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A BILL TO BE ENTITLED
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AN ACT
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relating to health care cost transparency by health benefit plan |
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issuers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Subtitle J, Title 8, Insurance |
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Code, is amended to read as follows: |
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SUBTITLE J. HEALTH INFORMATION TECHNOLOGY AND TRANSPARENCY |
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SECTION 2. Subtitle J, Title 8, Insurance Code, is amended |
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by adding Chapter 1663 to read as follows: |
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CHAPTER 1663. HEALTH CARE COST TRANSPARENCY |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1663.001. DEFINITIONS. In this chapter: |
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(1) "Allowed amount" means the amount paid by a health |
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benefit plan issuer to a participating provider for a covered |
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service under a contract between the issuer and provider. |
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(2) "Enrollee" means an individual who is eligible to |
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receive benefits for health care services through a health benefit |
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plan. |
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(3) "Health benefit plan" means: |
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(A) an individual, group, blanket, or franchise |
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insurance policy, a certificate issued under an individual or group |
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policy, or a group hospital service contract that provides benefits |
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for health care services; or |
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(B) a group subscriber contract or group or |
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individual evidence of coverage issued by a health maintenance |
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organization that provides benefits for health care services. |
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(4) "Health benefit plan issuer" means a health |
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maintenance organization operating under Chapter 843, a preferred |
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provider organization operating under Chapter 1301, an approved |
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nonprofit health corporation that holds a certificate of authority |
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under Chapter 844, and any other entity that issues a health benefit |
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plan, including: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a fraternal benefit society operating under |
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Chapter 885; or |
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(D) a stipulated premium company operating under |
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Chapter 884. |
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(5) "Health care provider" means a physician, |
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hospital, pharmacy, pharmacist, laboratory, or other person or |
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organization that furnishes health care services and that is |
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licensed or otherwise authorized to practice in this state. |
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(6) "Health care service" means a service for the |
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diagnosis, prevention, treatment, cure, or relief of a health |
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condition, illness, injury, or disease. |
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(7) "Managed care plan" means a health benefit plan |
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under which health care services are provided to enrollees through |
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contracts with health care providers and that requires enrollees to |
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use participating providers or that provides a different level of |
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coverage for enrollees who use participating providers. |
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(8) "Out-of-network provider," with respect to a |
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managed care plan, means a health care provider who is not a |
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participating provider of the plan. |
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(9) "Participating provider" means a health care |
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provider who has contracted with a health benefit plan issuer to |
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provide health care services to enrollees. |
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Sec. 1663.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this chapter applies to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) a basic coverage plan under Chapter 1551; |
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(4) a basic plan under Chapter 1575; |
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(5) a primary care coverage plan under Chapter 1579; |
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(6) a plan providing basic coverage under Chapter |
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1601; |
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(7) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(8) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(9) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(10) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; |
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(11) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code; |
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(12) county employee group health benefits provided |
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under Chapter 157, Local Government Code; and |
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(13) health and accident coverage provided by a risk |
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pool created under Chapter 172, Local Government Code. |
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Sec. 1663.003. RULES. The commissioner may adopt rules to |
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implement this chapter. |
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SUBCHAPTER B. TRANSPARENCY TOOLS |
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Sec. 1663.051. AVAILABILITY OF PRICE AND QUALITY |
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INFORMATION. (a) A health benefit plan issuer shall provide on its |
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publicly available Internet website an interactive mechanism that, |
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for a health care service classified by the Current Procedural |
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Terminology code associated with the service, allows an enrollee |
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to: |
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(1) request and obtain from the issuer: |
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(A) information on the payments made by the |
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issuer to participating providers under the enrollee's health |
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benefit plan; and |
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(B) the payment methodology for and an estimate |
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of the dollar amount the issuer will pay for a health care service |
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provided by a health care provider who is not a participating |
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provider, including an out-of-network provider; |
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(2) compare allowed amounts among participating |
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providers; and |
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(3) estimate the enrollee's out-of-pocket costs under |
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the enrollee's health benefit plan. |
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(b) The interactive mechanism must: |
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(1) have a brief description of each Current |
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Procedural Terminology code that allows an enrollee to find the |
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appropriate code for a particular health care service; |
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(2) allow an enrollee to receive the requested |
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information before the enrollee receives the health care service or |
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an associated supply for which the enrollee requested information; |
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and |
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(3) provide the information to the enrollee using |
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plain language. |
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(c) A health benefit plan issuer shall update the |
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interactive mechanism for a health benefit plan with each payment |
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made by the issuer with respect to the plan. |
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(d) A health benefit plan issuer may contract with a third |
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party to provide the interactive mechanism. |
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Sec. 1663.052. ESTIMATE REQUIREMENTS. To satisfy the |
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requirement under Section 1663.051(a)(3), a health benefit plan |
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issuer shall provide a good-faith estimate of the amount the |
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enrollee will be responsible to pay for a health care service based |
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on the information available to the issuer at the time the estimate |
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is requested. |
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Sec. 1663.053. NOTICE TO ENROLLEES. A health benefit plan |
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issuer shall inform an enrollee requesting an estimate under |
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Section 1663.051(a)(3) that the actual amount of the charges and |
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the amount the enrollee is responsible to pay for the service may |
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vary based upon unforeseen services that arise from the proposed |
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service. |
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SECTION 3. Chapter 1663, Insurance Code, as added by this |
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Act, applies only to a health benefit plan delivered, issued for |
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delivery, or renewed on or after January 1, 2022. A health benefit |
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plan that is delivered, issued for delivery, or renewed before |
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January 1, 2022, is governed by the law as it existed immediately |
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before the effective date of this Act, and that law is continued in |
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effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2021. |