|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to consumer protections against certain medical and health |
|
care billing by certain out-of-network providers. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
ARTICLE 1. ELIMINATION OF SURPRISE BILLING FOR CERTAIN HEALTH |
|
BENEFIT PLANS |
|
SECTION 1.01. Subtitle F, Title 8, Insurance Code, is |
|
amended by adding Chapter 1466 to read as follows: |
|
CHAPTER 1466. OUT-OF-NETWORK COVERAGES AND BALANCE BILLING |
|
PROHIBITIONS |
|
SUBCHAPTER A. GENERAL PROVISIONS |
|
Sec. 1466.0001. APPLICABILITY OF DEFINITIONS. In this |
|
chapter, terms defined by Section 1467.001 have the meanings |
|
assigned by that section. |
|
Sec. 1466.0002. APPLICABILITY OF CHAPTER. This chapter |
|
applies only to: |
|
(1) a health benefit plan offered by a health |
|
maintenance organization operating under Chapter 843; |
|
(2) a preferred provider benefit plan, including an |
|
exclusive provider benefit plan, offered by an insurer under |
|
Chapter 1301; and |
|
(3) a health benefit plan, other than a health |
|
maintenance organization plan, under Chapter 1551, 1575, or 1579. |
|
SUBCHAPTER B. REQUIRED COVERAGES |
|
Sec. 1466.0051. USUAL AND CUSTOMARY RATE FOR CERTAIN |
|
GOVERNMENTAL PLANS. For purposes of this subchapter, the usual and |
|
customary rate for a health benefit plan under Chapter 1551, 1575, |
|
or 1579 is the relevant allowable amount as described by the |
|
applicable master benefit plan document or policy. |
|
Sec. 1466.0052. EMERGENCY CARE COVERAGE. A health benefit |
|
plan that provides coverage for emergency care performed for or a |
|
supply related to that care provided to an enrollee by an |
|
out-of-network provider must provide the coverage at the usual and |
|
customary rate or at an agreed rate. |
|
Sec. 1466.0053. FACILITY-BASED PROVIDER COVERAGE; |
|
EXCEPTION. (a) Except as provided by Subsection (b), a health |
|
benefit plan that provides coverage for a health care or medical |
|
service performed for or a supply related to that service provided |
|
to an enrollee by an out-of-network provider who is a |
|
facility-based provider must provide the coverage at the usual and |
|
customary rate or at an agreed rate if the provider performed the |
|
service at a health care facility that is a participating provider. |
|
(b) This section does not apply to a nonemergency health |
|
care or medical service: |
|
(1) that an enrollee elects to receive in writing in |
|
advance of the service with respect to each out-of-network provider |
|
providing the service; and |
|
(2) for which an out-of-network provider, before |
|
providing the service, provides a complete written disclosure to |
|
the enrollee that: |
|
(A) explains that the provider does not have a |
|
contract with the enrollee's health benefit plan; |
|
(B) discloses projected amounts for which the |
|
enrollee may be responsible; and |
|
(C) discloses the circumstances under which the |
|
enrollee would be responsible for those amounts. |
|
Sec. 1466.0054. DIAGNOSTIC IMAGING PROVIDER OR LABORATORY |
|
SERVICE PROVIDER COVERAGE; EXCEPTION. (a) Except as provided by |
|
Subsection (b), a health benefit plan that provides coverage for a |
|
health care or medical service performed for or a supply related to |
|
that service provided to an enrollee by an out-of-network provider |
|
who is a diagnostic imaging provider or laboratory service provider |
|
must provide the coverage at the usual and customary rate or at an |
|
agreed rate if the provider performed the service in connection |
|
with a health care service performed by a participating provider. |
|
(b) This section does not apply to a nonemergency health |
|
care or medical service: |
|
(1) that an enrollee elects to receive in writing in |
|
advance of the service with respect to each out-of-network provider |
|
providing the service; and |
|
(2) for which an out-of-network provider, before |
|
providing the service, provides a complete written disclosure to |
|
the enrollee that: |
|
(A) explains that the provider does not have a |
|
contract with the enrollee's health benefit plan; |
|
(B) discloses projected amounts for which the |
|
enrollee may be responsible; and |
|
(C) discloses the circumstances under which the |
|
enrollee would be responsible for those amounts. |
|
Sec. 1466.0055. ACTION ON CLEAN CLAIMS FOR REQUIRED |
|
COVERAGES. (a) A health maintenance organization shall act on a |
|
clean claim as defined by Section 843.336 related to a health care |
|
or medical service or supply required to be covered under this |
|
subchapter in accordance with Section 843.338 as if the |
|
out-of-network provider is a participating physician or provider. |
|
(b) An insurer shall act on a clean claim as defined by |
|
Section 1301.101 related to a health care or medical service or |
|
supply required to be covered under this subchapter in accordance |
|
with Section 1301.103 as if the out-of-network provider is a |
|
preferred provider. |
|
(c) An administrator shall act on a clean claim as defined |
|
by Section 1301.101 related to a health care or medical service or |
|
supply required to be covered under this subchapter in accordance |
|
with Section 1301.103 as if: |
|
(1) the out-of-network provider is a preferred |
|
provider; and |
|
(2) the administrator is an insurer. |
|
SUBCHAPTER C. BALANCE BILLING PROHIBITIONS |
|
Sec. 1466.0101. BALANCE BILLING PROHIBITION NOTICE. A |
|
health benefit plan issuer or administrator shall provide written |
|
notice in accordance with this section in an explanation of |
|
benefits provided to the enrollee and the out-of-network provider |
|
in connection with a health care service or supply that is subject |
|
to Subchapter B. The notice must include: |
|
(1) a statement of the billing prohibition under |
|
Section 1466.0102; |
|
(2) the total amount the provider may bill the |
|
enrollee under the enrollee's health benefit plan and an |
|
itemization of copayments, deductibles, coinsurance, or other |
|
amounts included in that total; and |
|
(3) for an explanation of benefits provided to the |
|
provider, information required by commissioner rule advising the |
|
provider of the availability of mediation or arbitration, as |
|
applicable, under Chapter 1467. |
|
Sec. 1466.0102. CERTAIN BALANCE BILLING PROHIBITED. For a |
|
health care service or supply required to be covered under |
|
Subchapter B, an out-of-network provider or a person asserting a |
|
claim as an agent or assignee of the provider may not bill an |
|
enrollee in, and the enrollee does not have financial |
|
responsibility for, an amount greater than an applicable copayment, |
|
coinsurance, or deductible under the enrollee's health benefit plan |
|
that: |
|
(1) is based on: |
|
(A) the amount initially determined payable by |
|
the health benefit plan issuer or administrator; or |
|
(B) if applicable, a modified amount as |
|
determined under the issuer's or administrator's internal dispute |
|
resolution process; and |
|
(2) is not based on any additional amount determined |
|
to be owed to the provider under Chapter 1467. |
|
SUBCHAPTER D. ENFORCEMENT |
|
Sec. 1466.0151. INJUNCTION RELATED TO BALANCE BILLING |
|
VIOLATION. (a) If the attorney general receives a referral from |
|
the appropriate regulatory agency indicating that an individual or |
|
entity, including a health benefit plan issuer or administrator, |
|
has exhibited a pattern of intentionally violating Subchapter C, |
|
the attorney general may bring a civil action in the name of the |
|
state to enjoin the individual or entity from the violation. |
|
(b) If the attorney general prevails in an action brought |
|
under Subsection (a), the attorney general may recover reasonable |
|
attorney's fees, costs, and expenses, including court costs and |
|
witness fees, incurred in bringing the action. |
|
Sec. 1466.0152. ENFORCEMENT BY REGULATORY AGENCY. (a) An |
|
appropriate regulatory agency that licenses, certifies, or |
|
otherwise authorizes a physician, health care practitioner, health |
|
care facility, or other health care provider to practice or operate |
|
in this state shall take disciplinary action against the physician, |
|
practitioner, facility, or provider if the physician, |
|
practitioner, facility, or provider violates Section 1466.0102. |
|
(b) A regulatory agency described by Subsection (a) may |
|
adopt rules as necessary to implement this section. Section |
|
2001.0045, Government Code, does not apply to rules adopted under |
|
this subsection. |
|
ARTICLE 2. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION |
|
SECTION 2.01. Section 1467.001, Insurance Code, is amended |
|
by adding Subdivisions (1-a), (2-c), (2-d), (4-b), and (6-a) and |
|
amending Subdivisions (2-a), (2-b), (3), (5), and (7) to read as |
|
follows: |
|
(1-a) "Arbitration" means a process in which an |
|
impartial arbiter issues a binding determination in a dispute |
|
between a health benefit plan issuer or administrator and an |
|
out-of-network provider or the provider's representative to settle |
|
a health benefit claim. |
|
(2-a) "Diagnostic imaging provider" means a health |
|
care provider who performs a diagnostic imaging service on a |
|
patient for a fee or interprets imaging produced by a diagnostic |
|
imaging service. |
|
(2-b) "Diagnostic imaging service" means magnetic |
|
resonance imaging, computed tomography, positron emission |
|
tomography, or any hybrid technology that combines any of those |
|
imaging modalities. |
|
(2-c) "Emergency care" has the meaning assigned by |
|
Section 1301.155. |
|
(2-d) [(2-b)] "Emergency care provider" means a |
|
physician, health care practitioner, facility, or other health care |
|
provider who provides and bills an enrollee, administrator, or |
|
health benefit plan for emergency care. |
|
(3) "Enrollee" means an individual who is eligible to |
|
receive benefits through a [preferred provider benefit plan or a] |
|
health benefit plan subject to this chapter [under Chapter 1551,
|
|
1575, or 1579]. |
|
(4-b) "Laboratory service provider" means an |
|
accredited facility in which a specimen taken from a human body is |
|
interpreted and pathological diagnoses are made or a person who |
|
makes an interpretation of or diagnosis based on a specimen or |
|
information provided by a laboratory based on a specimen. |
|
(5) "Mediation" means a process in which an impartial |
|
mediator facilitates and promotes agreement between the health |
|
[insurer offering a preferred provider] benefit plan issuer or the |
|
administrator and an out-of-network [a facility-based] provider |
|
[or emergency care provider] or the provider's representative to |
|
settle a health benefit claim of an enrollee. |
|
(6-a) "Out-of-network provider" means a diagnostic |
|
imaging provider, emergency care provider, facility-based |
|
provider, or laboratory service provider that is not a |
|
participating provider for a health benefit plan. |
|
(7) "Party" means a health benefit plan issuer [an
|
|
insurer] offering a health [a preferred provider] benefit plan, an |
|
administrator, or an out-of-network [a facility-based provider or
|
|
emergency care] provider or the provider's representative who |
|
participates in a mediation or arbitration conducted under this |
|
chapter. [The enrollee is also considered a party to the
|
|
mediation.] |
|
SECTION 2.02. Sections 1467.002, 1467.003, and 1467.005, |
|
Insurance Code, are amended to read as follows: |
|
Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter |
|
applies to: |
|
(1) a health benefit plan offered by a health |
|
maintenance organization operating under Chapter 843; |
|
(2) a preferred provider benefit plan, including an |
|
exclusive provider benefit plan, offered by an insurer under |
|
Chapter 1301; and |
|
(3) [(2)] an administrator of a health benefit plan, |
|
other than a health maintenance organization plan, under Chapter |
|
1551, 1575, or 1579. |
|
Sec. 1467.003. RULES. (a) The commissioner, the Texas |
|
Medical Board, and any other appropriate regulatory agency[, and
|
|
the chief administrative law judge] shall adopt rules as necessary |
|
to implement their respective powers and duties under this chapter. |
|
(b) Section 2001.0045, Government Code, does not apply to a |
|
rule adopted under this chapter. |
|
Sec. 1467.005. REFORM. This chapter may not be construed to |
|
prohibit: |
|
(1) a health [an insurer offering a preferred
|
|
provider] benefit plan issuer or administrator from, at any time, |
|
offering a reformed claim settlement; or |
|
(2) an out-of-network [a facility-based provider or
|
|
emergency care] provider from, at any time, offering a reformed |
|
charge for health care or medical services or supplies. |
|
SECTION 2.03. Subchapter A, Chapter 1467, Insurance Code, |
|
is amended by adding Section 1467.006 to read as follows: |
|
Sec. 1467.006. BENCHMARKING DATABASE. (a) The |
|
commissioner shall select an organization to maintain a |
|
benchmarking database that contains information necessary to |
|
calculate, with respect to a health care or medical service or |
|
supply, for each geographical area in this state: |
|
(1) the 80th percentile of billed charges of all |
|
physicians or health care providers who are not facilities; and |
|
(2) the 50th percentile of rates paid to participating |
|
providers who are not facilities. |
|
(b) The commissioner may not select under Subsection (a) an |
|
organization that is financially affiliated with a health benefit |
|
plan issuer. |
|
SECTION 2.04. The heading to Subchapter B, Chapter 1467, |
|
Insurance Code, is amended to read as follows: |
|
SUBCHAPTER B. MANDATORY MEDIATION FOR OUT-OF-NETWORK FACILITIES |
|
SECTION 2.05. Subchapter B, Chapter 1467, Insurance Code, |
|
is amended by adding Sections 1467.050 and 1467.0505 to read as |
|
follows: |
|
Sec. 1467.050. APPLICABILITY OF SUBCHAPTER. This |
|
subchapter applies only with respect to a health benefit claim |
|
submitted by an out-of-network provider that is a facility. |
|
Sec. 1467.0505. ESTABLISHMENT AND ADMINISTRATION OF |
|
MEDIATION PROGRAM. (a) The commissioner shall establish and |
|
administer a mediation program to resolve disputes over |
|
out-of-network provider charges in accordance with this |
|
subchapter. |
|
(b) The commissioner: |
|
(1) shall adopt rules, forms, and procedures necessary |
|
for the implementation and administration of the mediation program, |
|
including the establishment of a portal on the department's |
|
Internet website through which a request for mediation under |
|
Section 1467.051 may be submitted; and |
|
(2) shall maintain a list of qualified mediators for |
|
the program. |
|
SECTION 2.06. The heading to Section 1467.051, Insurance |
|
Code, is amended to read as follows: |
|
Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION[;
|
|
EXCEPTION]. |
|
SECTION 2.07. Sections 1467.051(a) and (b), Insurance Code, |
|
are amended to read as follows: |
|
(a) An out-of-network provider, health benefit plan issuer, |
|
or administrator [An enrollee] may request mediation of a |
|
settlement of an out-of-network health benefit claim through a |
|
portal on the department's Internet website if: |
|
(1) there is an [the] amount billed by the provider and |
|
unpaid by the issuer or administrator [for which the enrollee is
|
|
responsible to a facility-based provider or emergency care
|
|
provider,] after copayments, deductibles, and coinsurance for |
|
which an enrollee may not be billed [, including the amount unpaid
|
|
by the administrator or insurer, is greater than $500]; and |
|
(2) the health benefit claim is for: |
|
(A) emergency care; [or] |
|
(B) an out-of-network laboratory service; or |
|
(C) an out-of-network diagnostic imaging service |
|
[a health care or medical service or supply provided by a
|
|
facility-based provider in a facility that is a preferred provider
|
|
or that has a contract with the administrator]. |
|
(b) If a person [Except as provided by Subsections (c) and
|
|
(d), if an enrollee] requests mediation under this subchapter, the |
|
out-of-network [facility-based] provider [or emergency care
|
|
provider,] or the provider's representative, and the health benefit |
|
plan issuer [insurer] or the administrator, as appropriate, shall |
|
participate in the mediation. |
|
SECTION 2.08. Section 1467.052, Insurance Code, is amended |
|
by amending Subsections (a) and (c) and adding Subsection (d) to |
|
read as follows: |
|
(a) Except as provided by Subsection (b), to qualify for an |
|
appointment as a mediator under this subchapter [chapter] a person |
|
must have completed at least 40 classroom hours of training in |
|
dispute resolution techniques in a course conducted by an |
|
alternative dispute resolution organization or other dispute |
|
resolution organization approved by the commissioner [chief
|
|
administrative law judge]. |
|
(c) A person may not act as mediator for a claim settlement |
|
dispute if the person has been employed by, consulted for, or |
|
otherwise had a business relationship with a health [an insurer
|
|
offering the preferred provider] benefit plan issuer or |
|
administrator or a facility [physician, health care practitioner,
|
|
or other health care provider] during the three years immediately |
|
preceding the request for mediation. |
|
(d) The commissioner shall immediately terminate the |
|
approval of a mediator who no longer meets the requirements under |
|
this subchapter and rules adopted under this subchapter to serve as |
|
a mediator. |
|
SECTION 2.09. Section 1467.053, Insurance Code, is amended |
|
by adding Subsection (b-1) and amending Subsection (d) to read as |
|
follows: |
|
(b-1) If the parties do not select a mediator by mutual |
|
agreement on or before the 30th day after the date the mediation is |
|
requested, the party requesting the mediation shall notify the |
|
commissioner, and the commissioner shall select a mediator from the |
|
commissioner's list of approved mediators. |
|
(d) The mediator's fees shall be split evenly and paid by |
|
the health benefit plan issuer [insurer] or administrator and the |
|
out-of-network [facility-based provider or emergency care] |
|
provider. |
|
SECTION 2.10. Section 1467.054, Insurance Code, is amended |
|
by amending Subsections (a) and (d) and adding Subsection (b-1) to |
|
read as follows: |
|
(a) An out-of-network provider, health benefit plan issuer, |
|
or administrator [enrollee] may request mandatory mediation under |
|
this subchapter [chapter]. |
|
(b-1) The person who requests the mediation shall provide |
|
written notice on the date the mediation is requested in the form |
|
and manner provided by commissioner rule to: |
|
(1) the department; and |
|
(2) each other party. |
|
(d) In an effort to settle the claim before mediation, all |
|
parties must participate in an informal settlement teleconference |
|
not later than the 30th day after the date on which a person [the
|
|
enrollee] submits a request for mediation under this subchapter |
|
[section]. |
|
SECTION 2.11. Sections 1467.055(g) and (i), Insurance Code, |
|
are amended to read as follows: |
|
(g) A [Except at the request of an enrollee, a] mediation |
|
shall be held not later than the 180th day after the date of the |
|
request for mediation. |
|
(i) A health care or medical service or supply provided by |
|
an out-of-network [a facility-based] provider [or emergency care
|
|
provider] may not be summarily disallowed. This subsection does not |
|
require a health benefit plan issuer [an insurer] or administrator |
|
to pay for an uncovered service or supply. |
|
SECTION 2.12. Sections 1467.056(a), (b), and (d), Insurance |
|
Code, are amended to read as follows: |
|
(a) In a mediation under this subchapter [chapter], the |
|
parties shall[:
|
|
[(1)] evaluate whether: |
|
(1) [(A)] the amount charged by the out-of-network |
|
[facility-based] provider [or emergency care provider] for the |
|
health care or medical service or supply is excessive; and |
|
(2) [(B)] the amount paid by the health benefit plan |
|
issuer [insurer] or administrator represents the usual and |
|
customary rate for the health care or medical service or supply or |
|
is unreasonably low[; and
|
|
[(2)
as a result of the amounts described by
|
|
Subdivision (1), determine the amount, after copayments,
|
|
deductibles, and coinsurance are applied, for which an enrollee is
|
|
responsible to the facility-based provider or emergency care
|
|
provider]. |
|
(b) The out-of-network [facility-based] provider [or
|
|
emergency care provider] may present information regarding the |
|
amount charged for the health care or medical service or supply. The |
|
health benefit plan issuer [insurer] or administrator may present |
|
information regarding the amount paid by the issuer [insurer] or |
|
administrator. |
|
(d) The goal of the mediation is to reach an agreement |
|
between [among the enrollee,] the out-of-network [facility-based] |
|
provider [or emergency care provider,] and the health benefit plan |
|
issuer [insurer] or administrator, as applicable, as to the amount |
|
paid by the issuer [insurer] or administrator to the out-of-network |
|
[facility-based] provider and [or emergency care provider,] the |
|
amount charged by the out-of-network [facility-based] provider [or
|
|
emergency care provider, and the amount paid to the facility-based
|
|
provider or emergency care provider by the enrollee]. |
|
SECTION 2.13. Subchapter B, Chapter 1467, Insurance Code, |
|
is amended by adding Section 1467.0575 to read as follows: |
|
Sec. 1467.0575. RIGHT TO RECEIVE PAYMENT; RIGHT TO FILE |
|
ACTION. (a) An out-of-network provider has a right to a reasonable |
|
payment from an enrollee's health benefit plan for covered services |
|
and supplies provided to the enrollee that are subject to this |
|
subchapter and for which the provider has not been fully |
|
reimbursed. |
|
(b) Not later than the 45th day after the date that the |
|
mediator's report is provided to the department under Section |
|
1467.060, either party to a mediation for which there was no |
|
agreement may file a civil action to determine the amount due to an |
|
out-of-network provider. A party may not bring a civil action |
|
before the conclusion of the mediation process under this |
|
subchapter. |
|
SECTION 2.14. Section 1467.060, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 1467.060. REPORT OF MEDIATOR. Not later than the 45th |
|
day after the date the mediation concludes, the [The] mediator |
|
shall report to the commissioner and the Texas Medical Board or |
|
other appropriate regulatory agency: |
|
(1) the names of the parties to the mediation; and |
|
(2) whether the parties reached an agreement [or the
|
|
mediator made a referral under Section 1467.057]. |
|
SECTION 2.15. Chapter 1467, Insurance Code, is amended by |
|
adding Subchapter B-1 to read as follows: |
|
SUBCHAPTER B-1. MANDATORY BINDING ARBITRATION FOR OTHER PROVIDERS |
|
Sec. 1467.081. APPLICABILITY OF SUBCHAPTER. This |
|
subchapter applies only with respect to a health benefit claim |
|
submitted by an out-of-network provider who is not a facility. |
|
Sec. 1467.082. ESTABLISHMENT AND ADMINISTRATION OF |
|
ARBITRATION PROGRAM. (a) The commissioner shall establish and |
|
administer an arbitration program to resolve disputes over |
|
out-of-network provider charges in accordance with this |
|
subchapter. |
|
(b) The commissioner: |
|
(1) shall adopt rules, forms, and procedures necessary |
|
for the implementation and administration of the arbitration |
|
program, including the establishment of a portal on the |
|
department's Internet website through which a request for |
|
arbitration under Section 1467.084 may be submitted; and |
|
(2) shall maintain a list of qualified arbitrators for |
|
the program. |
|
Sec. 1467.083. ISSUE TO BE ADDRESSED; BASIS FOR |
|
DETERMINATION. (a) The only issue that an arbitrator may |
|
determine under this subchapter is the reasonable amount for the |
|
health care or medical services or supplies provided to the |
|
enrollee by an out-of-network provider. |
|
(b) The determination must take into account: |
|
(1) whether there is a gross disparity between the fee |
|
billed by the out-of-network provider and: |
|
(A) fees paid to the out-of-network provider for |
|
the same services or supplies rendered by the provider to other |
|
enrollees for which the provider is an out-of-network provider; and |
|
(B) fees paid by the health benefit plan issuer |
|
to reimburse similarly qualified out-of-network providers for the |
|
same services or supplies in the same region; |
|
(2) the level of training, education, and experience |
|
of the out-of-network provider; |
|
(3) the out-of-network provider's usual billed charge |
|
for comparable services or supplies with regard to other enrollees |
|
for which the provider is an out-of-network provider; |
|
(4) the circumstances and complexity of the enrollee's |
|
particular case, including the time and place of the provision of |
|
the service or supply; |
|
(5) individual enrollee characteristics; |
|
(6) the 80th percentile of all billed charges for the |
|
service or supply performed by a health care provider in the same or |
|
similar specialty and provided in the same geographical area as |
|
reported in a benchmarking database described by Section 1467.006; |
|
(7) the 50th percentile of rates for the service or |
|
supply paid to participating providers in the same or similar |
|
specialty and provided in the same geographical area as reported in |
|
a benchmarking database described by Section 1467.006; |
|
(8) historical rates paid to participating providers; |
|
and |
|
(9) historical data for the percentiles described by |
|
Subdivisions (6) and (7). |
|
Sec. 1467.084. AVAILABILITY OF MANDATORY ARBITRATION. (a) |
|
Not later than the 90th day after the date an out-of-network |
|
provider receives the initial payment for a health care or medical |
|
service or supply, the out-of-network provider or the health |
|
benefit plan issuer or administrator may request arbitration of a |
|
settlement of an out-of-network health benefit claim through a |
|
portal on the department's Internet website if: |
|
(1) there is a charge billed by the provider and unpaid |
|
by the issuer or administrator after copayments, deductibles, and |
|
coinsurance for which an enrollee may not be billed; and |
|
(2) the health benefit claim is for: |
|
(A) emergency care; |
|
(B) a health care or medical service or supply |
|
provided by a facility-based provider in a facility that is a |
|
participating provider; |
|
(C) an out-of-network laboratory service; or |
|
(D) an out-of-network diagnostic imaging |
|
service. |
|
(b) If a person requests arbitration under this subchapter, |
|
the out-of-network provider or the provider's representative, and |
|
the health benefit plan issuer or the administrator, as |
|
appropriate, shall participate in the arbitration. |
|
(c) The person who requests the arbitration shall provide |
|
written notice on the date the arbitration is requested in the form |
|
and manner prescribed by commissioner rule to: |
|
(1) the department; and |
|
(2) each other party. |
|
(d) In an effort to settle the claim before arbitration, all |
|
parties must participate in an informal settlement teleconference |
|
not later than the 30th day after the date on which the arbitration |
|
is requested. A health benefit plan issuer or administrator, as |
|
applicable, shall make a reasonable effort to arrange the |
|
teleconference. |
|
(e) The commissioner shall adopt rules providing |
|
requirements for submitting arbitration in one proceeding. The |
|
rules must provide that: |
|
(1) a claim for a billed charge of $1,500 or more may |
|
not be combined with another claim; |
|
(2) the total amount in controversy for multiple |
|
claims in one arbitration may not exceed $5,000; and |
|
(3) the multiple claims in one arbitration must be |
|
limited to the same out-of-network provider. |
|
Sec. 1467.085. EFFECT OF ARBITRATION AND APPLICABILITY OF |
|
OTHER LAW. (a) Notwithstanding Section 1467.004, an |
|
out-of-network provider, health benefit plan issuer, or |
|
administrator may not file suit for an out-of-network claim subject |
|
to this chapter until the conclusion of the arbitration on the issue |
|
of the amount to be paid in the out-of-network claim dispute. |
|
(b) An arbitration conducted under this subchapter is not |
|
subject to Title 7, Civil Practice and Remedies Code. |
|
Sec. 1467.086. SELECTION AND APPROVAL OF ARBITRATOR. |
|
(a) If the parties do not select an arbitrator by mutual agreement |
|
on or before the 30th day after the date the arbitration is |
|
requested, the party requesting the arbitration shall notify the |
|
commissioner, and the commissioner shall select an arbitrator from |
|
the commissioner's list of approved arbitrators. |
|
(b) In selecting an arbitrator under this section, the |
|
commissioner shall give preference to an arbitrator who is |
|
knowledgeable and experienced in applicable principles of contract |
|
and insurance law and the health care industry generally. |
|
(c) In approving an individual as an arbitrator, the |
|
commissioner shall ensure that the individual does not have a |
|
conflict of interest that would adversely impact the individual's |
|
independence and impartiality in rendering a decision in an |
|
arbitration. A conflict of interest includes current or recent |
|
ownership or employment of the individual or a close family member |
|
in a health benefit plan issuer or out-of-network provider that may |
|
be involved in the arbitration. |
|
(d) The commissioner shall immediately terminate the |
|
approval of an arbitrator who no longer meets the requirements |
|
under this subchapter and rules adopted under this subchapter to |
|
serve as an arbitrator. |
|
Sec. 1467.087. PROCEDURES. (a) The arbitrator shall set a |
|
date for submission of all information to be considered by the |
|
arbitrator. |
|
(b) A party may not engage in discovery in connection with |
|
the arbitration. |
|
(c) On agreement of all parties, any deadline under this |
|
subchapter may be extended. |
|
(d) Unless otherwise agreed to by the parties, an arbitrator |
|
may not determine whether a health benefit plan covers a particular |
|
health care or medical service or supply. |
|
(e) The parties shall evenly split and pay the arbitrator's |
|
fees and expenses. |
|
Sec. 1467.088. DECISION. (a) Not later than the 75th day |
|
after the date the arbitration is requested, an arbitrator shall |
|
provide the parties with a written decision in which the |
|
arbitrator: |
|
(1) determines whether the billed charge or the |
|
initial payment made by the health benefit plan issuer or |
|
administrator is the closest to the reasonable amount for the |
|
services or supplies determined in accordance with Section |
|
1467.083(b), provided that if the out-of-network provider elects to |
|
participate in the issuer's or administrator's internal appeal |
|
process before arbitration: |
|
(A) the provider may revise the billed charge to |
|
correct a billing error before the completion of the appeal |
|
process; and |
|
(B) the health benefit plan issuer or |
|
administrator may increase the initial payment under the appeal |
|
process; and |
|
(2) selects the billed charge or initial payment |
|
described by Subdivision (1) as the binding award amount. |
|
(b) An arbitrator may not modify the binding award amount |
|
selected under Subsection (a). |
|
(c) An arbitrator shall provide written notice in the form |
|
and manner prescribed by commissioner rule of the reasonable amount |
|
for the services or supplies and the binding award amount. If the |
|
parties settle before a decision, the parties shall provide written |
|
notice in the form and manner prescribed by commissioner rule of the |
|
amount of the settlement. The department shall maintain a record of |
|
notices provided under this subsection. |
|
Sec. 1467.089. EFFECT OF DECISION. (a) An arbitrator's |
|
decision under Section 1467.088 is binding. |
|
(b) Not later than the 45th day after the date of an |
|
arbitrator's decision under Section 1467.088, a party not satisfied |
|
with the decision may file an action to determine the payment due to |
|
an out-of-network provider. |
|
(c) In an action filed under Subsection (b), the court shall |
|
determine whether the arbitrator's decision is proper based on a |
|
substantial evidence standard of review. |
|
(d) Not later than the 10th day after the date of an |
|
arbitrator's decision under Section 1467.088 or a court's |
|
determination in an action filed under Subsection (b), a health |
|
benefit plan issuer or administrator shall pay to an out-of-network |
|
provider any additional amount necessary to satisfy the binding |
|
award or the court's determination, as applicable. |
|
SECTION 2.16. Subchapter C, Chapter 1467, Insurance Code, |
|
is amended to read as follows: |
|
SUBCHAPTER C. BAD FAITH PARTICIPATION [MEDIATION] |
|
Sec. 1467.101. BAD FAITH. (a) The following conduct |
|
constitutes bad faith participation [mediation] for purposes of |
|
this chapter: |
|
(1) failing to participate in the informal settlement |
|
teleconference under Section 1467.084(d) or an arbitration or |
|
mediation under this chapter; |
|
(2) failing to provide information the arbitrator or |
|
mediator believes is necessary to facilitate a decision or [an] |
|
agreement; or |
|
(3) failing to designate a representative |
|
participating in the arbitration or mediation with full authority |
|
to enter into any [mediated] agreement. |
|
(b) Failure to reach an agreement under Subchapter B is not |
|
conclusive proof of bad faith participation [mediation]. |
|
Sec. 1467.102. PENALTIES. (a) Bad faith participation or |
|
otherwise failing to comply with Subchapter B-1 [mediation, by a
|
|
party other than the enrollee,] is grounds for imposition of an |
|
administrative penalty by the regulatory agency that issued a |
|
license or certificate of authority to the party who committed the |
|
violation. |
|
(b) Except for good cause shown, on a report of a mediator |
|
and appropriate proof of bad faith participation under Subchapter B |
|
[mediation], the regulatory agency that issued the license or |
|
certificate of authority shall impose an administrative penalty. |
|
SECTION 2.17. Sections 1467.151(a), (b), and (c), Insurance |
|
Code, are amended to read as follows: |
|
(a) The commissioner and the Texas Medical Board or other |
|
regulatory agency, as appropriate, shall adopt rules regulating the |
|
investigation and review of a complaint filed that relates to the |
|
settlement of an out-of-network health benefit claim that is |
|
subject to this chapter. The rules adopted under this section must: |
|
(1) distinguish among complaints for out-of-network |
|
coverage or payment and give priority to investigating allegations |
|
of delayed health care or medical care; |
|
(2) develop a form for filing a complaint [and
|
|
establish an outreach effort to inform enrollees of the
|
|
availability of the claims dispute resolution process under this
|
|
chapter]; and |
|
(3) ensure that a complaint is not dismissed without |
|
appropriate consideration[;
|
|
[(4)
ensure that enrollees are informed of the
|
|
availability of mandatory mediation; and
|
|
[(5)
require the administrator to include a notice of
|
|
the claims dispute resolution process available under this chapter
|
|
with the explanation of benefits sent to an enrollee]. |
|
(b) The department and the Texas Medical Board or other |
|
appropriate regulatory agency shall maintain information[:
|
|
[(1)] on each complaint filed that concerns a claim, |
|
arbitration, or mediation subject to this chapter[; and
|
|
[(2)
related to a claim that is the basis of an
|
|
enrollee complaint], including: |
|
(1) [(A)] the type of services or supplies that gave |
|
rise to the dispute; |
|
(2) [(B)] the type and specialty, if any, of the |
|
out-of-network [facility-based] provider [or emergency care
|
|
provider] who provided the out-of-network service or supply; |
|
(3) [(C)] the county and metropolitan area in which |
|
the health care or medical service or supply was provided; |
|
(4) [(D)] whether the health care or medical service |
|
or supply was for emergency care; and |
|
(5) [(E)] any other information about: |
|
(A) [(i)] the health benefit plan issuer |
|
[insurer] or administrator that the commissioner by rule requires; |
|
or |
|
(B) [(ii)] the out-of-network [facility-based] |
|
provider [or emergency care provider] that the Texas Medical Board |
|
or other appropriate regulatory agency by rule requires. |
|
(c) The information collected and maintained [by the
|
|
department and the Texas Medical Board and other appropriate
|
|
regulatory agencies] under Subsection (b) [(b)(2)] is public |
|
information as defined by Section 552.002, Government Code, and may |
|
not include personally identifiable information or health care or |
|
medical information. |
|
ARTICLE 3. CONFORMING AMENDMENTS |
|
SECTION 3.01. Section 1456.001(6), Insurance Code, is |
|
amended to read as follows: |
|
(6) "Provider network" means a health benefit plan |
|
under which health care services are provided to enrollees through |
|
contracts with health care providers and that requires those |
|
enrollees to use health care providers participating in the plan |
|
and procedures covered by the plan. [The term includes a network
|
|
operated by:
|
|
[(A) a health maintenance organization;
|
|
[(B) a preferred provider benefit plan issuer; or
|
|
[(C)
another entity that issues a health benefit
|
|
plan, including an insurance company.] |
|
SECTION 3.02. Sections 1456.002(a) and (c), Insurance Code, |
|
are amended to read as follows: |
|
(a) This chapter applies to any health benefit plan that: |
|
(1) provides benefits for medical or surgical expenses |
|
incurred as a result of a health condition, accident, or sickness, |
|
including an individual, group, blanket, or franchise insurance |
|
policy or insurance agreement, a group hospital service contract, |
|
or an individual or group evidence of coverage that is offered by: |
|
(A) an insurance company; |
|
(B) a group hospital service corporation |
|
operating under Chapter 842; |
|
(C) a fraternal benefit society operating under |
|
Chapter 885; |
|
(D) a stipulated premium company operating under |
|
Chapter 884; |
|
(E) [a health maintenance organization operating
|
|
under Chapter 843;
|
|
[(F)] a multiple employer welfare arrangement |
|
that holds a certificate of authority under Chapter 846; |
|
(F) [(G)] an approved nonprofit health |
|
corporation that holds a certificate of authority under Chapter |
|
844; or |
|
(G) [(H)] an entity not authorized under this |
|
code or another insurance law of this state that contracts directly |
|
for health care services on a risk-sharing basis, including a |
|
capitation basis; or |
|
(2) provides health and accident coverage through a |
|
risk pool created under Chapter 172, Local Government Code, |
|
notwithstanding Section 172.014, Local Government Code, or any |
|
other law. |
|
(c) This chapter does not apply to: |
|
(1) Medicaid managed care programs operated under |
|
Chapter 533, Government Code; |
|
(2) Medicaid programs operated under Chapter 32, Human |
|
Resources Code; [or] |
|
(3) the state child health plan operated under Chapter |
|
62 or 63, Health and Safety Code; or |
|
(4) a health benefit plan subject to Section |
|
1466.0053. |
|
SECTION 3.03. The following provisions of the Insurance |
|
Code are repealed: |
|
(1) Section 1456.004(c); |
|
(2) Section 1467.001(2); |
|
(3) Sections 1467.051(c) and (d); |
|
(4) Section 1467.0511; |
|
(5) Sections 1467.053(b) and (c); |
|
(6) Sections 1467.054(b), (c), (f), and (g); |
|
(7) Sections 1467.055(d) and (h); |
|
(8) Section 1467.057; |
|
(9) Section 1467.058; |
|
(10) Section 1467.059; and |
|
(11) Section 1467.151(d). |
|
ARTICLE 4. STUDY |
|
SECTION 4.01. Subchapter A, Chapter 38, Insurance Code, is |
|
amended by adding Section 38.004 to read as follows: |
|
Sec. 38.004. BALANCE BILLING PROHIBITION REPORT. (a) The |
|
department shall, each biennium, conduct a study on the impacts of |
|
S.B. No. 1264, Acts of the 86th Legislature, Regular Session, 2019, |
|
on Texas consumers and health coverage in this state, including: |
|
(1) trends in billed amounts for health care or |
|
medical services or supplies, especially emergency services, |
|
laboratory services, diagnostic imaging services, and |
|
facility-based services; |
|
(2) comparison of the total amount spent on |
|
out-of-network emergency services, laboratory services, diagnostic |
|
imaging services, and facility-based services by calendar year and |
|
provider type or physician specialty; |
|
(3) trends and changes in network participation by |
|
providers of emergency services, laboratory services, diagnostic |
|
imaging services, and facility-based services by provider type or |
|
physician specialty, including whether any terminations were |
|
initiated by a health benefit plan issuer, administrator, or |
|
provider; |
|
(4) trends and changes in the amounts paid to |
|
participating providers; |
|
(5) the number of complaints, completed |
|
investigations, and disciplinary sanctions for billing by |
|
providers of emergency services, laboratory services, diagnostic |
|
imaging services, or facility-based services of enrollees for |
|
amounts greater than the enrollee's responsibility under an |
|
applicable health benefit plan, including an applicable copayment, |
|
coinsurance, or deductible; |
|
(6) trends in amounts paid to out-of-network |
|
providers; |
|
(7) trends in the usual and customary rate for health |
|
care or medical services or supplies, especially emergency |
|
services, laboratory services, diagnostic imaging services, and |
|
facility-based services; and |
|
(8) the effectiveness of the claim dispute resolution |
|
process under Chapter 1467. |
|
(b) In conducting the study described by Subsection (a), the |
|
department shall collect settlement data and verdicts or |
|
arbitration awards, as applicable, from parties to mediation or |
|
arbitration under Chapter 1467. |
|
(c) The department: |
|
(1) shall collect data quarterly from a health benefit |
|
plan issuer or administrator subject to Chapter 1467 to conduct the |
|
study required by this section; and |
|
(2) may utilize any reliable external resource or |
|
entity to acquire information reasonably necessary to prepare the |
|
report required by Subsection (d). |
|
(d) Not later than December 1 of each even-numbered year, |
|
the department shall prepare and submit a written report on the |
|
results of the study under this section, including the department's |
|
findings, to the legislature. |
|
ARTICLE 5. TRANSITION AND EFFECTIVE DATE |
|
SECTION 5.01. The changes in law made by this Act apply only |
|
to a health care or medical service or supply provided on or after |
|
January 1, 2020. A health care or medical service or supply |
|
provided before January 1, 2020, is governed by the law in effect |
|
immediately before the effective date of this Act, and that law is |
|
continued in effect for that purpose. |
|
SECTION 5.02. The Texas Department of Insurance, the |
|
Employees Retirement System of Texas, the Teacher Retirement System |
|
of Texas, and any other state agency subject to this Act are |
|
required to implement a provision of this Act only if the |
|
legislature appropriates money specifically for that purpose. If |
|
the legislature does not appropriate money specifically for that |
|
purpose, those agencies may, but are not required to, implement a |
|
provision of this Act using other appropriations available for that |
|
purpose. |
|
SECTION 5.03. This Act takes effect September 1, 2019. |