administrator, as appropriate, shall
participate in the mediation.
(c) Except in the case of an
emergency and if requested by the enrollee, a facility-based physician or
a freestanding emergency medical care facility shall, before providing
a medical service or supply, provide a complete disclosure to an enrollee
that:
(1) explains that the
facility-based physician or the freestanding emergency medical care
facility does not have a contract with the enrollee's health benefit
plan;
(2) discloses projected
amounts for which the enrollee may be responsible; and
(3) discloses the
circumstances under which the enrollee would be responsible for those
amounts.
(d) A facility-based
physician or a freestanding emergency medical care facility that [who]
makes a disclosure under Subsection (c) and obtains the enrollee's written
acknowledgment of that disclosure may not be required to mediate a billed
charge under this subchapter if the amount billed is less than or equal to
the maximum amount projected in the disclosure.
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No
equivalent provision.
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SECTION 9. Section
1467.053(d), Insurance Code, is amended to read as follows:
(d) The mediator's fees
shall be split evenly and paid by:
(1) the insurer or
administrator; and
(2) the
facility-based physician or freestanding emergency medical care
facility, as applicable.
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No
equivalent provision.
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SECTION 10. Sections
1467.054(b) and (c), Insurance Code, are amended to read as follows:
(b) A request for mandatory
mediation must be provided to the department on a form prescribed by the
commissioner and must include:
(1) the name of the enrollee
requesting mediation;
(2) a brief description of
the claim to be mediated;
(3) contact information,
including a telephone number, for the requesting enrollee and the
enrollee's counsel, if the enrollee retains counsel;
(4) the name of the
facility-based physician or freestanding emergency medical care facility
and name of the insurer or administrator; and
(5) any other information
the commissioner may require by rule.
(c) On receipt of a request
for mediation, the department shall notify the facility-based physician or
freestanding emergency medical care facility, as applicable, and
insurer or administrator of the request.
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No
equivalent provision.
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SECTION 11. Sections
1467.055(d), (h), and (i), Insurance Code, are amended to read as follows:
(d) If the enrollee is
participating in the mediation in person, at the beginning of the mediation
the mediator shall inform the enrollee that if the enrollee is not
satisfied with the mediated agreement, the enrollee may, as applicable,
file a complaint with:
(1) the Texas Medical Board
against the facility-based physician for improper billing; [and]
(2) the department for
unfair claim settlement practices; and
(3) the Department of
State Health Services against the freestanding emergency medical care
facility for improper billing.
(h) On receipt of notice
from the department that an enrollee has made a request for mediation that
meets the requirements of this chapter, the facility-based physician or
freestanding emergency medical care facility may not pursue any
collection effort against the enrollee who has requested mediation for
amounts other than copayments, deductibles, and coinsurance before the
earlier of:
(1) the date the mediation
is completed; or
(2) the date the request to
mediate is withdrawn.
(i) A service provided by a
facility-based physician or freestanding emergency medical care facility
may not be summarily disallowed. This subsection does not require an
insurer or administrator to pay for an uncovered service.
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No
equivalent provision.
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SECTION 12. Sections
1467.056(a), (b), and (d), Insurance Code, are amended to read as follows:
(a) In a mediation under
this chapter, the parties shall:
(1) evaluate whether:
(A) the amount charged by
the facility-based physician or freestanding emergency medical care
facility for the medical service or supply or facility fee is
excessive; and
(B) the amount paid by the
insurer or administrator represents the usual and customary rate for the
medical service or supply or facility fee or is unreasonably low;
and
(2) as a result of the
amounts described by Subdivision (1), determine the amount, after
copayments, deductibles, and coinsurance are applied, for which an enrollee
is responsible to the facility-based physician or freestanding emergency
medical care facility.
(b) The facility-based
physician or freestanding emergency medical care facility may
present information regarding the amount charged for the medical service or
supply or facility fee. The insurer or administrator may present
information regarding the amount paid by the insurer.
(d) The goal of the
mediation is to reach an agreement among the enrollee, the facility-based
physician or freestanding emergency medical care facility, and the
insurer or administrator, as applicable, as to the amount paid by the
insurer or administrator to the facility-based physician or freestanding
emergency medical care facility, the amount charged by the
facility-based physician or freestanding emergency medical care facility,
and the amount paid to the facility-based physician or freestanding
emergency medical care facility by the enrollee.
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No
equivalent provision.
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SECTION 13. Section
1467.057(a), Insurance Code, is amended to read as follows:
(a) The mediator of an
unsuccessful mediation under this chapter shall report the outcome of the
mediation to:
(1) the department;
(2) [,] the
Texas Medical Board when the mediation involves a facility-based
physician;
(3) the Department of
State Health Services when the mediation involves a freestanding emergency
medical care facility;[,] and
(4) the chief
administrative law judge.
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No
equivalent provision.
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SECTION 14. Section
1467.058, Insurance Code, is amended to read as follows:
Sec. 1467.058. CONTINUATION
OF MEDIATION. After a referral is made under Section 1467.057, the
facility-based physician or the freestanding emergency medical care
facility and the insurer or administrator, as applicable, may
elect to continue the mediation to further determine their
responsibilities. Continuation of mediation under this section does not
affect the amount of the billed charge to the enrollee.
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No
equivalent provision.
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SECTION 15. Section
1467.059, Insurance Code, is amended to read as follows:
Sec. 1467.059. MEDIATION
AGREEMENT. The mediator shall prepare a confidential mediation agreement
and order that states:
(1) the total amount for
which the enrollee will be responsible to the facility-based physician or
freestanding emergency medical care facility, after copayments,
deductibles, and coinsurance; and
(2) any agreement reached by
the parties under Section 1467.058.
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No
equivalent provision.
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SECTION 16. Section
1467.060, Insurance Code, is amended to read as follows:
Sec. 1467.060. REPORT OF
MEDIATOR. The mediator shall report to the commissioner and, as
applicable, to the Texas Medical Board when the mediation involves a
facility-based physician or the Department of State Health Services when
the mediation involves a freestanding emergency medical care facility:
(1) the names of the parties
to the mediation; and
(2) whether the parties
reached an agreement or the mediator made a referral under Section
1467.057.
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No
equivalent provision.
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SECTION 17. Section
1467.101(c), Insurance Code, is amended to read as follows:
(c) A mediator shall report
bad faith mediation to the commissioner, [or] the Texas
Medical Board, or the Department of State Health Services, as
appropriate, following the conclusion of the mediation.
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No
equivalent provision.
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SECTION 18. Sections
1467.151(a), (b), and (c), Insurance Code, are amended to read as follows:
(a) The commissioner,
[and] the Texas Medical Board, and the executive commissioner of
the Health and Human Services Commission for the Department of State Health
Services, as appropriate, shall adopt rules regulating the
investigation and review of a complaint filed that relates to the
settlement of an out-of-network health benefit claim that is subject to
this chapter. The rules adopted under this section must:
(1) distinguish among
complaints for out-of-network coverage or payment and give priority to
investigating allegations of delayed medical care;
(2) develop a form for
filing a complaint and establish an outreach effort to inform enrollees of
the availability of the claims dispute resolution process under this
chapter;
(3) ensure that a complaint
is not dismissed without appropriate consideration;
(4) ensure that enrollees
are informed of the availability of mandatory mediation; and
(5) require the administrator
to include a notice of the claims dispute resolution process available
under this chapter with the explanation of benefits sent to an enrollee.
(b) The department, [and]
the Texas Medical Board, and the Department of State Health Services
shall maintain information:
(1) on each complaint filed
that concerns a claim or mediation subject to this chapter; and
(2) related to a claim that
is the basis of an enrollee complaint, including:
(A) the type of services or
fee that gave rise to the dispute;
(B) the type and specialty
of the facility-based physician who provided the out-of-network service,
if any;
(C) the county and
metropolitan area in which the medical service or supply was provided or
facility fee was charged, as applicable;
(D) whether the medical
service or supply or facility fee was for emergency care; and
(E) any other information
about:
(i) the insurer or
administrator that the commissioner by rule requires; [or]
(ii) the physician that the
Texas Medical Board by rule requires; or
(iii) the freestanding
emergency medical care facility that the executive commissioner of the
Health and Human Services Commission by rule requires for the Department of
State Health Services.
(c) The information
collected and maintained by the department, [and] the Texas
Medical Board, and the Department of State Health Services under
Subsection (b)(2) is public information as defined by Section 552.002,
Government Code, and may not include personally identifiable information or
medical information.
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No
equivalent provision.
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No
equivalent provision.
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SECTION 5. Section 241.183,
Health and Safety Code, as added by Chapter 917 (H.B. 1376), Acts of the
83rd Legislature, Regular Session, 2013, and as amended by S.B. No. 219,
Acts of the 84th Legislature, Regular Session, 2015, is repealed.
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SECTION 19. (a) Not later than December 1, 2015, the
executive commissioner of the Health and Human Services Commission shall
adopt the rules necessary to implement the changes in law made by this Act.
(b) Notwithstanding
Subchapter J, Chapter 241, Health and Safety Code, and Sections 254.155 and 254.156, Health and Safety Code, as
added by this Act, a freestanding emergency medical care facility is not
required to comply with those provisions until January 1, 2016.
(c) Notwithstanding Chapter
324, Health and Safety Code, as amended by this Act, a freestanding
emergency medical care facility is not required to comply with Chapter 324,
Health and Safety Code, until January 1, 2016.
(d)
Notwithstanding Chapter 1467, Insurance Code, as amended by this Act, a
mandatory mediation applies only to a facility fee that is incurred on or
after January 1, 2016. A facility fee incurred before January 1, 2016, is
governed by the law as it existed immediately before the effective date of
this Act, and that law is continued in effect for that purpose.
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SECTION 6.
(a) Notwithstanding
Subchapter J, Chapter 241, Health and Safety Code, and Section 254.155,
Health and Safety Code, as added by this Act, a freestanding emergency
medical care facility is not required to comply with those provisions until
January 1, 2016.
(b) Notwithstanding Chapter
324, Health and Safety Code, as amended by this Act, a freestanding
emergency medical care facility is not required to comply with Chapter 324,
Health and Safety Code, until January 1, 2016.
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SECTION 20. This Act takes
effect September 1, 2015.
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SECTION 7. Same as introduced
version.
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