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A BILL TO BE ENTITLED
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AN ACT
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relating to the determination of a usual and customary amount under |
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the Insurance Code. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 2, Insurance Code, is amended |
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by adding Chapter 41 to read as follows: |
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CHAPTER 41. USUAL AND CUSTOMARY AMOUNTS |
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Sec. 41.0001. STANDARDIZED PROCEDURE. (a) The |
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commissioner of insurance by rule shall adopt a standardized |
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procedure to determine the usual and customary rate or amount for a |
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particular medical care or health care service or supply, including |
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a dental care service or supply, for purposes of this code. |
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(b) The procedure may include the use of a database or |
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clearing house, a survey procedure, or any other mechanism that |
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facilitates the determination of whether an amount is usual and |
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customary. |
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Sec. 41.0002. SIMILAR STATUTORY PROVISIONS. For a |
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provision of this code that establishes a payment standard for a |
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medical care or health care service or supply using statutory |
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language that is similar to "usual and customary," including |
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"reasonable and customary" or "usual, customary, and reasonable," |
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the commissioner by rule shall determine whether the provision is |
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subject to the standardized procedure adopted under Section |
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41.0001. |
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Sec. 41.0003. USE OF PROCEDURE. (a) The issuer of any |
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health benefit plan regulated under this code, including a health |
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maintenance organization or a preferred provider organization, |
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must use the standardized procedure adopted under this chapter to |
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determine whether the amount of a rate, charge, claim, or analogous |
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payment to be paid to a physician, health care practitioner, or |
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other health care provider, including a dentist, for a medical care |
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or health care service or supply, including a dental care service or |
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supply, is the usual and customary amount for the service or supply. |
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(b) The standardized procedure adopted under this chapter |
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is applicable to the determination of the usual and customary rate |
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for a service or supply in a mediation conducted under Chapter 1467. |
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SECTION 2. Not later than December 31, 2019, the |
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commissioner of insurance shall adopt rules as necessary to |
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implement Chapter 41, Insurance Code, as added by this Act. |
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SECTION 3. The standardized procedure adopted under Chapter |
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41, Insurance Code, as added by this Act, does not apply to the |
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amount of a rate, charge, claim, or analogous payment to be paid for |
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a medical care or health care service or supply provided before |
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January 1, 2020. |
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SECTION 4. This Act takes effect September 1, 2019. |