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A BILL TO BE ENTITLED
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AN ACT
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relating to health care information provided by and notice of |
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facility fees charged by certain freestanding emergency medical |
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care facilities and the availability of mediation. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 241, Health and Safety Code, is amended |
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by adding Subchapter J to read as follows: |
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SUBCHAPTER J. NOTICE OF FACILITY FEES IN CERTAIN FREESTANDING |
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EMERGENCY MEDICAL CARE FACILITIES |
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Sec. 241.251. APPLICABILITY. This subchapter applies only |
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to a freestanding emergency medical care facility, as that term is |
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defined by Section 254.001, that is exempt from the licensing |
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requirements of Chapter 254 under Section 254.052(8). |
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Sec. 241.252. NOTICE OF FEES. (a) In this section, |
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"provider network" has the meaning assigned by Section 1456.001, |
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Insurance Code. |
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(b) A facility described by Section 241.251 shall post |
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notice that states: |
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(1) that the facility is a freestanding emergency |
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medical care facility and not an urgent care center; |
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(2) either: |
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(A) that the facility does not participate in a |
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provider network; or |
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(B) that the facility participates in a provider |
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network; and |
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(3) any facility fee charged by the facility, |
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including the minimum and maximum facility fee amounts charged per |
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visit. |
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(c) The notice required under Subsection (b)(2)(B) must: |
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(1) identify the provider network; |
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(2) identify each physician providing medical care at |
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the facility who is excluded from the provider network; and |
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(3) for each physician described by Subdivision (2), |
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state that the physician may bill separately from the facility for |
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the medical care provided to a patient and provide the minimum and |
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maximum amounts the physician charges for each patient visit. |
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(d) The notices required by this section must be posted |
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prominently and conspicuously: |
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(1) at the primary entrance to the facility; |
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(2) in each patient treatment room; and |
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(3) at each location within the facility at which a |
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person pays for health care services. |
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(e) A facility that is required to post notice under this |
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section and Section 241.183, as added by Chapter 917 (H.B. 1376), |
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Acts of the 83rd Legislature, Regular Session, 2013, may post the |
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required notices on the same sign. |
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Sec. 241.253. REQUIRED DISCLOSURE FOR CERTAIN ENROLLEES. |
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(a) In this section: |
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(1) "Administrator" has the meaning assigned by |
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Section 1467.001, Insurance Code. |
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(2) "Enrollee" has the meaning assigned by Section |
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1467.001, Insurance Code. |
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(b) A facility that bills an enrollee covered by a preferred |
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provider benefit plan or a health benefit plan under Chapter 1551, |
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Insurance Code, shall make a disclosure to the enrollee under this |
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section if: |
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(1) the facility is not a network provider for the |
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enrollee's plan; and |
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(2) the facility fee amount for which the enrollee is |
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responsible is greater than $1,000 after copayments, deductibles, |
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and coinsurance, including the amount unpaid by the administrator |
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or insurer. |
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(c) The disclosure required under this section must be made |
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in the billing statement provided to the enrollee and must include |
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information sufficient to notify the patient of the mandatory |
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mediation process available under Chapter 1467, Insurance Code. |
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SECTION 2. Section 254.001, Health and Safety Code, is |
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amended by adding Subdivision (6) to read as follows: |
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(6) "Provider network" has the meaning assigned by |
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Section 1456.001, Insurance Code. |
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SECTION 3. Subchapter D, Chapter 254, Health and Safety |
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Code, is amended by adding Sections 254.155 and 254.156 to read as |
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follows: |
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Sec. 254.155. NOTICE OF FEES. (a) A facility shall post |
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notice that states: |
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(1) that the facility is a freestanding emergency |
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medical care facility and not an urgent care center; |
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(2) either: |
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(A) that the facility does not participate in a |
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provider network; or |
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(B) that the facility participates in a provider |
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network; and |
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(3) any facility fee charged by the facility, |
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including the minimum and maximum facility fee amounts charged per |
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visit. |
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(b) The notice required under Subsection (a)(2)(B) must: |
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(1) identify the provider network; |
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(2) identify each physician providing medical care at |
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the facility who is excluded from the provider network; and |
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(3) for each physician described by Subdivision (2), |
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state that the physician may bill separately from the facility for |
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the medical care provided to a patient and provide the minimum and |
|
maximum amounts the physician charges for each patient visit. |
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(c) The notices required by this section must be posted |
|
prominently and conspicuously: |
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(1) at the primary entrance to the facility; |
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(2) in each patient treatment room; and |
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(3) at each location within the facility at which a |
|
person pays for health care services. |
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(d) A facility that is required to post notice under this |
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section may post the required notices on the same sign. |
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Sec. 254.156. REQUIRED DISCLOSURE FOR CERTAIN ENROLLEES. |
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(a) In this section: |
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(1) "Administrator" has the meaning assigned by |
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Section 1467.001, Insurance Code. |
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(2) "Enrollee" has the meaning assigned by Section |
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1467.001, Insurance Code. |
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(b) A facility that bills an enrollee covered by a preferred |
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provider benefit plan or a health benefit plan under Chapter 1551, |
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Insurance Code, shall make a disclosure to the enrollee under this |
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section if: |
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(1) the facility is not a network provider for the |
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enrollee's plan; and |
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(2) the facility fee amount for which the enrollee is |
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responsible is greater than $1,000 after copayments, deductibles, |
|
and coinsurance, including the amount unpaid by the administrator |
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or insurer. |
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(c) The disclosure required under this section must be made |
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in the billing statement provided to the enrollee and must include |
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information sufficient to notify the patient of the mandatory |
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mediation process available under Chapter 1467, Insurance Code. |
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SECTION 4. Section 324.001(7), Health and Safety Code, is |
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amended to read as follows: |
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(7) "Facility" means: |
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(A) an ambulatory surgical center licensed under |
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Chapter 243; |
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(B) a birthing center licensed under Chapter 244; |
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[or] |
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(C) a hospital licensed under Chapter 241; or |
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(D) a freestanding emergency medical care |
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facility, as defined in Section 254.001, including a freestanding |
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emergency medical care facility that is exempt from the licensing |
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requirements of Chapter 254 under Section 254.052(8). |
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SECTION 5. Section 1467.001, Insurance Code, is amended by |
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amending Subdivisions (4), (5), and (7) and adding Subdivision |
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(4-a) to read as follows: |
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(4) "Facility-based physician" means a radiologist, |
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an anesthesiologist, a pathologist, an emergency department |
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physician, or a neonatologist: |
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(A) to whom the facility or freestanding |
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emergency medical care facility has granted clinical privileges; |
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and |
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(B) who provides services to patients of the |
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facility under those clinical privileges. |
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(4-a) "Freestanding emergency medical care facility" |
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has the meaning assigned by Section 254.001, Health and Safety |
|
Code, and includes a freestanding emergency medical care facility |
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that is exempt from the licensing requirements of Chapter 254 under |
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Section 254.052(8). |
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(5) "Mediation" means a process in which an impartial |
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mediator facilitates and promotes agreement between the insurer |
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offering a preferred provider benefit plan or the administrator and |
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a facility-based physician, a freestanding emergency medical care |
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facility, or the physician's or facility's representative to settle |
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a health benefit claim of an enrollee. |
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(7) "Party" means an insurer offering a preferred |
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provider benefit plan, an administrator, [or] a facility-based |
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physician, a freestanding emergency medical care facility, or the |
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physician's or facility's representative who participates in a |
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mediation conducted under this chapter. The enrollee is also |
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considered a party to the mediation. |
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SECTION 6. Section 1467.003, Insurance Code, is amended to |
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read as follows: |
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Sec. 1467.003. RULES. The commissioner, the Texas Medical |
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Board, the executive commissioner of the Health and Human Services |
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Commission for the Department of State Health Services, and the |
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chief administrative law judge shall adopt rules as necessary to |
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implement their respective powers and duties under this chapter. |
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SECTION 7. Section 1467.005, Insurance Code, is amended to |
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read as follows: |
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Sec. 1467.005. REFORM. This chapter may not be construed to |
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prohibit: |
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(1) an insurer offering a preferred provider benefit |
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plan or administrator from, at any time, offering a reformed claim |
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settlement; or |
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(2) a facility-based physician or a freestanding |
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emergency medical care facility from, at any time, offering a |
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reformed charge for medical services or a facility fee. |
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SECTION 8. Section 1467.051, Insurance Code, is amended to |
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read as follows: |
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Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION; |
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EXCEPTION. (a) An enrollee may request mediation of a settlement |
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of an out-of-network health benefit claim if: |
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(1) the amount for which the enrollee is responsible |
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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 |
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[(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 |
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the administrator; or |
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(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. |
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(b) Except as provided by Subsections (c) and (d), if an |
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enrollee requests mediation under this subchapter, the |
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facility-based physician, the freestanding emergency medical care |
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facility, or the physician's or facility's representative and the |
|
insurer or the administrator, as appropriate, shall participate in |
|
the mediation. |
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(c) Except in the case of an emergency and if requested by |
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the enrollee, a facility-based physician or a freestanding |
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emergency medical care facility shall, before providing a medical |
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service or supply, provide a complete disclosure to an enrollee |
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that: |
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(1) explains that the facility-based physician or the |
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freestanding emergency medical care facility does not have a |
|
contract with the enrollee's health benefit plan; |
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(2) discloses projected amounts for which the enrollee |
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may be responsible; and |
|
(3) discloses the circumstances under which the |
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enrollee would be responsible for those amounts. |
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(d) A facility-based physician or a freestanding emergency |
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medical care facility that [who] makes a disclosure under |
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Subsection (c) and obtains the enrollee's written acknowledgment of |
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that disclosure may not be required to mediate a billed charge under |
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this subchapter if the amount billed is less than or equal to the |
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maximum amount projected in the disclosure. |
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SECTION 9. Section 1467.053(d), Insurance Code, is amended |
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to read as follows: |
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(d) The mediator's fees shall be split evenly and paid by: |
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(1) the insurer or administrator; and |
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(2) the facility-based physician or freestanding |
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emergency medical care facility, as applicable. |
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SECTION 10. Sections 1467.054(b) and (c), Insurance Code, |
|
are amended to read as follows: |
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(b) A request for mandatory mediation must be provided to |
|
the department on a form prescribed by the commissioner and must |
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include: |
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(1) the name of the enrollee requesting mediation; |
|
(2) a brief description of the claim to be mediated; |
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(3) contact information, including a telephone |
|
number, for the requesting enrollee and the enrollee's counsel, if |
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the enrollee retains counsel; |
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(4) the name of the facility-based physician or |
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freestanding emergency medical care facility and name of the |
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insurer or administrator; and |
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(5) any other information the commissioner may require |
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by rule. |
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(c) On receipt of a request for mediation, the department |
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shall notify the facility-based physician or freestanding |
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emergency medical care facility, as applicable, and insurer or |
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administrator of the request. |
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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 |
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practices; and |
|
(3) the Department of State Health Services against |
|
the freestanding emergency medical care facility for improper |
|
billing. |
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(h) On receipt of notice from the department that an |
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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: |
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(1) the date the mediation is completed; or |
|
(2) the date the request to mediate is withdrawn. |
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(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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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: |
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(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. |
|
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. |
|
SECTION 14. Section 1467.058, Insurance Code, is amended to |
|
read as follows: |
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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. |
|
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. |
|
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. |
|
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. |
|
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. |
|
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. |
|
SECTION 20. This Act takes effect September 1, 2015. |