86R9507 SCL-F
 
  By: Burrows H.B. No. 2525
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to participation in the health care market by enrollees of
  certain governmental managed care plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle H, Title 8, Insurance Code, is amended
  by adding Chapter 1580 to read as follows:
  CHAPTER 1580. HEALTH CARE MARKET PARTICIPATION FOR CERTAIN
  GOVERNMENTAL MANAGED CARE PLANS
  SUBCHAPTER A. GENERAL PROVISIONS
         Sec. 1580.0001.  DEFINITIONS. In this chapter:
               (1)  "Enrollee" means an individual who is eligible to
  receive benefits for health care services through a health benefit
  plan.
               (2)  "Health benefit plan" means a plan to which this
  chapter applies under Section 1580.0002.
               (3)  "Health care provider" means a physician,
  hospital, pharmacy, pharmacist, laboratory, or other person or
  organization that furnishes health care services and that is
  licensed or otherwise authorized to practice in this state.
               (4)  "Health care service" means a service for the
  diagnosis, prevention, treatment, cure, or relief of a health
  condition, illness, injury, or disease.
               (5)  "Managed care plan" means a health benefit plan
  under which health care services are provided to enrollees through
  contracts with health care providers and that requires enrollees to
  use participating providers or that provides a different level of
  coverage for enrollees who use participating providers.
               (6)  "Participating provider" means a health care
  provider who has contracted with a health benefit plan issuer or
  administrator to provide health care services to enrollees.
         Sec. 1580.0002.  APPLICABILITY OF CHAPTER. (a) This
  chapter applies only with respect to nonemergency health care
  services covered under a managed care plan.
         (b)  Notwithstanding any provision in Chapter 1551, 1575, or
  1579 or any other law, this chapter applies only to:
               (1)  a basic coverage plan under Chapter 1551;
               (2)  a basic plan under Chapter 1575; and
               (3)  a health coverage plan under Chapter 1579.
         (c)  Notwithstanding any other law, this chapter applies to
  an independent administrator, manager, or third-party
  administrator of a health benefit plan described by this section.
         Sec. 1580.0003.  RULES. The board of trustees of the
  Employees Retirement System of Texas or Teacher Retirement System
  of Texas, as applicable, may adopt rules to implement this chapter.
  SUBCHAPTER B. TRANSPARENCY TOOLS
         Sec. 1580.0051.  AVAILABILITY OF PRICE AND QUALITY
  INFORMATION. (a)  A health benefit plan issuer or administrator
  shall provide by a toll-free telephone number and on its publicly
  available Internet website an interactive mechanism that, for a
  specific health care service, allows an enrollee to request and
  obtain from the issuer or administrator:
               (1)  information on the payments made by the issuer or
  administrator to participating providers under the enrollee's
  health benefit plan sufficient for the enrollee to compare costs
  for that service among participating providers, including costs for
  that service among participating providers after an enrollee has
  exceeded the enrollee's deductible;
               (2)  quality data on participating providers to the
  extent that data is available; and
               (3)  an estimate of the enrollee's out-of-pocket costs
  under the enrollee's health benefit plan.
         (b)  A health benefit plan issuer or administrator may
  contract with a third-party vendor to satisfy the requirements of
  this section.
         Sec. 1580.0052.  NOTICE TO ENROLLEES. A health benefit plan
  issuer or administrator shall inform an enrollee requesting an
  estimate under Section 1580.0051 that any out-of-pocket amount
  provided is only an estimate and that the actual amount of the cost
  and the amount the enrollee is responsible to pay for the service
  may vary based upon unforeseen issues that arise in connection with
  the proposed service.
         Sec. 1580.0053.  EFFECT OF SUBCHAPTER. This subchapter does
  not prohibit a health benefit plan issuer or administrator from
  imposing deductibles, copayments, or coinsurance under the health
  benefit plan for a health care service that was not included in the
  original estimate provided under Section 1580.0051.
  SUBCHAPTER C. SHARED SAVINGS INCENTIVE PROGRAM
         Sec. 1580.0101.  ESTABLISHMENT OF INCENTIVE PROGRAM. A
  health benefit plan issuer or administrator shall establish a
  shared savings incentive program for all enrollees of the health
  benefit plan. The program must provide an incentive paid in
  accordance with this subchapter to an enrollee who elects to
  receive a health care service from a participating provider who
  provides a high-quality service at a reasonable cost, as determined
  by the Employees Retirement System of Texas or the Teacher
  Retirement System of Texas, as applicable.
         Sec. 1580.0102.  NOTICE TO ENROLLEES. The health benefit
  plan issuer or administrator shall annually provide written notice
  to enrollees about the program.
         Sec. 1580.0103.  INCENTIVE PAYMENTS. A health benefit plan
  issuer or administrator may pay a program incentive in the form and
  manner approved by the Employees Retirement System of Texas or
  Teacher Retirement System of Texas, as applicable.
         SECTION 2.  Chapter 1580, Insurance Code, as added by this
  Act, applies only to a health benefit plan for a plan year that
  begins after the first open enrollment period that occurs on or
  after January 1, 2020.
         SECTION 3.  This Act takes effect September 1, 2019.