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A BILL TO BE ENTITLED
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AN ACT
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relating to preferred provider benefit plan reimbursement of |
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certain services provided by out-of-network providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1301.069, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND |
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HEALTH CARE PROVIDERS. (a) The provisions of this chapter relating |
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to prompt payment by an insurer of a physician or health care |
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provider and to verification of medical care or health care |
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services apply to a physician or provider who: |
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(1) is not a preferred provider included in the |
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preferred provider network; and |
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(2) provides to an insured: |
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(A) care related to an emergency or its attendant |
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episode of care as required by state or federal law; or |
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(B) specialty or other medical care or health |
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care services at the request of the insurer or a preferred provider |
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because the services are not reasonably available from a preferred |
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provider who is included in the preferred delivery network. |
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(b) In reimbursing a physician or health care provider who |
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is not a preferred provider included in the preferred provider |
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network for services provided to an insured under Subsection |
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(a)(2)(B) after the physician or provider received a waiver from |
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the insurer to provide the services to the insured, the insurer: |
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(1) may not base the reimbursement to the physician or |
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provider on the insurer's usual and customary rate; and |
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(2) shall reimburse the physician or provider at the |
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physician's or provider's specialty rate in accordance with the |
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physician's or provider's expertise, experience, and rate history. |
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SECTION 2. The changes in law made by this Act apply only to |
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a health benefit plan delivered, issued for delivery, or renewed on |
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or after June 1, 2022. |
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SECTION 3. This Act takes effect on the 91st day after the |
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last day of the legislative session. |