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A BILL TO BE ENTITLED
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AN ACT
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relating to participation in the health care market by managed care |
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plan enrollees. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle C, Title 8, Insurance Code, is amended |
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by adding Chapter 1275 to read as follows: |
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CHAPTER 1275. HEALTH CARE MARKET PARTICIPATION |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1275.0001. DEFINITIONS. In this chapter: |
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(1) "Allowed amount" means the amount paid by a health |
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benefit plan issuer to a participating provider for a covered |
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service under a contract between the issuer and provider. |
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(2) "Enrollee" means an individual who is eligible to |
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receive benefits for health care services through a health benefit |
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plan. |
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(3) "Health benefit plan" means: |
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(A) an individual, group, blanket, or franchise |
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insurance policy, a certificate issued under an individual or group |
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policy, or a group hospital service contract that provides benefits |
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for health care services; or |
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(B) a group subscriber contract or group or |
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individual evidence of coverage issued by a health maintenance |
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organization that provides benefits for health care services. |
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(4) "Health benefit plan issuer" means a health |
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maintenance organization operating under Chapter 843, a preferred |
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provider organization operating under Chapter 1301, an approved |
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nonprofit health corporation that holds a certificate of authority |
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under Chapter 844, and any other entity that issues a health benefit |
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plan, including: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a fraternal benefit society operating under |
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Chapter 885; or |
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(D) a stipulated premium company operating under |
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Chapter 884. |
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(5) "Health care provider" means a physician, |
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hospital, pharmacy, pharmacist, laboratory, or other person or |
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organization that furnishes health care services and that is |
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licensed or otherwise authorized to practice in this state. |
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(6) "Health care service" means a service for the |
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diagnosis, prevention, treatment, cure, or relief of a health |
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condition, illness, injury, or disease. |
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(7) "Managed care plan" means a health benefit plan |
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under which health care services are provided to enrollees through |
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contracts with health care providers and that requires enrollees to |
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use participating providers or that provides a different level of |
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coverage for enrollees who use participating providers. |
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(8) "Out-of-network provider," with respect to a |
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managed care plan, means a health care provider who is not a |
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participating provider of the plan. |
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(9) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer to |
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provide health care services to enrollees. |
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Sec. 1275.0002. APPLICABILITY OF CHAPTER; EXEMPTION. (a) |
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This chapter applies only with respect to nonemergency health care |
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services covered under a managed care plan. |
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(b) Notwithstanding Subsection (a), Subchapters B and C do |
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not apply to a covered health care service described by Subsection |
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(a) for which the commissioner approves an application for |
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exemption filed by the issuer with the department in the form and |
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manner prescribed by the commissioner that includes sufficient |
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evidence to demonstrate that the variation in allowed amounts for |
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the service among participating providers is less than $50. |
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Sec. 1275.0003. RULES. The commissioner may adopt rules to |
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implement this chapter. |
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SUBCHAPTER B. TRANSPARENCY TOOLS |
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Sec. 1275.0051. APPLICABILITY OF SUBCHAPTER. This |
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subchapter applies only to: |
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(1) a small employer health benefit plan written under |
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Chapter 1501; |
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(2) an individual insurance policy or insurance |
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agreement; or |
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(3) an individual evidence of coverage or similar |
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coverage document. |
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Sec. 1275.0052. AVAILABILITY OF PRICE AND QUALITY |
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INFORMATION. (a) A health benefit plan issuer shall provide on its |
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publicly available Internet website an interactive mechanism that, |
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for a specific health care service, allows an enrollee to: |
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(1) request and obtain from the issuer: |
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(A) information on the payments made by the |
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issuer to participating providers under the enrollee's health |
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benefit plan; and |
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(B) quality data on participating providers to |
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the extent that data is available; |
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(2) compare allowed amounts among participating |
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providers; |
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(3) estimate the enrollee's out-of-pocket costs under |
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the enrollee's health benefit plan; and |
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(4) view the median or mode amount paid to |
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participating providers under the enrollee's health benefit plan |
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within a reasonable time not to exceed one year. |
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(b) A health benefit plan issuer may contract with a third |
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party to provide the interactive mechanism described by Subsection |
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(a). |
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Sec. 1275.0053. ESTIMATE REQUIREMENTS. To satisfy the |
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requirement under Section 1275.0052(a)(3), a health benefit plan |
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issuer shall provide a good-faith estimate of the amount the |
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enrollee will be responsible to pay for a health care service |
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provided by a participating provider based on the information |
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available to the issuer at the time the estimate is requested. |
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Sec. 1275.0054. NOTICE TO ENROLLEES. A health benefit plan |
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issuer shall inform an enrollee requesting an estimate under |
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Section 1275.0052(a)(3) that the actual amount of the charges and |
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the amount the enrollee is responsible to pay for the service may |
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vary based upon unforeseen services that arise from the proposed |
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service. |
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Sec. 1275.0055. WAIVER. (a) A health benefit plan issuer |
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may file with the department a request for a waiver from compliance |
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with this subchapter for a health care service for which the issuer |
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determines that the issuer is unable to comply with Section |
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1275.0052. |
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(b) A health benefit plan issuer filing a request under |
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Subsection (a) must: |
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(1) file the request in the form and manner prescribed |
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by the commissioner; and |
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(2) include evidence supporting the issuer's |
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determination that the issuer cannot comply with Section 1275.0052 |
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for the health care service. |
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(c) The commissioner shall approve a waiver request under |
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this section if the commissioner determines that the issuer |
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provided sufficient evidence to support the waiver. If the |
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commissioner approves a waiver request, the commissioner shall |
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publicly release the contents of the request. |
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Sec. 1275.0056. EFFECT OF SUBCHAPTER. This subchapter does |
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not prohibit a health benefit plan issuer from imposing |
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deductibles, copayments, or coinsurance under the health benefit |
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plan for an unforeseen health care service: |
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(1) arising from the health care service that is the |
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basis for the original estimate to the enrollee provided under |
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Section 1275.0052; and |
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(2) that was not included in the original estimate |
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provided under Section 1275.0052. |
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SUBCHAPTER C. INCENTIVE PROGRAM |
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Sec. 1275.0101. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to: |
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(1) a small employer health benefit plan written under |
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Chapter 1501; |
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(2) an individual insurance policy or insurance |
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agreement; or |
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(3) an individual evidence of coverage or similar |
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coverage document. |
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(b) This subchapter does not apply to a health benefit plan |
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for which an enrollee receives a premium subsidy under the Patient |
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Protection and Affordable Care Act (Pub. L. No. 111-148). |
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Sec. 1275.0102. ESTABLISHMENT OF INCENTIVE PROGRAM. A |
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health benefit plan issuer shall establish an incentive program for |
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each health benefit plan subject to this subchapter. The program |
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must provide an incentive paid in accordance with this subchapter |
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to an enrollee who elects to receive a health care service from a |
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participating provider who provides that service at a cost that is |
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lower than the median or mode allowed amount for that service. |
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Sec. 1275.0103. PROGRAM DESCRIPTION REQUIRED. Before |
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offering the program required by this subchapter, a health benefit |
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plan issuer shall file a description of the program with the |
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department in the form and manner prescribed by the commissioner. |
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Sec. 1275.0104. NOTICE TO ENROLLEES. Annually and at |
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enrollment or renewal of a health benefit plan, the health benefit |
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plan issuer shall provide written notice to enrollees about: |
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(1) the availability of the program; |
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(2) the program's incentives; and |
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(3) methods to obtain the program's incentives. |
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Sec. 1275.0105. INCENTIVE PAYMENTS. (a) A health benefit |
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plan issuer shall pay an incentive under the program regardless of |
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whether the enrollee has exceeded the out-of-pocket limit under the |
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enrollee's health benefit plan. |
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(b) A health benefit plan issuer may pay a program incentive |
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in the form of: |
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(1) cash; |
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(2) a gift card; or |
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(3) a credit or reduction in the health benefit plan's |
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premium, deductible, copayment, or coinsurance. |
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(c) An incentive payment made in accordance with this |
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section is not an administrative expense of a health benefit plan |
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issuer for purposes of rate development or rate filing. |
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SUBCHAPTER D. PARTICIPATION IN OUT-OF-NETWORK PROVIDER MARKET |
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Sec. 1275.0151. ENROLLEE ELECTION OF CERTAIN |
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OUT-OF-NETWORK CARE; PROVIDER REIMBURSEMENT. (a) If an enrollee |
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elects to receive a covered health care service from an |
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out-of-network provider who is based in the United States and the |
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provider makes the agreement described by Subsection (b), the |
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enrollee's health benefit plan issuer shall: |
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(1) allow the enrollee to obtain the service from the |
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out-of-network provider; and |
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(2) pay the provider an amount not to exceed the median |
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or mode contracted amount for the service during a reasonable |
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period not to exceed one year. |
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(b) An out-of-network provider may elect to receive a |
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payment under Subsection (a) if the provider agrees to not charge |
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the enrollee an amount that exceeds the enrollee's responsibility |
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under the health benefit plan for the same service provided by a |
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participating provider. |
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Sec. 1275.0152. APPLICATION OF ENROLLEE PAYMENT. (a) An |
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enrollee who makes an election under Section 1275.0151(a) may file |
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with a health benefit plan issuer a request for the enrollee's |
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payment to the out-of-network provider to be treated as a payment to |
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a participating provider under the enrollee's health benefit plan |
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for purposes of a deductible or out-of-pocket maximum if: |
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(1) the out-of-network provider made the election |
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described by Section 1275.0151(b) with respect to the service that |
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is the basis for the request; and |
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(2) the enrollee provides proof of payment to the |
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out-of-network provider. |
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(b) A health benefit plan issuer shall provide a |
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downloadable or interactive online form for submitting a request |
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under Subsection (a). |
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(c) A health benefit plan issuer shall grant a request that |
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complies with Subsection (a) and rules adopted under this chapter. |
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Sec. 1275.0153. NOTICE TO ENROLLEES. A health benefit plan |
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issuer shall provide written notice to enrollees on the issuer's |
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Internet website and in the enrollees' health benefit plan |
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materials of the enrollees' rights to make an election under |
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Section 1275.0151 and a request under Section 1275.0152 and the |
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process for making the election and request. |
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SECTION 2. Chapter 1275, Insurance Code, as added by this |
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Act, applies only to a health benefit plan delivered, issued for |
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delivery, or renewed on or after January 1, 2020. A health benefit |
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plan that is delivered, issued for delivery, or renewed before |
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January 1, 2020, is governed by the law as it existed immediately |
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before the effective date of this Act, and that law is continued in |
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effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2019. |