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A BILL TO BE ENTITLED
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AN ACT
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relating to payment of and disclosures related to certain |
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out-of-network provider charges; providing a penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1301, Insurance Code, is amended by |
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adding Subchapter C-2 to read as follows: |
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SUBCHAPTER C-2. PAYMENT OF OUT-OF-NETWORK PROVIDER CHARGES |
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Sec. 1301.141. DEFINITIONS. In this subchapter: |
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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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term, the geozip area is the closest geozip area to the location in |
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which the health care service was performed if the location does not |
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have a zip code. |
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(2) "Out-of-network provider," with respect to a |
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preferred provider benefit plan, means a physician or health care |
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provider that is not a preferred provider of the plan. |
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(3) "Usual and customary charge" means 135% of the |
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highest allowed charge for a service, classified by geozip area and |
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Current Procedural Terminology code. |
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Sec. 1301.1414. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to an insurer providing a preferred |
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provider benefit plan that provides benefits for services provided |
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by out-of-network providers. |
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(b) This subchapter does not apply to: |
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(1) the Employees Retirement System of Texas or |
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another entity issuing or administering a basic coverage plan under |
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Chapter 1551; |
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(2) the Teacher Retirement System of Texas or another |
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entity issuing or administering a basic plan under Chapter 1575 or a |
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health coverage plan under Chapter 1579; and |
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(3) The Texas A&M University System or The University |
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of Texas System or another entity issuing or administering basic |
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coverage under Chapter 1601. |
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Sec. 1301.1415. PAYMENT OF CERTAIN OUT-OF-NETWORK |
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PROVIDERS. (a) If an out-of-network provider submits to an insurer |
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a claim for payment of a charge that is less than or equal to the |
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usual and customary charge for the service provided and includes an |
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election by the out-of-network provider to participate in this |
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subchapter, the insurer shall pay the charge 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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(b) An insurer may not pay less than the amount the insurer |
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is required to pay under this section because the insurer has not |
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received a portion of the charge that is the insured's |
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responsibility. |
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Sec. 1301.1416. PROMPT PAYMENT OF CERTAIN CLAIMS. If an |
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out-of-network provider submits to an insurer a claim described by |
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Section 1301.1415, the insurer shall pay the claim in accordance |
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with Subchapter C as if the physician or health care provider were a |
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preferred provider. |
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Sec. 1301.142. DISCLOSURES REGARDING PAYMENT OF |
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OUT-OF-NETWORK PROVIDER. (a) An insurer that provides benefits |
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under a preferred provider benefit plan for services provided by |
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out-of-network providers must disclose in the summary plan |
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description, on an Internet website maintained by the insurer, and |
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to a prospective purchaser of the plan: |
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(1) the definition of "usual and customary charge" |
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assigned by Section 1301.141; |
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(2) examples of the anticipated portion of the charge |
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that will be the insured's responsibility for frequently billed |
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health care services by out-of-network providers; and |
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(3) a methodology for determining the anticipated |
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portion of the charge that will be the insured's responsibility for |
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a specific health care service that is based on the amount, not an |
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approximation, that the insurer pays. |
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(b) Disclosures under this section must: |
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(1) be made in language easily understood by |
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purchasers and prospective purchasers of preferred provider |
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benefit plans; |
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(2) be made in a uniform, clearly organized manner; |
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(3) be of sufficient detail and comprehensiveness as |
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to provide for full and fair disclosure; and |
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(4) be updated as necessary to ensure that the |
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disclosures are accurate. |
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Sec. 1301.1425. PAYMENT IN FULL. If the insurer's payment |
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due under a preferred provider benefit plan's out-of-network |
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benefit provisions is greater than or equal to the usual and |
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customary charge but is not sufficient to cover the total billed |
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charge, an out-of-network provider electing to participate in this |
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subchapter agrees to accept as payment in full the amount paid by |
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the plan in accordance with those provisions plus any portion of the |
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charge that is the insured's responsibility under the plan. |
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Sec. 1301.143. REMEDIES. (a) An insurer that violates |
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Section 1301.1416 is subject to the penalties imposed under Section |
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1301.137 as if the out-of-network provider were a preferred |
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provider. |
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(b) The remedies provided by this section are in addition to |
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remedies available under any other provision of this code. |
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SECTION 2. Subchapter C-2, Chapter 1301, Insurance Code, as |
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added by this Act, applies only to charges for services provided to |
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an insured under a health insurance policy delivered, issued for |
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delivery, or renewed on or after January 1, 2018. Charges for |
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services provided to an insured under a policy delivered, issued |
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for delivery, or renewed before January 1, 2018, are governed by the |
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law in effect immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2017. |