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A BILL TO BE ENTITLED
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AN ACT
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relating to establishment of a shared savings program for certain |
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managed care plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle C, Title 8, Insurance Code, is amended |
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by adding Chapter 1276 to read as follows: |
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CHAPTER 1276. SHARED SAVINGS PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1276.001. DEFINITIONS. In this chapter: |
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(1) "Health care provider" means a health care |
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practitioner or health care facility that provides health care |
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services or supplies under a license, certificate, registration, or |
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similar authorization issued by this state. |
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(2) "Managed care plan" means a health benefit plan |
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under which health care services or supplies are provided to |
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enrollees through contracts with health care providers and that |
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requires enrollees to use contracting providers or that provides a |
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different level of coverage for enrollees who use contracting |
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providers. |
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(3) "Out-of-network provider" means a health care |
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provider of any health care service or supply that does not have a |
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contract under an enrollee's health benefit plan. |
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(4) "Program" means the shared savings program |
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established under this chapter. |
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Sec. 1276.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only with respect to nonemergency health care services or |
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supplies covered under a managed care plan. |
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(b) This chapter applies only to the following health |
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benefit plans: |
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(1) a health benefit plan provided by a health |
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maintenance organization operating under Chapter 843; |
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(2) a preferred provider benefit plan provided under |
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Chapter 1301; or |
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(3) a basic coverage plan provided under Chapter 1551. |
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(c) Notwithstanding any other law, this chapter applies to |
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an administrator of a health benefit plan described by this |
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section. |
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Sec. 1276.003. RULES. The commissioner may adopt rules |
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necessary to implement this chapter. |
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SUBCHAPTER B. PROGRAM REQUIREMENTS |
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Sec. 1276.051. PROGRAM REQUIRED. (a) A health benefit plan |
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issuer or administrator to which this chapter applies shall |
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establish a shared savings program in accordance with this chapter. |
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(b) A health benefit plan issuer or administrator shall |
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provide written notice to its enrollees of the program. |
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Sec. 1276.052. AVERAGE CONTRACTED RATE DISCLOSURE. (a) As |
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part of the program, a health benefit plan issuer or administrator |
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shall establish and operate a toll-free telephone number and |
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publicly accessible Internet website for a plan enrollee to request |
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that the plan disclose to the enrollee the average contracted rate |
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paid under the plan to a health care provider in the plan's provider |
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network for a particular health care service or supply in the |
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preceding 12 months. |
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(b) A health benefit plan issuer or administrator shall |
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disclose to the enrollee the amount requested by the enrollee under |
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Subsection (a). |
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Sec. 1276.053. HEALTH CARE PROVIDER ESTIMATE. An |
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out-of-network provider shall, on an enrollee's request, provide |
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the enrollee a written estimate of the final charge for a proposed |
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health care service or supply that is eligible for the enrollee's |
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program. The estimate must include all costs associated with the |
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service or supply and reflect the enrollee's final out-of-pocket |
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cost associated with the proposed service or supply. |
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Sec. 1276.054. SHARED SAVINGS PAYMENT. (a) Except as |
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provided by Subsection (b), if an enrollee who requests a |
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disclosure under Section 1276.052 elects and receives a health care |
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service or supply the actual cost of which is less than the amount |
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disclosed under Section 1276.052, the health benefit plan issuer or |
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administrator shall pay to the enrollee 50 percent of the |
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difference between the amount disclosed under Section 1276.052 and |
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the actual cost, minus any applicable deductible, copayment, or |
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coinsurance. |
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(b) A health benefit plan issuer is not required to pay an |
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enrollee under Subsection (a) if the difference described by that |
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subsection is less than $50. |
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(c) A health benefit plan issuer or administrator shall pay |
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an enrollee under Subsection (a) not later than the 30th day after |
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the date on which the enrollee submits a program claim. |
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Sec. 1276.055. DEDUCTIBLES UNDER PROGRAM. (a) This section |
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applies only to a health care service or supply for which an |
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enrollee received: |
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(1) a disclosure under Section 1276.052; and |
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(2) an estimate under Section 1276.053 that is at |
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least $50 less than the amount provided under the disclosure. |
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(b) A health benefit plan issuer or administrator shall |
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apply the same deductible to a health care service or supply to |
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which this section applies as would be applied to a network service |
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or supply. |
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Sec. 1276.056. LIABILITY FOR UNFORESEEN CHARGE OVER |
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ESTIMATE. If the final charge for the health care service or supply |
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described by Section 1276.055(a) is greater than the estimate |
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provided under Section 1276.053 due to unforeseen circumstances, |
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the enrollee's health benefit plan issuer or administrator shall |
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pay 95 percent of the difference up to the allowed amount for the |
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service or supply and the enrollee is responsible for the remaining |
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difference. |
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SECTION 2. Chapter 1276, 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, 2024. |
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SECTION 3. This Act takes effect September 1, 2023. |