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A BILL TO BE ENTITLED
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AN ACT
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relating to payment standards for preferred provider benefit plans |
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to reduce balance billing of insureds for out-of-network health |
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care services. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter C-1, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.140 to read as follows: |
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Sec. 1301.140. BALANCE BILLING; PAYMENTS TO OUT-OF-NETWORK |
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PROVIDERS. (a) In this section: |
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(1) "Geozip area" means an area that includes all zip |
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codes with the identical first three digits. For purposes of this |
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section, a covered service performed at a location that does not |
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have a zip code is considered to be performed in the geozip area |
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closest to the location at which the service is performed. |
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(2) "Usual and customary charge" means 135% of the |
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average maximum allowed charge for a covered service by a physician |
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or health care provider with the same type of license in the same |
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geozip area. |
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(b) An insurer may not cause balance billing of an insured |
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by paying an out-of-network provider based on an allowed charge for |
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a covered service that is less than the usual and customary charge |
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for the service. |
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(c) If an out-of-network provider submits to an insurer a |
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claim for payment for a covered service, the insurer shall pay the |
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out-of-network provider an amount that is equal to or greater than |
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the usual and customary charge for the service minus any portion of |
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the charge that is the insured's responsibility under the preferred |
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provider benefit plan. |
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SECTION 2. Section 1301.140, Insurance Code, as added by |
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this Act, applies only to a preferred provider benefit plan that is |
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delivered, issued for delivery, or renewed on or after January 1, |
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2018. A preferred provider benefit plan that is delivered, issued |
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for delivery, or renewed before January 1, 2018, is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2017. |