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