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A BILL TO BE ENTITLED
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AN ACT
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relating to provider reimbursements and enrollee cost-sharing |
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payments for services provided under a managed care plan by certain |
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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. Subchapter A, Chapter 533, Government Code, is |
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amended by adding Section 533.01316 to read as follows: |
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Sec. 533.01316. REIMBURSEMENT FOR CERTAIN OUT-OF-NETWORK |
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SERVICES. (a) This section applies only to a Medicaid service |
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provided to a recipient by a provider who, on the date the recipient |
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was initially enrolled or was reenrolled for a subsequent |
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enrollment period in a managed care plan offered by a Medicaid |
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managed care organization, was included in the organization's |
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provider network directory but is no longer in the provider network |
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on the date the service is provided to the recipient. |
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(b) Except as provided by Subsection (c), the commission |
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shall require a Medicaid managed care organization to reimburse a |
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provider of a service to which this section applies at the |
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organization's in-network reimbursement rate if the service is |
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provided to the recipient during the enrollment period that began |
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on the date described by Subsection (a). |
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(c) Subsection (b) does not apply if the provider is no |
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longer in the Medicaid managed care organization's provider network |
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on the date the service is provided because: |
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(1) the provider's license to provide health care |
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services is expired, suspended, or revoked; or |
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(2) the provider unilaterally terminated |
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participation in the network for a reason other than the |
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organization's default or breach of the contract between the |
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provider and the organization. |
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SECTION 2. Subchapter K, Chapter 1451, Insurance Code, is |
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amended by adding Section 1451.506 to read as follows: |
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Sec. 1451.506. PAYMENT OR REIMBURSEMENT FOR CERTAIN |
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OUT-OF-NETWORK HEALTH CARE SERVICES. (a) If a provider is included |
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in a health benefit plan issuer's provider directory on the date an |
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enrollee enrolls in the plan, the issuer shall, until the |
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expiration of the health benefit plan contract year or other |
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contract period during which the enrollee enrolled: |
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(1) pay or reimburse the provider the in-network rate |
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for services provided to the enrollee; and |
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(2) ensure that the enrollee is not responsible for a |
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cost-sharing amount that is higher than the amount the enrollee |
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would have been required to pay if the service had been provided by |
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an in-network provider. |
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(b) This section does not apply if the provider is no longer |
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in the health benefit plan issuer's provider network on the date the |
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service is provided because: |
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(1) the provider's license to provide health care |
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services is expired, suspended, or revoked; or |
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(2) the provider unilaterally terminated |
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participation in the network for a reason other than the issuer's |
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default or breach of the contract between the provider and the |
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issuer. |
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SECTION 3. (a) The Health and Human Services Commission |
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shall, in a contract between the commission and a managed care |
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organization under Chapter 533, Government Code, that is entered |
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into or renewed on or after the effective date of this Act, require |
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that the managed care organization comply with Section 533.01316, |
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Government Code, as added by this Act. |
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(b) The Health and Human Services Commission shall seek to |
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amend contracts entered into with managed care organizations under |
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Chapter 533, Government Code, before the effective date of this Act |
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to require those managed care organizations to comply with Section |
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533.01316, Government Code, as added by this Act. To the extent of |
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a conflict between that section and a provision of a contract with a |
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managed care organization entered into before the effective date of |
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this Act, the contract provision prevails. |
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SECTION 4. Section 1451.506, Insurance Code, as added by |
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this Act, applies only to a health benefit plan that is delivered, |
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issued for delivery, or renewed on or after January 1, 2022. A |
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health benefit plan delivered, issued for delivery, or renewed |
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before January 1, 2022, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 5. If before implementing any provision of this Act |
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a state agency determines that a waiver or authorization from a |
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federal agency is necessary for implementation of that provision, |
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the agency affected by the provision shall request the waiver or |
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authorization and may delay implementing that provision until the |
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waiver or authorization is granted. |
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SECTION 6. This Act takes effect September 1, 2021. |