88R3824 SCL-D
 
  By: Gates H.B. No. 840
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the establishment of a bundled-pricing program to
  reduce certain health care costs in the state employees group
  benefits program.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 1551, Insurance Code, is amended by
  adding Subchapter K to read as follows:
  SUBCHAPTER K. BUNDLED-PRICING PROGRAM
         Sec. 1551.501.  DEFINITIONS.  In this subchapter:
               (1)  "Facility-based provider" has the meaning
  assigned by Section 1551.229.
               (2)  "Program" means the bundled-pricing program
  developed under this subchapter.
         Sec. 1551.502.  BUNDLED-PRICING PROGRAM. (a) The board of
  trustees shall develop a cost-positive bundled-pricing program for
  health benefit plans provided under the group benefits program.
         (b)  The program must be designed to reduce health care costs
  in the group benefits program by contracting with a health care
  facility, physician, or health care provider at a consolidated rate
  for an inpatient or outpatient surgery procedure that is a covered
  health care or medical service under a health benefit plan provided
  under the group benefits program. 
         (c)  A consolidated rate described by Subsection (b) must
  include all fees related to the covered surgery procedure,
  including fees for a health care facility, physician, health care
  provider, laboratory, anesthesia, perioperative service,
  prescription drug, or pharmacy service.
         (d)  The board of trustees shall contract with a third-party
  administrator to administer the program. The program administrator
  may be independent from the administrator of a health benefit plan
  under the group benefits program.
         Sec. 1551.503.  PARTICIPATION; COST-SHARING OBLIGATION.
  (a) A participant may have only an inpatient or outpatient surgery
  procedure under the program.
         (b)  Except as provided by Subsection (c), the board of
  trustees or a participating health care facility, physician, or
  health care provider may not require a participant to pay a
  deductible, copayment, coinsurance, or other cost-sharing
  obligation for a covered surgery procedure provided under the
  program.
         (c)  The board of trustees may require a participant in the
  state consumer-directed health plan established under Section
  1551.452 to meet the participant's deductible before the plan pays
  for a covered surgery procedure provided under the program.
         Sec. 1551.504.  PROVIDER PARTICIPATION. (a) A health care
  facility, physician, or health care provider is not required to
  participate in the program.  To participate, a health care
  facility, physician, or health care provider must voluntarily and
  expressly agree in writing to participate.
         (b)  A health care facility may not directly or indirectly:
               (1)  coerce a facility-based provider or physician to
  participate in the program or accept a lower rate for an inpatient
  or outpatient surgery procedure;
               (2)  condition a physician's staff membership or
  privileges on the physician's participation in the program;
               (3)  consider a physician's participation or lack of
  participation in the program in credentialing the physician;
               (4)  offer preferential scheduling to a participating
  physician as compared to a physician who elects not to participate;
  or
               (5)  terminate or otherwise penalize a physician or
  health care provider for an election to not participate in the
  program.
         (c)  The board of trustees, a health benefit plan, an
  administrator of a health benefit plan provided under the group
  program, or a health benefit plan issuer may not directly or
  indirectly:
               (1)  coerce a health care facility, physician, or
  health care provider to participate in the program;
               (2)  condition any plan participation on participation
  in the program; or
               (3)  terminate or otherwise penalize a health care
  facility, physician, or health care provider for electing not to
  participate in the program.
         Sec. 1551.505.  PROCEDURE APPROVAL. (a)  Before scheduling
  a procedure under the program, a participating health care
  facility, physician, or health care provider must apply for
  approval from the program administrator in the form and manner
  prescribed by the board of trustees.
         (b)  The approval application must include the consolidated
  rate for the procedure and any other information determined
  necessary by the program administrator.
         (c)  In determining whether to approve a procedure under this
  section, the program administrator shall:
               (1)  ensure that the quality of care is comparable to
  the care provided by a network provider for a health benefit plan
  under the group benefits program;
               (2)  ensure that the procedure's cost is lower than the
  procedure's cost if performed outside of the program; and
               (3)  if there is not a quality differential and
  multiple health care facilities, physicians, or health care
  providers apply to perform the same procedure for a participant,
  consider the procedure's consolidated rate and the time the
  procedure will be performed as the most important factors.
         Sec. 1551.506.  PAYMENT. (a)  The board of trustees shall
  ensure that a participating health care facility, physician, or
  health care provider receives payment for a covered surgery
  procedure not later than the 30th day after the date the program
  administrator receives a claim for the procedure that includes, at
  a minimum, each current procedural terminology code associated with
  the bundled procedure and each ICD-10 code associated with the
  patient.
         (b)  The program must include the methods by which payments
  are allocated among a participating health care facility,
  physician, or health care provider. If the consolidated bundled
  payment is to be paid to an entity for further distribution to other
  participating health care facilities, physicians, or health care
  providers, the entity receiving the consolidated payment must be a
  physician-led organization and have contracting authority on
  behalf of the other participating facilities, physicians, and
  providers.
         (c)  A participating health care facility, physician, or
  health care provider may submit a request for payment to the
  administrator for unanticipated services required to be provided
  while performing a procedure under the program. The request must
  include information on the reason the services were required.
         Sec. 1551.507.  BUNDLED-PRICING DISCLOSURE. (a) A
  participating health care facility, physician, or health care
  provider shall provide a written disclosure to a participant or the
  participant's representative of the consolidated rate for a
  procedure provided under the program before scheduling the
  procedure.
         (b)  A health care facility, physician, or health care
  provider that participates in the program may disclose a
  consolidated rate for an inpatient or outpatient surgery procedure
  on the facility's, physician's, or provider's Internet website and
  marketing materials.
         Sec. 1551.508.  PUBLICATION OF INFORMATION. The board of
  trustees shall publish information on the program, including a list
  of participating health care facilities, physicians, and health
  care providers and the consolidated rates offered by each
  participating facility, physician, and provider, on the Employees
  Retirement System of Texas website.
         Sec. 1551.509.  UNAUTHORIZED PRACTICE OF MEDICINE
  PROHIBITED. This subchapter may not be construed to authorize:
               (1)  a lay person or entity to supervise or otherwise
  control the practice of medicine as prohibited under Subtitle B,
  Title 3, Occupations Code;
               (2)  a person or entity to engage in the unauthorized
  practice of medicine in this state;
               (3)  a person or entity to misrepresent that the person
  or entity is entitled to practice medicine; or
               (4)  a violation of Section 155.001, 155.003, 157.001,
  164.052, or 165.156, Occupations Code.
         Sec. 1551.510.  RULEMAKING. The board of trustees may adopt
  rules as necessary to implement this subchapter.
         SECTION 2.  This Act takes effect September 1, 2023.