INTRODUCED
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HOUSE COMMITTEE
SUBSTITUTE
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SECTION 1. Section 1467.001,
Insurance Code, is amended by amending Subdivisions (1), (3), (4), (5), and
(7) and adding Subdivisions (2-a), (3-a), and (4-a) to read as follows:
(1)
"Administrator" means:
(A) an administering firm
for a health benefit plan providing coverage under Chapter 1551, 1575,
or 1579; and
(B) if applicable, the
claims administrator for the health benefit plan.
(2-a) "Emergency
care provider" means a physician, health care practitioner, facility,
or other health care provider who provides and bills an enrollee,
administrator, or health benefit plan for emergency care.
(3) "Enrollee"
means an individual who is eligible to receive benefits through a preferred
provider benefit plan or a health benefit plan under Chapter 1551, 1575,
or 1579.
(3-a)
"Facility" has the meaning assigned by Section 324.001, Health
and Safety Code.
(4) "Facility-based provider
[physician]" means a physician, health care practitioner, or
other health care provider [radiologist, an anesthesiologist, a
pathologist, an emergency department physician, a neonatologist, or an
assistant surgeon:
[(A) to whom the facility
has granted clinical privileges; and
[(B)] who provides health
care or medical services to patients of a [the] facility
[under those clinical privileges].
(4-a) "Health care
practitioner" means an individual who is licensed to provide health
care services.
(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 provider or emergency care
provider [physician] or the provider's [physician'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 provider or emergency care provider [physician]
or the provider's [physician'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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SECTION 1. Section 1467.001,
Insurance Code, is amended by amending Subdivisions (1), (3), (4), (5), and
(7) and adding Subdivisions (2-a), (2-b), (3-a), and (4-a) to read as
follows:
(1)
"Administrator" means:
(A) an administering firm
for a health benefit plan providing coverage under Chapter 1551, 1575,
or 1579; and
(B) if applicable, the
claims administrator for the health benefit plan.
(2-a) "Emergency care" has the meaning
assigned by Section 1301.155.
(2-b) "Emergency
care provider" means a physician, health care practitioner, facility,
or other health care provider who provides and bills an enrollee,
administrator, or health benefit plan for emergency care.
(3) "Enrollee"
means an individual who is eligible to receive benefits through a preferred
provider benefit plan or a health benefit plan under Chapter 1551, 1575,
or 1579.
(3-a)
"Facility" has the meaning assigned by Section 324.001, Health
and Safety Code.
(4) "Facility-based provider
[physician]" means a physician, health care practitioner, or
other health care provider [radiologist, an anesthesiologist, a
pathologist, an emergency department physician, a neonatologist, or an
assistant surgeon:
[(A) to whom the facility
has granted clinical privileges; and
[(B)] who provides health
care or medical services to patients of a [the] facility
[under those clinical privileges].
(4-a) "Health care
practitioner" means an individual who is licensed to provide health
care services.
(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 provider or emergency care
provider [physician] or the provider's [physician'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 provider or emergency care provider [physician]
or the provider's [physician'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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SECTION 2. Section 1467.002,
Insurance Code, is amended.
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SECTION 2. Same as introduced
version.
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SECTION 3. Section 1467.003,
Insurance Code, is amended.
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SECTION 3. Same as introduced
version.
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SECTION 4. 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 provider
or emergency care provider [physician] from, at any time,
offering a reformed charge for health care or medical services.
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SECTION 4. 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 provider
or emergency care provider [physician] from, at any time,
offering a reformed charge for health care or medical services or supplies.
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SECTION 5. 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 provider or emergency care
provider [physician], after copayments, deductibles, and
coinsurance, including the amount unpaid by the administrator or insurer,
is greater than $500; and
(2) the health benefit claim
is for:
(A) emergency care; or
(B) a health care
or medical service or supply provided by a facility-based provider
[physician] in a facility [hospital] that is a
preferred provider or that has a contract with the administrator.
(b) Except as provided by
Subsections (c) and (d), if an enrollee requests mediation under this
subchapter, the facility-based provider or emergency care provider,
[physician] or the provider's [physician'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 provider
[physician] shall, before providing a health care or medical
service or supply, provide a complete disclosure to an enrollee that:
(1) explains that the
facility-based provider [physician] 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 provider
[physician] 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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SECTION 5. Section 1467.051,
Insurance Code, is amended to read as follows:
Sec. 1467.051. AVAILABILITY
OF MANDATORY MEDIATION; EXCEPTION.
(a) Same as introduced
version.
(b) Same as introduced
version.
(c) Same as introduced
version.
(d) Same as introduced
version.
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(e) A bill sent to an
enrollee by a facility-based provider or emergency care provider for an
out-of-network health benefit claim eligible for mediation under this
chapter must contain, in not less than 10-point boldface type, a
conspicuous, plain-language explanation of the mediation process available
under this chapter, including information on how to request mediation and a
statement substantially similar to the following: "This statement is a balance bill for out-of-network
services that may be eligible for mediation. You may obtain more
information at www.tdi.texas.gov/consumer/cpmmediation.html."
No
equivalent provision.
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SECTION 6. Subchapter B,
Chapter 1467, Insurance Code, is amended by adding Section 1467.0511 to
read as follows:
Sec. 1467.0511. NOTICE
AND INFORMATION PROVIDED TO ENROLLEE.
(a) A bill sent to an
enrollee by a facility-based provider or emergency care provider or an explanation of benefits sent to an
enrollee by an insurer or administrator for an out-of-network health
benefit claim eligible for mediation under this chapter must contain, in
not less than 10-point boldface type, a conspicuous, plain-language
explanation of the mediation process available under this chapter,
including information on how to request mediation and a statement that is
substantially similar to the following:
"You may be able to reduce some of your out-of-pocket costs
for an out-of-network medical or health care claim that is eligible for
mediation by contacting the Texas Department of Insurance at (website) and
(phone number)."
(b) If an enrollee
contacts an insurer, administrator, facility-based provider, or emergency
care provider about a bill that may be eligible for mediation under this
chapter, the insurer, administrator, facility-based provider, or emergency
care provider is encouraged to:
(1) inform the enrollee
about mediation under this chapter; and
(2) provide the enrollee
with the department's toll-free telephone number and Internet website
address.
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SECTION 6. Section 1467.052(c),
Insurance Code, is amended.
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SECTION 7. Same as introduced
version.
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SECTION 7. Section 1467.053(d),
Insurance Code, is amended.
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SECTION 8. Same as introduced
version.
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SECTION 8. Sections
1467.054(b), (c), (d), and (e), 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 provider or emergency care provider [physician]
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 provider
or emergency care provider [physician] and insurer or
administrator of the request.
(d) In an effort to settle
the claim before mediation, all parties must participate in an informal
settlement teleconference not later than the 30th day after the date on
which the enrollee submits a request for mediation under this section unless
otherwise agreed by all parties. The facility-based provider or emergency
care provider and the insurer or administrator are equally responsible for
scheduling the informal settlement teleconference.
(e) A dispute to be mediated
under this chapter that does not settle as a result of a teleconference
conducted under Subsection (d) must be conducted in the county in which the
health care or medical services were rendered.
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SECTION 9. Sections
1467.054(b), (c), and (e), Insurance Code, are amended to read as follows:
(b) Same as introduced
version.
(c) Same as introduced
version.
No
equivalent provision.
(e) Same as introduced
version.
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SECTION 9. Sections
1467.055(d), (g), (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 file a complaint
with:
(1) the Texas Medical Board or
other appropriate regulatory agency against the facility-based provider
or emergency care provider [physician] for improper billing; and
(2) the department for
unfair claim settlement practices.
(g) Except at the request of
an enrollee or as otherwise agreed by all parties, a mediation shall
be held not later than the 180th day after the date of the request for
mediation.
(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 provider or
emergency care provider [physician] 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 health care or
medical service provided by a facility-based provider or emergency
care provider [physician] 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 10. Sections
1467.055(d), (h), and (i), Insurance Code, are amended to read as follows:
(d) Same as introduced
version.
No
equivalent provision.
(h) Same as introduced
version.
(i) A health care or
medical service or supply
provided by a facility-based provider or emergency care provider [physician]
may not be summarily disallowed. This subsection does not require an
insurer or administrator to pay for an uncovered service or supply.
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SECTION 10. Sections
1467.056(a), (b), and (d), Insurance Code, are amended.
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SECTION 11. Same as
introduced version.
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SECTION 11. Section
1467.057(a), Insurance Code, is amended.
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SECTION 12. Same as
introduced version.
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SECTION 12. Section 1467.058,
Insurance Code, is amended.
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SECTION 13. Same as
introduced version.
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SECTION 13. Section 1467.059,
Insurance Code, is amended.
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SECTION 14. Same as
introduced version.
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SECTION 14. Section 1467.060,
Insurance Code, is amended.
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SECTION 15. Same as
introduced version.
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SECTION 15. 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 other regulatory agency, as appropriate,
following the conclusion of the mediation.
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SECTION 17. Section
1467.101(c), Insurance Code, is repealed.
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SECTION 16. Section
1467.151, Insurance Code, is amended to read as follows:
Sec. 1467.151. CONSUMER
PROTECTION; RULES.
(a) The commissioner and the
Texas Medical Board or other regulatory agency, 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 health care or 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 or other appropriate regulatory agency 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
that gave rise to the dispute;
(B) the type and specialty,
if any, of the facility-based provider or emergency care provider
[physician] who provided the out-of-network service;
(C) the county and
metropolitan area in which the health care or medical service or
supply was provided;
(D) whether the health
care or medical service or supply was for emergency care; and
(E) any other information
about:
(i) the insurer or
administrator that the commissioner by rule requires; or
(ii) the facility-based
provider or emergency care provider [physician] that the Texas
Medical Board or other appropriate regulatory agency by rule
requires.
(c) The information
collected and maintained by the department and the Texas Medical Board and
other appropriate regulatory agencies under Subsection (b)(2) is public
information as defined by Section 552.002, Government Code, and may not
include personally identifiable information or health care or
medical information.
(d) A facility-based provider
or emergency care provider [physician] who fails to provide a
disclosure under Section 1467.051 is not subject to discipline by the Texas
Medical Board or other appropriate regulatory agency for that
failure and a cause of action is not created by a failure to disclose as
required by Section 1467.051.
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SECTION 16. Section
1467.151, Insurance Code, is amended to read as follows:
Sec. 1467.151. CONSUMER
PROTECTION; RULES.
(a) Same as introduced
version.
(b) Same as introduced
version.
(c) Same as introduced version.
(d) A facility-based provider
or emergency care provider [physician] who fails to provide a
disclosure under Section 1467.051 or
1467.0511 is not subject to discipline by the Texas Medical
Board or other appropriate regulatory agency for that failure and a
cause of action is not created by a failure to disclose as required by
Section 1467.051 or 1467.0511.
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SECTION 17. The changes in
law made by this Act apply only to a claim for health care or medical
services provided on or after January 1, 2018. A claim for health care or
medical services provided before January 1, 2018, is governed by the law in
effect immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
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SECTION 18. The changes in
law made by this Act apply only to a claim for health care or medical
services or supplies provided on
or after January 1, 2018. A claim for health care or medical services or supplies provided before January 1,
2018, is governed by the law in effect immediately before the effective
date of this Act, and that law is continued in effect for that purpose.
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SECTION 18. This Act takes
effect September 1, 2017.
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SECTION 19. Same as
introduced version.
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