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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 enrollees of |
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certain governmental managed care plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle H, Title 8, Insurance Code, is amended |
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by adding Chapter 1580 to read as follows: |
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CHAPTER 1580. HEALTH CARE MARKET PARTICIPATION FOR CERTAIN |
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GOVERNMENTAL MANAGED CARE PLANS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1580.0001. DEFINITIONS. In this chapter: |
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(1) "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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(2) "Health benefit plan" means a plan to which this |
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chapter applies under Section 1580.0002. |
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(3) "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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(4) "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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(5) "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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(6) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer or |
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administrator to provide health care services to enrollees. |
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Sec. 1580.0002. APPLICABILITY OF CHAPTER. (a) This |
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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 any provision in Chapter 1551, 1575, or |
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1579 or any other law, this chapter applies only to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; and |
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(3) a health coverage plan under Chapter 1579. |
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(c) Notwithstanding any other law, this chapter applies to |
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an independent administrator, manager, or third-party |
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administrator of a health benefit plan described by this section. |
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Sec. 1580.0003. RULES. The board of trustees of the |
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Employees Retirement System of Texas or Teacher Retirement System |
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of Texas, as applicable, may adopt rules to implement this chapter. |
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SUBCHAPTER B. TRANSPARENCY TOOLS |
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Sec. 1580.0051. AVAILABILITY OF PRICE AND QUALITY |
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INFORMATION. (a) A health benefit plan issuer or administrator |
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shall provide by a toll-free telephone number and on its publicly |
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available Internet website an interactive mechanism that, for a |
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specific health care service, allows an enrollee to request and |
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obtain from the issuer or administrator: |
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(1) information on the payments made by the issuer or |
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administrator to participating providers under the enrollee's |
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health benefit plan sufficient for the enrollee to compare costs |
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for that service among participating providers, including costs for |
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that service among participating providers after an enrollee has |
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exceeded the enrollee's deductible; |
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(2) quality data on participating providers to the |
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extent that data is available; and |
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(3) an estimate of the enrollee's out-of-pocket costs |
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under the enrollee's health benefit plan. |
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(b) A health benefit plan issuer or administrator may |
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contract with a third-party vendor to satisfy the requirements of |
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this section. |
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Sec. 1580.0052. NOTICE TO ENROLLEES. A health benefit plan |
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issuer or administrator shall inform an enrollee requesting an |
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estimate under Section 1580.0051 that any out-of-pocket amount |
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provided is only an estimate and that the actual amount of the cost |
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and the amount the enrollee is responsible to pay for the service |
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may vary based upon unforeseen issues that arise in connection with |
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the proposed service. |
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Sec. 1580.0053. EFFECT OF SUBCHAPTER. This subchapter does |
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not prohibit a health benefit plan issuer or administrator from |
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imposing deductibles, copayments, or coinsurance under the health |
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benefit plan for a health care service that was not included in the |
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original estimate provided under Section 1580.0051. |
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SUBCHAPTER C. SHARED SAVINGS INCENTIVE PROGRAM |
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Sec. 1580.0101. ESTABLISHMENT OF INCENTIVE PROGRAM. A |
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health benefit plan issuer or administrator shall establish a |
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shared savings incentive program for all enrollees of the health |
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benefit plan. The program must provide an incentive paid in |
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accordance with this subchapter to an enrollee who elects to |
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receive a health care service from a participating provider who |
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provides a high-quality service at a reasonable cost, as determined |
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by the Employees Retirement System of Texas or the Teacher |
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Retirement System of Texas, as applicable. |
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Sec. 1580.0102. NOTICE TO ENROLLEES. The health benefit |
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plan issuer or administrator shall annually provide written notice |
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to enrollees about the program. |
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Sec. 1580.0103. INCENTIVE PAYMENTS. A health benefit plan |
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issuer or administrator may pay a program incentive in the form and |
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manner approved by the Employees Retirement System of Texas or |
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Teacher Retirement System of Texas, as applicable. |
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SECTION 2. Chapter 1580, Insurance Code, as added by this |
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Act, applies only to a health benefit plan for a plan year that |
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begins after the first open enrollment period that occurs on or |
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after January 1, 2020. |
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SECTION 3. This Act takes effect September 1, 2019. |