87S30841 JES-D

By: Jetton H.B. No. 174

A BILL TO BE ENTITLED

AN ACT

relating to preferred provider benefit plan reimbursement of certain services provided by out-of-network providers.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 1301.069, Insurance Code, is amended to read as follows:

Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND HEALTH CARE PROVIDERS. (a) The provisions of this chapter relating to prompt payment by an insurer of a physician or health care provider and to verification of medical care or health care services apply to a physician or provider who:

(1) is not a preferred provider included in the preferred provider network; and

(2) provides to an insured:

(A) care related to an emergency or its attendant episode of care as required by state or federal law; or

(B) specialty or other medical care or health care services at the request of the insurer or a preferred provider because the services are not reasonably available from a preferred provider who is included in the preferred delivery network.

(b) In reimbursing a physician or health care provider who is not a preferred provider included in the preferred provider network for services provided to an insured under Subsection (a)(2)(B) after the physician or provider received a waiver from the insurer to provide the services to the insured, the insurer:

(1) may not base the reimbursement to the physician or provider on the insurer's usual and customary rate; and

(2) shall reimburse the physician or provider at the physician's or provider's specialty rate in accordance with the physician's or provider's expertise, experience, and rate history.

SECTION 2. The changes in law made by this Act apply only to a health benefit plan delivered, issued for delivery, or renewed on or after June 1, 2022.

SECTION 3. This Act takes effect on the 91st day after the last day of the legislative session.