Bill Text: TX HB4536 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the determination of a usual and customary amount under the Insurance Code.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2019-03-26 - Referred to Insurance [HB4536 Detail]
Download: Texas-2019-HB4536-Introduced.html
| 86R13583 SMT-D | ||
| By: Lucio III | H.B. No. 4536 | |
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| relating to the determination of a usual and customary amount under | ||
| the Insurance Code. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. Subtitle A, Title 2, Insurance Code, is amended | ||
| by adding Chapter 41 to read as follows: | ||
| CHAPTER 41. USUAL AND CUSTOMARY AMOUNTS | ||
| Sec. 41.0001. STANDARDIZED PROCEDURE. (a) The | ||
| commissioner of insurance by rule shall adopt a standardized | ||
| procedure to determine the usual and customary rate or amount for a | ||
| particular medical care or health care service or supply, including | ||
| a dental care service or supply, for purposes of this code. | ||
| (b) The procedure may include the use of a database or | ||
| clearing house, a survey procedure, or any other mechanism that | ||
| facilitates the determination of whether an amount is usual and | ||
| customary. | ||
| Sec. 41.0002. SIMILAR STATUTORY PROVISIONS. For a | ||
| provision of this code that establishes a payment standard for a | ||
| medical care or health care service or supply using statutory | ||
| language that is similar to "usual and customary," including | ||
| "reasonable and customary" or "usual, customary, and reasonable," | ||
| the commissioner by rule shall determine whether the provision is | ||
| subject to the standardized procedure adopted under Section | ||
| 41.0001. | ||
| Sec. 41.0003. USE OF PROCEDURE. (a) The issuer of any | ||
| health benefit plan regulated under this code, including a health | ||
| maintenance organization or a preferred provider organization, | ||
| must use the standardized procedure adopted under this chapter to | ||
| determine whether the amount of a rate, charge, claim, or analogous | ||
| payment to be paid to a physician, health care practitioner, or | ||
| other health care provider, including a dentist, for a medical care | ||
| or health care service or supply, including a dental care service or | ||
| supply, is the usual and customary amount for the service or supply. | ||
| (b) The standardized procedure adopted under this chapter | ||
| is applicable to the determination of the usual and customary rate | ||
| for a service or supply in a mediation conducted under Chapter 1467. | ||
| SECTION 2. Not later than December 31, 2019, the | ||
| commissioner of insurance shall adopt rules as necessary to | ||
| implement Chapter 41, Insurance Code, as added by this Act. | ||
| SECTION 3. The standardized procedure adopted under Chapter | ||
| 41, Insurance Code, as added by this Act, does not apply to the | ||
| amount of a rate, charge, claim, or analogous payment to be paid for | ||
| a medical care or health care service or supply provided before | ||
| January 1, 2020. | ||
| SECTION 4. This Act takes effect September 1, 2019. | ||
