|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
|
relating to consumer protections against certain medical and health |
|
care billing by certain out-of-network providers; authorizing a |
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fee. |
|
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 G, Title 5, Insurance Code, is |
|
amended by adding Chapter 752 to read as follows: |
|
CHAPTER 752. ENFORCEMENT OF BALANCE BILLING PROHIBITIONS |
|
Sec. 752.0001. INJUNCTION FOR BALANCE BILLING. (a) If the |
|
attorney general believes that an individual or entity is violating |
|
a law prohibiting the individual or entity from billing an insured, |
|
participant, or enrollee in an amount greater than the insured's, |
|
participant's, or enrollee's responsibility under the insured's, |
|
participant's, or enrollee's managed care plan, 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. 752.0002. 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 may take disciplinary action against the physician, |
|
practitioner, facility, or provider if the physician, |
|
practitioner, facility, or provider violates a law prohibiting the |
|
physician, practitioner, facility, or provider from billing an |
|
insured, participant, or enrollee in an amount greater than the |
|
insured's, participant's, or enrollee's responsibility under the |
|
insured's, participant's, or enrollee's managed care plan. |
|
(b) A regulatory agency described by Subsection (a) may |
|
adopt rules as necessary to implement this section. |
|
SECTION 1.02. Subchapter A, Chapter 1271, Insurance Code, |
|
is amended by adding Section 1271.008 to read as follows: |
|
Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. A |
|
health maintenance organization shall provide written notice of the |
|
billing prohibitions provided by Sections 1271.155, 1271.157, and |
|
1271.158 in each explanation of benefits provided to an enrollee or |
|
a physician or provider in connection with a health care service |
|
that is subject to one of those sections. |
|
SECTION 1.03. Section 1271.155, Insurance Code, is amended |
|
by adding Subsection (f) to read as follows: |
|
(f) For emergency care subject to this section, a |
|
non-network physician or provider may not bill an enrollee in, and |
|
the enrollee does not have financial responsibility for, an amount |
|
greater than the enrollee's responsibility under the enrollee's |
|
health care plan, including an applicable copayment, coinsurance, |
|
or deductible. |
|
SECTION 1.04. Subchapter D, Chapter 1271, Insurance Code, |
|
is amended by adding Sections 1271.157 and 1271.158 to read as |
|
follows: |
|
Sec. 1271.157. NON-NETWORK FACILITY-BASED PROVIDERS. |
|
(a) In this section, "facility-based provider" means a physician |
|
or provider who provides health care services to patients of a |
|
health care facility. |
|
(b) A health maintenance organization shall pay for a health |
|
care service performed for an enrollee by a non-network physician |
|
or provider who is a facility-based provider 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 network provider. |
|
(c) A non-network facility-based provider may not bill an |
|
enrollee receiving a health care service described by Subsection |
|
(b) in, and the enrollee does not have financial responsibility |
|
for, an amount greater than the enrollee's responsibility under the |
|
enrollee's health care plan, including an applicable copayment, |
|
coinsurance, or deductible. |
|
Sec. 1271.158. NON-NETWORK DIAGNOSTIC IMAGING PROVIDER OR |
|
LABORATORY. (a) In this section, "diagnostic imaging provider" |
|
and "laboratory" have the meanings assigned by Section 1467.001. |
|
(b) A health maintenance organization shall pay for a health |
|
care service performed by a non-network diagnostic imaging provider |
|
or laboratory at the usual and customary rate or at an agreed rate |
|
if the provider or laboratory performed the service in connection |
|
with a health care service performed by a network physician or |
|
provider. |
|
(c) A non-network diagnostic imaging provider or laboratory |
|
may not bill an enrollee receiving a health care service described |
|
by Subsection (b) in, and the enrollee does not have financial |
|
responsibility for, an amount greater than the enrollee's |
|
responsibility under the enrollee's health care plan, including an |
|
applicable copayment, coinsurance, or deductible. |
|
SECTION 1.05. Section 1301.0053, Insurance Code, is amended |
|
to read as follows: |
|
Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS: |
|
EMERGENCY CARE. (a) If an out-of-network [a nonpreferred] |
|
provider provides emergency care as defined by Section 1301.155 to |
|
an enrollee in an exclusive provider benefit plan, the issuer of the |
|
plan shall reimburse the out-of-network [nonpreferred] provider at |
|
the usual and customary rate or at a rate agreed to by the issuer and |
|
the out-of-network [nonpreferred] provider for the provision of the |
|
services. |
|
(b) For emergency care subject to this section, an |
|
out-of-network provider may not bill an insured in, and the insured |
|
does not have financial responsibility for, an amount greater than |
|
the insured's responsibility under the insured's exclusive provider |
|
benefit plan, including an applicable copayment, coinsurance, or |
|
deductible. |
|
SECTION 1.06. Subchapter A, Chapter 1301, Insurance Code, |
|
is amended by adding Section 1301.010 to read as follows: |
|
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. An |
|
insurer shall provide written notice of the billing prohibitions |
|
provided by Sections 1301.0053, 1301.155, 1301.164, and 1301.165 in |
|
each explanation of benefits provided to an insured or a physician |
|
or health care provider in connection with a medical care or health |
|
care service that is subject to one of those sections. |
|
SECTION 1.07. Section 1301.155, Insurance Code, is amended |
|
by amending Subsection (b) and adding Subsection (c) to read as |
|
follows: |
|
(b) If an insured cannot reasonably reach a preferred |
|
provider, an insurer shall provide reimbursement for the following |
|
emergency care services at the usual and customary rate or at an |
|
agreed rate and at the preferred level of benefits until the insured |
|
can reasonably be expected to transfer to a preferred provider: |
|
(1) a medical screening examination or other |
|
evaluation required by state or federal law to be provided in the |
|
emergency facility of a hospital that is necessary to determine |
|
whether a medical emergency condition exists; |
|
(2) necessary emergency care services, including the |
|
treatment and stabilization of an emergency medical condition; and |
|
(3) services originating in a hospital emergency |
|
facility or freestanding emergency medical care facility following |
|
treatment or stabilization of an emergency medical condition. |
|
(c) For emergency care subject to this section, an |
|
out-of-network provider may not bill an insured in, and the insured |
|
does not have financial responsibility for, an amount greater than |
|
the insured's responsibility under the insured's preferred provider |
|
benefit plan, including an applicable copayment, coinsurance, or |
|
deductible. |
|
SECTION 1.08. Subchapter D, Chapter 1301, Insurance Code, |
|
is amended by adding Sections 1301.164 and 1301.165 to read as |
|
follows: |
|
Sec. 1301.164. OUT-OF-NETWORK FACILITY-BASED PROVIDERS. |
|
(a) In this section, "facility-based provider" means a physician |
|
or health care provider who provides health care services to |
|
patients of a health care facility. |
|
(b) An insurer shall pay for a health care service performed |
|
for an insured by an out-of-network provider who is a |
|
facility-based provider 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 preferred provider. |
|
(c) An out-of-network provider who is a facility-based |
|
provider may not bill an insured receiving a health care service |
|
described by Subsection (b) in, and the insured does not have |
|
financial responsibility for, an amount greater than the insured's |
|
responsibility under the insured's preferred provider benefit |
|
plan, including an applicable copayment, coinsurance, or |
|
deductible. |
|
Sec. 1301.165. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER |
|
OR LABORATORY. (a) In this section, "diagnostic imaging provider" |
|
and "laboratory" have the meanings assigned by Section 1467.001. |
|
(b) An insurer shall pay for a medical care or health care |
|
service performed by an out-of-network provider who is a diagnostic |
|
imaging provider or laboratory at the usual and customary rate or at |
|
an agreed rate if the provider or laboratory performed the service |
|
in connection with a medical care or health care service performed |
|
by a preferred provider. |
|
(c) An out-of-network provider who is a diagnostic imaging |
|
provider or laboratory may not bill an insured receiving a medical |
|
care or health care service described by Subsection (b) in, and the |
|
insured does not have financial responsibility for, an amount |
|
greater than the insured's responsibility under the insured's |
|
preferred provider benefit plan, including an applicable |
|
copayment, coinsurance, or deductible. |
|
SECTION 1.09. Section 1551.003, Insurance Code, is amended |
|
by adding Subdivision (15) to read as follows: |
|
(15) "Usual and customary rate" means the relevant |
|
allowable amount as described by the applicable master benefit plan |
|
document or policy. |
|
SECTION 1.10. Subchapter A, Chapter 1551, Insurance Code, |
|
is amended by adding Section 1551.015 to read as follows: |
|
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. The |
|
administrator of a managed care plan provided under the group |
|
benefits program shall provide written notice of the billing |
|
prohibitions provided by Sections 1551.228, 1551.229, and 1551.230 |
|
in each explanation of benefits provided to a participant or a |
|
physician or health care provider in connection with a health care |
|
service that is subject to one of those sections. |
|
SECTION 1.11. Subchapter E, Chapter 1551, Insurance Code, |
|
is amended by adding Sections 1551.228, 1551.229, and 1551.230 to |
|
read as follows: |
|
Sec. 1551.228. EMERGENCY CARE COVERAGE. (a) In this |
|
section, "emergency care" has the meaning assigned by Section |
|
1301.155. |
|
(b) A managed care plan provided under the group benefits |
|
program must provide out-of-network emergency care coverage for |
|
participants in accordance with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for emergency care performed by an out-of-network provider |
|
at the usual and customary rate or at an agreed rate. |
|
(d) For emergency care subject to this section, an |
|
out-of-network provider may not bill a participant in, and the |
|
participant does not have financial responsibility for, an amount |
|
greater than the participant's responsibility under the |
|
participant's managed care plan, including an applicable |
|
copayment, coinsurance, or deductible. |
|
Sec. 1551.229. OUT-OF-NETWORK FACILITY-BASED PROVIDER |
|
COVERAGE. (a) In this section, "facility-based provider" means a |
|
physician or health care provider who provides health care services |
|
to patients of a health care facility. |
|
(b) A managed care plan provided under the group benefits |
|
program must provide out-of-network facility-based provider |
|
coverage for participants in accordance with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for a health care service performed for a participant by an |
|
out-of-network provider who is a facility-based provider 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. |
|
(d) An out-of-network provider who is a facility-based |
|
provider may not bill a participant receiving a health care service |
|
described by Subsection (c) in, and the participant does not have |
|
financial responsibility for, an amount greater than the |
|
participant's responsibility under the participant's managed care |
|
plan, including an applicable copayment, coinsurance, or |
|
deductible. |
|
Sec. 1551.230. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER |
|
OR LABORATORY. (a) In this section, "diagnostic imaging provider" |
|
and "laboratory" have the meanings assigned by Section 1467.001. |
|
(b) A managed care plan provided under the group benefits |
|
program must provide out-of-network diagnostic imaging provider |
|
and laboratory coverage for participants in accordance with this |
|
section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for a health care service performed for a participant by an |
|
out-of-network provider who is a diagnostic imaging provider or |
|
laboratory at the usual and customary rate or at an agreed rate if |
|
the provider or laboratory performed the service in connection with |
|
a health care service performed by a participating provider. |
|
(d) An out-of-network provider who is a diagnostic imaging |
|
provider or laboratory may not bill a participant receiving a |
|
health care service described by Subsection (c) in, and the |
|
participant does not have financial responsibility for, an amount |
|
greater than the participant's responsibility under the |
|
participant's managed care plan, including an applicable |
|
copayment, coinsurance, or deductible. |
|
SECTION 1.12. Section 1575.002, Insurance Code, is amended |
|
by adding Subdivision (8) to read as follows: |
|
(8) "Usual and customary rate" means the relevant |
|
allowable amount as described by the applicable master benefit plan |
|
document or policy. |
|
SECTION 1.13. Subchapter A, Chapter 1575, Insurance Code, |
|
is amended by adding Section 1575.009 to read as follows: |
|
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. The |
|
administrator of a managed care plan provided under the group |
|
program shall provide written notice of the billing prohibitions |
|
provided by Sections 1575.171, 1575.172, and 1575.173 in each |
|
explanation of benefits provided to an enrollee or a physician or |
|
health care provider in connection with a health care service that |
|
is subject to one of those sections. |
|
SECTION 1.14. Subchapter D, Chapter 1575, Insurance Code, |
|
is amended by adding Sections 1575.171, 1575.172, and 1575.173 to |
|
read as follows: |
|
Sec. 1575.171. EMERGENCY CARE COVERAGE. (a) In this |
|
section, "emergency care" has the meaning assigned by Section |
|
1301.155. |
|
(b) A managed care plan provided under the group program |
|
must provide out-of-network emergency care coverage in accordance |
|
with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for emergency care performed by an out-of-network provider |
|
at the usual and customary rate or at an agreed rate. |
|
(d) For emergency care subject to this section, an |
|
out-of-network provider may not bill an enrollee in, and the |
|
enrollee does not have financial responsibility for, an amount |
|
greater than the enrollee's responsibility under the enrollee's |
|
managed care plan, including an applicable copayment, coinsurance, |
|
or deductible. |
|
Sec. 1575.172. OUT-OF-NETWORK FACILITY-BASED PROVIDER |
|
COVERAGE. (a) In this section, "facility-based provider" means a |
|
physician or health care provider who provides health care services |
|
to patients of a health care facility. |
|
(b) A managed care plan provided under the group program |
|
must provide out-of-network facility-based provider coverage for |
|
enrollees in accordance with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for a health care service performed for an enrollee by an |
|
out-of-network provider who is a facility-based provider 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. |
|
(d) An out-of-network provider who is a facility-based |
|
provider may not bill an enrollee receiving a health care service |
|
described by Subsection (c) in, and the enrollee does not have |
|
financial responsibility for, an amount greater than the enrollee's |
|
responsibility under the enrollee's managed care plan, including an |
|
applicable copayment, coinsurance, or deductible. |
|
Sec. 1575.173. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER |
|
OR LABORATORY. (a) In this section, "diagnostic imaging provider" |
|
and "laboratory" have the meanings assigned by Section 1467.001. |
|
(b) A managed care plan provided under the group program |
|
must provide out-of-network diagnostic imaging provider and |
|
laboratory coverage for enrollees in accordance with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for a health care service performed for an enrollee by an |
|
out-of-network provider who is a diagnostic imaging provider or |
|
laboratory at the usual and customary rate or at an agreed rate if |
|
the provider or laboratory performed the service in connection with |
|
a health care service performed by a participating provider. |
|
(d) An out-of-network provider who is a diagnostic imaging |
|
provider or laboratory may not bill an enrollee receiving a health |
|
care service described by Subsection (c) in, and the enrollee does |
|
not have financial responsibility for, an amount greater than the |
|
enrollee's responsibility under the enrollee's managed care plan, |
|
including an applicable copayment, coinsurance, or deductible. |
|
SECTION 1.15. Section 1579.002, Insurance Code, is amended |
|
by adding Subdivision (8) to read as follows: |
|
(8) "Usual and customary rate" means the relevant |
|
allowable amount as described by the applicable master benefit plan |
|
document or policy. |
|
SECTION 1.16. Subchapter A, Chapter 1579, Insurance Code, |
|
is amended by adding Section 1579.009 to read as follows: |
|
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. The |
|
administrator of a managed care plan provided under this chapter |
|
shall provide written notice of the billing prohibitions provided |
|
by Sections 1579.109, 1579.110, and 1579.111 in each explanation of |
|
benefits provided to an enrollee or a physician or health care |
|
provider in connection with a health care service that is subject to |
|
one of those sections. |
|
SECTION 1.17. Subchapter C, Chapter 1579, Insurance Code, |
|
is amended by adding Sections 1579.109, 1579.110, and 1579.111 to |
|
read as follows: |
|
Sec. 1579.109. EMERGENCY CARE COVERAGE. (a) In this |
|
section, "emergency care" has the meaning assigned by Section |
|
1301.155. |
|
(b) A managed care plan provided under this chapter must |
|
provide out-of-network emergency care coverage in accordance with |
|
this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for emergency care performed by an out-of-network provider |
|
at the usual and customary rate or at an agreed rate. |
|
(d) For emergency care subject to this section, an |
|
out-of-network provider may not bill an enrollee in, and the |
|
enrollee does not have financial responsibility for, an amount |
|
greater than the enrollee's responsibility under the enrollee's |
|
managed care plan, including an applicable copayment, coinsurance, |
|
or deductible. |
|
Sec. 1579.110. OUT-OF-NETWORK FACILITY-BASED PROVIDER |
|
COVERAGE. (a) In this section, "facility-based provider" means a |
|
physician or health care provider who provides health care services |
|
to patients of a health care facility. |
|
(b) A managed care plan provided under this chapter must |
|
provide out-of-network facility-based provider coverage to |
|
enrollees in accordance with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for a health care service performed for an enrollee by an |
|
out-of-network provider who is a facility-based provider 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. |
|
(d) An out-of-network provider who is a facility-based |
|
provider may not bill an enrollee receiving a health care service |
|
described by Subsection (c) in, and the enrollee does not have |
|
financial responsibility for, an amount greater than the enrollee's |
|
responsibility under the enrollee's managed care plan, including an |
|
applicable copayment, coinsurance, or deductible. |
|
Sec. 1579.111. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER |
|
OR LABORATORY. (a) In this section, "diagnostic imaging provider" |
|
and "laboratory" have the meanings assigned by Section 1467.001. |
|
(b) A managed care plan provided under this chapter must |
|
provide out-of-network diagnostic imaging provider and laboratory |
|
coverage for enrollees in accordance with this section. |
|
(c) The coverage must require the administrator of the plan |
|
to pay for a health care service performed for an enrollee by an |
|
out-of-network provider who is a diagnostic imaging provider or |
|
laboratory at the usual and customary rate or at an agreed rate if |
|
the provider or laboratory performed the service in connection with |
|
a health care service performed by a participating provider. |
|
(d) An out-of-network provider who is a diagnostic imaging |
|
provider or laboratory may not bill an enrollee receiving a health |
|
care service described by Subsection (c) in, and the enrollee does |
|
not have financial responsibility for, an amount greater than the |
|
enrollee's responsibility under the enrollee's managed care plan, |
|
including an applicable copayment, coinsurance, or deductible. |
|
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), 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. |
|
(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" means an accredited facility in |
|
which a specimen taken from a human body is interpreted and |
|
pathological diagnoses are made. |
|
(6-a) "Out-of-network provider" means a diagnostic |
|
imaging provider, emergency care provider, facility-based |
|
provider, or laboratory 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 an arbitration [a mediation] 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 managed care [health
|
|
benefit] plan[, other than a health maintenance organization plan,] |
|
under Chapter 1551, 1575, or 1579. |
|
Sec. 1467.003. RULES. 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. |
|
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 amounts of all |
|
physicians or health care providers; and |
|
(2) the 50th percentile of rates paid to participating |
|
providers. |
|
(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 BINDING ARBITRATION [MEDIATION] |
|
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. ESTABLISHMENT AND ADMINISTRATION OF |
|
ARBITRATION PROGRAM. (a) The commissioner shall establish and |
|
administer an arbitration program to resolve disputes over |
|
out-of-network provider amounts 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; |
|
(2) may impose a fee on the parties participating in |
|
the program as necessary to cover the cost of implementation and |
|
administration of the arbitration program and to evenly split the |
|
costs of the arbitrator between the parties; and |
|
(3) shall maintain a list of qualified arbitrators for |
|
the program. |
|
Sec. 1467.0505. 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 amount |
|
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 amounts 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; |
|
and |
|
(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. |
|
SECTION 2.06. The heading to Section 1467.051, Insurance |
|
Code, is amended to read as follows: |
|
Sec. 1467.051. AVAILABILITY OF MANDATORY ARBITRATION |
|
[MEDIATION; EXCEPTION]. |
|
SECTION 2.07. Section 1467.051, Insurance Code, is amended |
|
by amending Subsections (a) and (b) and adding Subsections (e), |
|
(f), (g), and (h) to read as follows: |
|
(a) An out-of-network provider, health benefit plan issuer, |
|
or administrator [An enrollee] may request arbitration [mediation] |
|
of a settlement of an out-of-network health benefit claim 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[,
|
|
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) a health care or medical service or supply |
|
provided by a facility-based provider in a facility that is a |
|
participating [preferred] provider or that has a contract with the |
|
administrator; |
|
(C) an out-of-network laboratory service; or |
|
(D) an out-of-network diagnostic imaging |
|
service; and |
|
(3) the provider and the issuer or administrator have |
|
exhausted the issuer's or administrator's internal dispute |
|
resolution process. |
|
(b) If a person [Except as provided by Subsections (c) and
|
|
(d), if an enrollee] requests arbitration [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 arbitration [mediation]. |
|
(e) The person who requests the arbitration shall provide |
|
written notice on the date the arbitration is requested to: |
|
(1) the department in the form and manner prescribed |
|
by commissioner rule; and |
|
(2) each other party. |
|
(f) Not later than the 15th day after the date a party |
|
receives notice of a request under Subsection (e), the party shall |
|
provide written notice to the person requesting the arbitration |
|
that the party received notice of the arbitration request. |
|
(g) The department shall post on the department's Internet |
|
website a mailing address and e-mail address to receive notice |
|
under this section. If a party has not previously participated in |
|
an arbitration under this subchapter, the party shall provide the |
|
department with a mailing address and e-mail address to receive |
|
notice under this section. |
|
(h) 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 person |
|
requesting the arbitration receives notice under Subsection (f) |
|
from all other parties. |
|
SECTION 2.08. Subchapter B, Chapter 1467, Insurance Code, |
|
is amended by adding Section 1467.0515 to read as follows: |
|
Sec. 1467.0515. EFFECT OF ARBITRATION AND APPLICABILITY OF |
|
OTHER LAW. (a) Each party to an arbitration under this subchapter |
|
waives a right to pursue any other legal action 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. |
|
SECTION 2.09. Subchapter B, Chapter 1467, Insurance Code, |
|
is amended by adding Sections 1467.0535, 1467.0545, 1467.0555, and |
|
1467.0565 to read as follows: |
|
Sec. 1467.0535. 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 |
|
initiated, the commissioner shall select an arbitrator from the |
|
commissioner's list of qualified arbitrators. |
|
(b) To be eligible to serve as an arbitrator, an individual |
|
must be knowledgeable and experienced in applicable principles of |
|
contract and insurance law and the health care industry generally |
|
and be approved by the commissioner. |
|
(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. 1467.0545. 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, a deadline under this |
|
subchapter may be extended. |
|
Sec. 1467.0555. DECISION. (a) Not later than the 10th day |
|
after the deadline for submission of information, an arbitrator |
|
shall provide the parties with a written decision in which the |
|
arbitrator: |
|
(1) determines whether the billed amount 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 |
|
1467.0505(b); and |
|
(2) selects the amount described by Subdivision (1) as |
|
the binding award amount. |
|
(b) An arbitrator may not modify the binding award amount |
|
selected under Subsection (a). |
|
Sec. 1467.0565. EFFECT OF DECISION. (a) An arbitrator's |
|
decision under Section 1467.0555 is binding. |
|
(b) Not later than the 90th day after the date of an |
|
arbitrator's decision under Section 1467.0555, a party not |
|
satisfied with the decision may file an action to determine the |
|
payment due to an out-of-network provider. |
|
(c) An action filed under Subsection (b) is by trial de |
|
novo. The arbitrator's decision under Section 1467.0555 is |
|
admissible to demonstrate the arbitrator's determination of the |
|
reasonable amount for the services or supplies provided by the |
|
out-of-network provider. |
|
SECTION 2.10. 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 1467.051(h) or arbitration under |
|
Subchapter B [mediation]; |
|
(2) failing to provide information the arbitrator |
|
[mediator] believes is necessary to facilitate a decision [an
|
|
agreement]; [or] |
|
(3) failing to designate a representative |
|
participating in the arbitration [mediation] with full authority to |
|
enter into any [mediated] agreement; or |
|
(4) failing to appear for the arbitration. |
|
[(b)
Failure to reach an agreement is not conclusive proof
|
|
of bad faith mediation.] |
|
Sec. 1467.102. PENALTIES. [(a)] Bad faith participation |
|
or otherwise failing to comply with this chapter [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 mediation, the regulatory agency
|
|
that issued the license or certificate of authority shall impose an
|
|
administrative penalty.] |
|
SECTION 2.11. 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 or |
|
arbitration [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 1271.157, |
|
1301.164, 1551.229, 1575.172, or 1579.110. |
|
SECTION 3.03. The following provisions of the Insurance |
|
Code are repealed: |
|
(1) Section 1456.004(c); |
|
(2) Sections 1467.001(2), (5), and (6); |
|
(3) Sections 1467.051(c) and (d); |
|
(4) Section 1467.0511; |
|
(5) Section 1467.052; |
|
(6) Section 1467.053; |
|
(7) Section 1467.054; |
|
(8) Section 1467.055; |
|
(9) Section 1467.056; |
|
(10) Section 1467.057; |
|
(11) Section 1467.058; |
|
(12) Section 1467.059; |
|
(13) Section 1467.060; and |
|
(14) 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 charges for health care services, |
|
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) 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 insureds, |
|
enrollees, or plan participants for amounts greater than the |
|
insured's, enrollee's, or participant's responsibility under an |
|
applicable managed care plan, including an applicable copayment, |
|
coinsurance, or deductible; and |
|
(5) trends in amounts paid to out-of-network |
|
providers. |
|
(b) In conducting the study described by Subsection (a), the |
|
department shall collect settlement data and verdicts or |
|
arbitration awards from parties to arbitration under Chapter 1467. |
|
(c) The department may: |
|
(1) collect data as necessary from a health benefit |
|
plan issuer or administrator subject to Chapter 1467 to conduct the |
|
study required by this section; and |
|
(2) 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 |
|
the effective date of this Act. A health care or medical service or |
|
supply provided before the effective date of this Act 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. |
|
|
|
* * * * * |