| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to the establishment of the state health benefit plan |
|
|
reimbursement review board and the reimbursement for health care |
|
|
services or supplies provided under certain state-funded health |
|
|
benefit plans. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Subtitle C, Title 3, Government Code, is amended |
|
|
by adding Chapter 331 to read as follows: |
|
|
CHAPTER 331. STATE HEALTH BENEFIT PLAN REIMBURSEMENT REVIEW BOARD |
|
|
Sec. 331.001. DEFINITIONS. In this chapter: |
|
|
(1) "Board" means the state health benefit plan |
|
|
reimbursement review board. |
|
|
(2) "Enrollee" means an individual entitled to health |
|
|
benefit coverage under a state health benefit plan. |
|
|
(3) "Facility" means: |
|
|
(A) a hospital; |
|
|
(B) an ambulatory surgical center licensed under |
|
|
Chapter 243, Health and Safety Code; |
|
|
(C) a birthing center; or |
|
|
(D) a freestanding emergency medical care |
|
|
facility, as defined by Section 254.001, Health and Safety Code, |
|
|
including a freestanding emergency medical care facility that is |
|
|
exempt from the licensing requirements of Chapter 254, Health and |
|
|
Safety Code, under Section 254.052(8), Health and Safety Code. |
|
|
(4) "State health benefit plan" means a health benefit |
|
|
plan provided under Chapter 1551, 1575, 1579, or 1601, Insurance |
|
|
Code. |
|
|
Sec. 331.002. ESTABLISHMENT; PURPOSE. The state health |
|
|
benefit plan reimbursement review board is established for the |
|
|
purpose of controlling present and future cost growth for state |
|
|
health benefit plans while maintaining access for enrollees to |
|
|
high-quality health care services and supplies. |
|
|
Sec. 331.003. MEMBERSHIP. (a) The board consists of: |
|
|
(1) the lieutenant governor; |
|
|
(2) the speaker of the house of representatives; |
|
|
(3) the chair of the senate finance committee; |
|
|
(4) the chair of the house appropriations committee; |
|
|
(5) three members of the senate appointed by the |
|
|
lieutenant governor; and |
|
|
(6) three members of the house appointed by the |
|
|
speaker. |
|
|
(b) The lieutenant governor and the speaker of the house of |
|
|
representatives are joint chairs of the board. |
|
|
Sec. 331.004. QUORUM; MEETINGS. (a) A majority of the |
|
|
members of the board from each house constitutes a quorum to |
|
|
transact business. If a quorum is present, the board may act on any |
|
|
matter that is within its jurisdiction by a majority vote. |
|
|
(b) The board shall meet as often as necessary to perform |
|
|
the board's duties. Meetings may be held at any time at the request |
|
|
of either of the joint chairs of the board. |
|
|
(c) The board shall meet in Austin, except that if a |
|
|
majority of the members of the board from each house agree, the |
|
|
board may meet in any location determined by the board. |
|
|
(d) As an exception to Chapter 551 and other law, if a |
|
|
meeting is located in Austin and the joint chairs of the board are |
|
|
physically present at the meeting, then any number of the other |
|
|
members of the board may attend the meeting by use of telephone |
|
|
conference call, video conference call, or other similar |
|
|
telecommunication device. This subsection applies for purposes of |
|
|
constituting a quorum, for purposes of voting, and for any other |
|
|
purpose allowing a member of the board to otherwise fully |
|
|
participate in any meeting of the board. This subsection applies |
|
|
without exception with regard to the subject of the meeting or |
|
|
topics considered by the members. |
|
|
(e) A meeting held by use of telephone conference call, |
|
|
video conference call, or other similar telecommunication device: |
|
|
(1) is subject to the notice requirements applicable |
|
|
to other meetings; |
|
|
(2) must specify in the notice of the meeting the |
|
|
location in Austin of the meeting at which the joint chairs will be |
|
|
physically present; |
|
|
(3) must be open to the public and shall be audible to |
|
|
the public at the location in Austin specified in the notice of the |
|
|
meeting as the location of the meeting at which the joint chairs |
|
|
will be physically present; and |
|
|
(4) must provide two-way audio communication between |
|
|
all members of the board attending the meeting during the entire |
|
|
meeting, and if the two-way audio communication link with any |
|
|
member attending the meeting is disrupted at any time, the meeting |
|
|
may not continue until the two-way audio communication link is |
|
|
reestablished. |
|
|
Sec. 331.005. DUTY TO ADOPT REIMBURSEMENT STRUCTURE. The |
|
|
board shall adopt a provider reimbursement structure, regardless of |
|
|
methodology, that each state health benefit plan will use to |
|
|
determine reimbursement to a facility for a health care service or |
|
|
supply, determined by provider type and class and according to |
|
|
whether the facility is an in-network or out-of-network facility. |
|
|
The board may not adopt a reimbursement structure that is in excess |
|
|
of the aggregated provider reimbursement, regardless of |
|
|
methodology, reported by participating state health benefit plans |
|
|
under Section 331.006 for that health care service or supply. |
|
|
Sec. 331.006. REPORTS BY STATE HEALTH BENEFIT PLANS. (a) |
|
|
Each state health benefit plan shall submit to the board in the form |
|
|
and manner prescribed by the board a report that includes: |
|
|
(1) information on reimbursements and costs for |
|
|
applicable provider types and classes paid by that plan during the |
|
|
preceding plan year; |
|
|
(2) recommendations to the board regarding the |
|
|
provider reimbursement structure to be adopted by the board; and |
|
|
(3) a summary of public comments received by the plan |
|
|
on the recommendations provided to the board under Subdivision (2). |
|
|
(b) Each state health benefit plan shall, before submitting |
|
|
the report required under Subsection (a), allow for public comment |
|
|
on the plan's recommendations to be submitted under that |
|
|
subsection. |
|
|
Sec. 331.007. REIMBURSEMENT STRUCTURE REPORT. (a) The |
|
|
board shall analyze the reports submitted under Section 331.006, |
|
|
including the recommendations provided, and issue a report on the |
|
|
reimbursement structure for state health benefit plans. The report |
|
|
issued by the board must: |
|
|
(1) establish a provider reimbursement structure, |
|
|
regardless of methodology, in accordance with Section 331.005 that |
|
|
provides for reimbursement that a facility that provides health |
|
|
care services or supplies to an enrollee under a state health |
|
|
benefit plan will receive for those health care services or |
|
|
supplies and specify any other requirements or limitations related |
|
|
to reimbursement; |
|
|
(2) be made publicly available on an Internet website; |
|
|
and |
|
|
(3) specify that the reimbursement structure in the |
|
|
report is applicable to each state health benefit plan for each plan |
|
|
year beginning after the date the report is issued until the plan |
|
|
year beginning after the date a later report is issued under this |
|
|
subsection. |
|
|
(b) The reimbursement structure adopted by the board's |
|
|
report under Subsection (a) is applicable to a state health benefit |
|
|
plan for each plan year beginning after the date the report is |
|
|
issued until the plan year beginning after the date a later report |
|
|
is issued under Subsection (a). |
|
|
SECTION 2. Subchapter A, Chapter 1551, Insurance Code, is |
|
|
amended by adding Section 1551.016 to read as follows: |
|
|
Sec. 1551.016. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a) |
|
|
In this section: |
|
|
(1) "Facility" has the meaning assigned by Section |
|
|
331.001, Government Code. |
|
|
(2) "Review board" means the state health benefit plan |
|
|
reimbursement review board established under Chapter 331, |
|
|
Government Code. |
|
|
(b) Notwithstanding any other law or a provision of a |
|
|
contract to the contrary, and subject to limitations imposed by the |
|
|
General Appropriations Act, a facility that bills the group |
|
|
benefits program, an administering firm, or a health benefit plan |
|
|
provided under this chapter, or a designee of the program, firm, or |
|
|
plan, for a health care service or supply provided to a plan |
|
|
enrollee must be reimbursed for the health care service or supply in |
|
|
accordance with the reimbursement structure adopted for the service |
|
|
or supply by the review board for the applicable plan year. |
|
|
(c) A facility that receives reimbursement for a health care |
|
|
service or supply as provided by Subsection (b) must consider that |
|
|
reimbursement as payment in full for the service or supply. Except |
|
|
as provided by this subsection, the facility may not charge an |
|
|
enrollee to recover from the enrollee the balance of the facility's |
|
|
fee for a service or supply received by the enrollee from the |
|
|
facility that is not fully reimbursed under Subsection (b). The |
|
|
facility may charge the enrollee an applicable copayment, |
|
|
coinsurance, or deductible under the enrollee's health benefit |
|
|
plan. |
|
|
(d) A facility may not discriminate against an enrollee or |
|
|
the group benefits program based on the limitation on reimbursement |
|
|
under Subsection (b) by: |
|
|
(1) refusing to provide health care services or |
|
|
supplies to the enrollee; or |
|
|
(2) providing health care services or supplies of a |
|
|
lower quality to the enrollee than those the facility provides to |
|
|
similar patients who are not enrolled in a health benefit plan under |
|
|
this chapter. |
|
|
SECTION 3. Subchapter A, Chapter 1575, Insurance Code, is |
|
|
amended by adding Section 1575.011 to read as follows: |
|
|
Sec. 1575.011. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a) |
|
|
In this section: |
|
|
(1) "Facility" has the meaning assigned by Section |
|
|
331.001, Government Code. |
|
|
(2) "Review board" means the state health benefit plan |
|
|
reimbursement review board established under Chapter 331, |
|
|
Government Code. |
|
|
(b) Notwithstanding any other law or a provision of a |
|
|
contract to the contrary, and subject to limitations imposed by the |
|
|
General Appropriations Act, a facility that bills the group |
|
|
program, an administrator of a health benefit plan provided under |
|
|
this chapter, or a health benefit plan provided under this chapter, |
|
|
or a designee of the program, administrator, or plan, for a health |
|
|
care service or supply provided to a plan enrollee must be |
|
|
reimbursed for the health care service or supply in accordance with |
|
|
the reimbursement structure adopted for the service or supply by |
|
|
the review board for the applicable plan year. |
|
|
(c) A facility that receives reimbursement for a health care |
|
|
service or supply as provided by Subsection (b) must consider that |
|
|
reimbursement as payment in full for the service or supply. Except |
|
|
as provided by this subsection, the facility may not charge an |
|
|
enrollee to recover from the enrollee the balance of the facility's |
|
|
fee for a service or supply received by the enrollee from the |
|
|
facility that is not fully reimbursed under Subsection (b). The |
|
|
facility may charge the enrollee an applicable copayment, |
|
|
coinsurance, or deductible under the enrollee's health benefit |
|
|
plan. |
|
|
(d) A facility may not discriminate against an enrollee or |
|
|
the group program based on the limitation on reimbursement under |
|
|
Subsection (b) by: |
|
|
(1) refusing to provide health care services or |
|
|
supplies to the enrollee; or |
|
|
(2) providing health care services or supplies of a |
|
|
lower quality to the enrollee than those the facility provides to |
|
|
similar patients who are not enrolled in a health benefit plan under |
|
|
this chapter. |
|
|
SECTION 4. Subchapter A, Chapter 1579, Insurance Code, is |
|
|
amended by adding Section 1579.011 to read as follows: |
|
|
Sec. 1579.011. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a) |
|
|
In this section: |
|
|
(1) "Facility" has the meaning assigned by Section |
|
|
331.001, Government Code. |
|
|
(2) "Review board" means the state health benefit plan |
|
|
reimbursement review board established under Chapter 331, |
|
|
Government Code. |
|
|
(b) Notwithstanding any other law or a provision of a |
|
|
contract to the contrary, and subject to limitations imposed by the |
|
|
General Appropriations Act, a facility that bills the program, an |
|
|
administering firm, or a health coverage plan provided under this |
|
|
chapter, or a designee of the program, firm, or plan, for a health |
|
|
care service or supply provided to a plan enrollee must be |
|
|
reimbursed for the health care service or supply in accordance with |
|
|
the reimbursement structure adopted for the service or supply by |
|
|
the review board for the applicable plan year. |
|
|
(c) A facility that receives reimbursement for a health care |
|
|
service or supply as provided by Subsection (b) must consider that |
|
|
reimbursement as payment in full for the service or supply. Except |
|
|
as provided by this subsection, the facility may not charge an |
|
|
enrollee to recover from the enrollee the balance of the facility's |
|
|
fee for a service or supply received by the enrollee from the |
|
|
facility that is not fully reimbursed under Subsection (b). The |
|
|
facility may charge the enrollee an applicable copayment, |
|
|
coinsurance, or deductible under the enrollee's health coverage |
|
|
plan. |
|
|
(d) A facility may not discriminate against an enrollee or |
|
|
the program based on the limitation on reimbursement under |
|
|
Subsection (b) by: |
|
|
(1) refusing to provide health care services or |
|
|
supplies to the enrollee; or |
|
|
(2) providing health care services or supplies of a |
|
|
lower quality to the enrollee than those the facility provides to |
|
|
similar patients who are not enrolled in a health coverage plan |
|
|
under this chapter. |
|
|
SECTION 5. Subchapter A, Chapter 1601, Insurance Code, is |
|
|
amended by adding Section 1601.012 to read as follows: |
|
|
Sec. 1601.012. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a) |
|
|
In this section: |
|
|
(1) "Facility" has the meaning assigned by Section |
|
|
331.001, Government Code. |
|
|
(2) "Review board" means the state health benefit plan |
|
|
reimbursement review board established under Chapter 331, |
|
|
Government Code. |
|
|
(b) Notwithstanding any other law or a provision of a |
|
|
contract to the contrary, and subject to limitations imposed by the |
|
|
General Appropriations Act, a facility that bills the uniform |
|
|
program, an administering carrier, or a health benefit plan |
|
|
provided under this chapter, or a designee of the program, carrier, |
|
|
or plan, for a health care service or supply provided to a plan |
|
|
enrollee must be reimbursed for the health care service or supply in |
|
|
accordance with the reimbursement structure adopted for the service |
|
|
or supply by the review board for the applicable plan year. |
|
|
(c) A facility that receives reimbursement for a health care |
|
|
service or supply as provided by Subsection (b) must consider that |
|
|
reimbursement as payment in full for the service or supply. Except |
|
|
as provided by this subsection, the facility may not charge an |
|
|
enrollee to recover from the enrollee the balance of the facility's |
|
|
fee for a service or supply received by the enrollee from the |
|
|
facility that is not fully reimbursed under Subsection (b). The |
|
|
facility may charge the enrollee an applicable copayment, |
|
|
coinsurance, or deductible under the enrollee's health benefit |
|
|
plan. |
|
|
(d) A facility may not discriminate against an enrollee or |
|
|
the uniform program based on the limitation on reimbursement under |
|
|
Subsection (b) by: |
|
|
(1) refusing to provide health care services or |
|
|
supplies to the enrollee; or |
|
|
(2) providing health care services or supplies of a |
|
|
lower quality to the enrollee than those the facility provides to |
|
|
similar patients who are not enrolled in a health benefit plan under |
|
|
this chapter. |
|
|
SECTION 6. The changes in law made by this Act apply only |
|
|
to: |
|
|
(1) a plan year beginning on or after September 1, |
|
|
2024; and |
|
|
(2) a contract entered into or renewed on or after |
|
|
September 1, 2023. |
|
|
SECTION 7. This Act takes effect September 1, 2023. |