|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to disclosure of certain health care costs and shared |
|
savings between certain health benefit plans and state employees. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Chapter 1551, Insurance Code, is amended by |
|
adding Subchapters K and L to read as follows: |
|
SUBCHAPTER K. HEALTH CARE PRICE DISCLOSURES |
|
Sec. 1551.501. DEFINITIONS. In this subchapter: |
|
(1) "Administrator" means an administering firm for a |
|
health benefit plan provided as basic coverage under this chapter. |
|
(2) "Enrollee" means a participant enrolled in a |
|
health benefit plan provided as basic coverage under this chapter. |
|
(3) "Facility" means a hospital, outpatient clinic, |
|
birthing center, ambulatory surgical center, or other licensed |
|
facility providing health care services. The term does not include |
|
an emergency clinic, a freestanding emergency medical care |
|
facility, or other facility providing only emergency care. |
|
(4) "Practitioner" means an individual who is licensed |
|
to provide and provides medical or other health care services. |
|
Sec. 1551.502. PROVIDER PRICE DISCLOSURE OR ESTIMATE. (a) |
|
On the request of an enrollee and before providing a nonemergency |
|
health care service offered to the enrollee by the facility or |
|
practitioner, a facility or practitioner shall provide a price |
|
disclosure described by Subsection (b) or an estimate described by |
|
Subsection (c), as applicable, not later than the second business |
|
day after the date on which the enrollee requests the disclosure or |
|
estimate. |
|
(b) Except as provided by Subsection (c), a facility or |
|
practitioner required to provide a price disclosure under |
|
Subsection (a) shall disclose to the enrollee the amount, including |
|
facility fees, that: |
|
(1) the enrollee's health benefit plan will reimburse |
|
the facility or practitioner for the service, if the facility or |
|
practitioner is participating in the enrollee's health benefit plan |
|
provider network; or |
|
(2) the facility or practitioner will charge for the |
|
service, if the facility or practitioner is not participating in |
|
the enrollee's health benefit plan provider network. |
|
(c) If a facility or practitioner is unable to quote a |
|
specific amount under Subsection (b) because of the facility's or |
|
practitioner's inability to predict the specific service the |
|
enrollee will need, the facility or practitioner shall provide an |
|
estimate of the amount required to be disclosed, including facility |
|
fees. |
|
(d) A facility or practitioner that provides an estimate |
|
described by Subsection (c) shall: |
|
(1) disclose the incomplete nature of the estimate; |
|
and |
|
(2) inform the enrollee that the facility or |
|
practitioner may be able to provide an updated estimate after the |
|
facility or practitioner obtains additional information. |
|
Sec. 1551.503. EFFECT OF OTHER LAW. A facility that |
|
provides an estimate under Section 324.101(d) is not relieved of |
|
the obligation to provide a price disclosure or estimate under |
|
Section 1551.502. |
|
Sec. 1551.504. HEALTH CARE SERVICE INFORMATION. On |
|
request, a facility or practitioner participating in the enrollee's |
|
health benefit plan provider network shall provide an enrollee with |
|
sufficient information about a proposed nonemergency health care |
|
service to enable the enrollee to obtain a cost estimate to |
|
determine the amount for which the enrollee will be personally |
|
liable by using the enrollee's health benefit plan's toll-free |
|
telephone number or Internet website or a third-party service. The |
|
facility or practitioner shall provide the information to the |
|
enrollee based on the information that is available to the facility |
|
or practitioner at the time of the request. The facility or |
|
practitioner may assist the enrollee in using the telephone number, |
|
website, or third-party service. |
|
Sec. 1551.505. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. |
|
(a) The administrator for an enrollee's health benefit plan shall, |
|
on the request of the enrollee, provide a good faith estimate of |
|
payments that will be made for any medically necessary, covered |
|
health care service from a network provider and shall also specify |
|
any deductibles, copayments, coinsurance, or other amounts for |
|
which the enrollee is responsible, based on the information |
|
available to the administrator at the time the estimate was |
|
requested. The estimate must be provided not later than the second |
|
business day after the date on which the estimate was requested. |
|
The administrator must advise the enrollee that the actual payment |
|
and charges for the services may vary based upon the enrollee's |
|
actual medical condition and other factors associated with |
|
performance of medical services, including any factors unknown to |
|
or unforeseeable by the administrator or provider at the time the |
|
estimate was requested. |
|
(b) An administrator may require an enrollee to pay any |
|
deductibles, copayments, coinsurance, or other amounts disclosed |
|
in the enrollee's coverage documents for an unforeseen health care |
|
service that arises out of the provision of the proposed health care |
|
service. |
|
SUBCHAPTER L. SHARED SAVINGS INCENTIVE PROGRAM |
|
Sec. 1551.551. DEFINITIONS. In this subchapter: |
|
(1) "Administrator" means an administering firm for a |
|
health benefit plan provided as basic coverage under this chapter. |
|
(2) "Enrollee" means a participant enrolled in a |
|
health benefit plan provided as basic coverage under this chapter. |
|
(3) "Program" means the shared savings incentive |
|
program established under this subchapter. |
|
(4) "Shoppable health care service" means a health |
|
care service covered by an enrollee's health benefit plan for which |
|
the plan provides an incentive under the program. The term |
|
includes: |
|
(A) physical and occupational therapy services; |
|
(B) obstetrical and gynecological services; |
|
(C) radiology and imaging services; |
|
(D) laboratory services; |
|
(E) infusion therapy; |
|
(F) inpatient and outpatient surgical |
|
procedures; |
|
(G) outpatient nonsurgical diagnostic tests or |
|
procedures; and |
|
(H) any other health care service designated as a |
|
shoppable health care service by the commissioner for purposes of |
|
this subchapter. |
|
Sec. 1551.552. APPLICABILITY. This subchapter applies to a |
|
health benefit plan provided as basic coverage under this chapter. |
|
Sec. 1551.553. RULES. The commissioner may adopt rules to |
|
implement this subchapter. |
|
Sec. 1551.554. SHARED SAVINGS INCENTIVE PROGRAM. An |
|
administrator shall develop and implement a shared savings |
|
incentive program through which a health benefit plan provides an |
|
incentive in accordance with this subchapter to an enrollee for |
|
electing to receive a shoppable health care service at a lower cost |
|
than the average cost for that service paid by the health benefit |
|
plan. |
|
Sec. 1551.555. DEPARTMENT REVIEW OF PROGRAM. Before |
|
offering the program, an administrator shall file a description of |
|
the program with the department in the form and manner prescribed by |
|
the commissioner. The department shall review the description to |
|
determine whether the program complies with this subchapter and |
|
rules adopted under this subchapter. A description of a shared |
|
savings incentive program and any supporting documentation filed |
|
under this section are confidential until the department has |
|
reviewed and approved a program. |
|
Sec. 1551.556. NOTICE TO PARTICIPANTS. Annually and at |
|
enrollment or renewal of a health benefit plan, the board of |
|
trustees or administrator shall provide written notice to |
|
participants and enrollees about the availability of the program. |
|
Sec. 1551.557. PRICE DISCLOSURE TELEPHONE NUMBER AND |
|
WEBSITE. (a) An administrator shall establish and operate a |
|
toll-free telephone number and an interactive mechanism on the |
|
publicly accessible Internet website for the health benefit plan |
|
that an enrollee may use to: |
|
(1) request and obtain from the administrator or a |
|
designated third party the average amount paid under the health |
|
benefit plan to providers in the health benefit plan provider |
|
network for a particular health care service; and |
|
(2) compare the cost of a shoppable health care |
|
service among network providers. |
|
(b) An administrator may contract with a third party to |
|
operate the telephone number or interactive mechanism described by |
|
Subsection (a). |
|
Sec. 1551.558. AVERAGE COST DETERMINATION. (a) Except as |
|
provided by Subsection (b), for purposes of this subchapter an |
|
administrator shall determine the average amount paid under a |
|
health benefit plan to providers in the health benefit plan |
|
provider network for a particular health care service using amounts |
|
paid within a reasonable period of not more than one year. |
|
(b) The commissioner may approve an alternative method for |
|
determining the average cost amount described by Subsection (a). |
|
Sec. 1551.559. INCENTIVE PAYMENTS. (a) An administrator |
|
must calculate an incentive under this section as a percentage of |
|
the difference in price, as a flat dollar amount, or by some other |
|
reasonable method approved by the commissioner. The administrator |
|
must provide the incentive as a cash payment to the enrollee. |
|
(b) Except as provided by Subsection (c), if an enrollee |
|
elects to receive a shoppable health care service the total cost of |
|
which is less than the average cost amount determined for the |
|
service under Section 1551.558, the administrator shall pay to the |
|
enrollee an incentive payment that is at least 50 percent of the |
|
health benefit plan's saved cost. |
|
(c) An administrator is not required to pay an enrollee |
|
under Subsection (b) if the health benefit plan's saved cost is $50 |
|
or less. |
|
(d) If an enrollee elects to receive a shoppable health care |
|
service from a provider outside the enrollee's health benefit plan |
|
provider network the total cost of which is less than the average |
|
cost amount determined for the service under Section 1551.558, the |
|
administrator, in addition to paying any incentive payment due |
|
under Subsection (b): |
|
(1) may hold the enrollee responsible only for any |
|
deductible, copayment, or coinsurance that would be due if the |
|
service were provided by a provider in the health benefit plan |
|
provider network; and |
|
(2) shall apply the amount paid for the service toward |
|
the enrollee's cost-sharing maximums, as if the service were |
|
provided by a provider in the health benefit plan provider network. |
|
(e) An incentive payment made in accordance with this |
|
section is not an administrative expense of the administrator for |
|
purposes of rate development or rate filing. |
|
Sec. 1551.560. SHARED SAVINGS REPORTING. (a) Not later |
|
than February 1 of each year, an administrator shall submit to the |
|
commissioner and the board of trustees a report for the preceding |
|
calendar year stating: |
|
(1) the total number of incentive payments made under |
|
Section 1551.559; |
|
(2) the total amount of those incentive payments; |
|
(3) the average amount of those incentive payments by |
|
category of health care service; |
|
(4) the total number and percentage of the health |
|
benefit plan's enrollees who received an incentive payment; |
|
(5) the number of shoppable health care services by |
|
category for which incentive payments were made and the average |
|
cost amount for those services; and |
|
(6) the total savings achieved by the health benefit |
|
plan for each category of health care service for which an incentive |
|
payment was made. |
|
(b) Not later than April 1 of each year, the department |
|
shall submit a report aggregating the information submitted by each |
|
health benefit plan administrator under this section to the |
|
governor, the lieutenant governor, the speaker of the house of |
|
representatives, and each legislative committee with jurisdiction |
|
over health insurance matters. |
|
SECTION 2. Section 324.101, Health and Safety Code, is |
|
amended by adding Subsection (d-1) to read as follows: |
|
(d-1) A facility that provides a price disclosure or |
|
estimate under Section 1551.502, Insurance Code, is not relieved of |
|
the obligation to provide an estimate under Subsection (d). |
|
SECTION 3. (a) Subchapter K, Chapter 1551, Insurance Code, |
|
as added by this Act, applies only to a service provided by a |
|
facility or practitioner during a plan year beginning on or after |
|
January 1, 2018. A service provided during a plan year beginning |
|
before January 1, 2018, 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. |
|
(b) Subchapter L, Chapter 1551, Insurance Code, as added by |
|
this Act, applies only to a health benefit plan for a plan year |
|
beginning on or after January 1, 2018. A health benefit plan for a |
|
plan year beginning before January 1, 2018, 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 4. This Act takes effect September 1, 2017. |