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A BILL TO BE ENTITLED
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AN ACT
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relating to a direct payment to a health care provider in lieu of a |
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claim for benefits under a health benefit plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1204, Insurance Code, is amended by |
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adding Subchapter G to read as follows: |
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SUBCHAPTER G. DIRECT PAYMENT TO HEALTH CARE PROVIDER |
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Sec. 1204.301. DEFINITION. In this subchapter, "health |
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care provider" means a health care practitioner or health care |
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facility that provides health care services under a license, |
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certificate, registration, or other similar evidence of regulation |
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issued by this or another state of the United States. |
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Sec. 1204.302. APPLICABILITY OF SUBCHAPTER. (a) This |
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subchapter applies only to a health benefit plan that provides |
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benefits for medical or surgical expenses incurred as a result of a |
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health condition, accident, or sickness, including an individual, |
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group, blanket, or franchise insurance policy or insurance |
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agreement, a group hospital service contract, or an individual or |
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group evidence of coverage or similar coverage document that is |
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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 subchapter applies |
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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. 1204.303. DIRECT PAYMENT IN LIEU OF CLAIM FOR |
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BENEFITS; EFFECT ON PLAN. (a) A health care provider may not be |
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prohibited from accepting directly from an enrollee full payment |
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for a health care service in lieu of submitting a claim to the |
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enrollee's health benefit plan. |
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(b) Notwithstanding Section 552.003 or any other law, a |
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health care provider's discounted cash price for services rendered |
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is considered full payment for purposes of Subsection (a). |
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(c) A health benefit plan shall apply the charge for a |
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health care service for which a health care provider accepts a |
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payment described by Subsection (a) from an enrollee towards the |
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enrollee's out-of-pocket maximum if the service is a covered |
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service under the plan. Payments for uncovered services are |
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ineligible to apply towards an enrollee's out-of-pocket maximum. |
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SECTION 2. 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 3. Section 1204.303, Insurance Code, as added by |
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this Act, applies only to a health benefit plan delivered, issued |
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for delivery, or renewed on or after January 1, 2024. |
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SECTION 4. This Act takes effect September 1, 2023. |