Bill Text: TX SB1264 | 2019-2020 | 86th Legislature | Engrossed
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Relating to consumer protections against certain medical and health care billing by certain out-of-network providers.
Spectrum: Slight Partisan Bill (Republican 57-26)
Status: (Passed) 2019-06-14 - Effective on 9/1/19 [SB1264 Detail]
Download: Texas-2019-SB1264-Engrossed.html
Bill Title: Relating to consumer protections against certain medical and health care billing by certain out-of-network providers.
Spectrum: Slight Partisan Bill (Republican 57-26)
Status: (Passed) 2019-06-14 - Effective on 9/1/19 [SB1264 Detail]
Download: Texas-2019-SB1264-Engrossed.html
By: Hancock, et al. | S.B. No. 1264 |
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relating to consumer protections against certain medical and health | ||
care billing by certain out-of-network providers; authorizing a | ||
fee. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
ARTICLE 1. ELIMINATION OF SURPRISE BILLING FOR CERTAIN HEALTH | ||
BENEFIT PLANS | ||
SECTION 1.01. Subtitle G, Title 5, Insurance Code, is | ||
amended by adding Chapter 752 to read as follows: | ||
CHAPTER 752. ENFORCEMENT OF BALANCE BILLING PROHIBITIONS | ||
Sec. 752.0001. INJUNCTION FOR BALANCE BILLING. (a) If the | ||
attorney general believes that an individual or entity has | ||
exhibited a pattern of intentionally violating a law that prohibits | ||
the individual or entity from billing an insured, participant, or | ||
enrollee in an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the insured's, participant's, or | ||
enrollee's managed care plan or that imposes a requirement related | ||
to that prohibition, the attorney general may bring a civil action | ||
in the name of the state to enjoin the individual or entity from the | ||
violation. | ||
(b) If the attorney general prevails in an action brought | ||
under Subsection (a), the attorney general may recover reasonable | ||
attorney's fees, costs, and expenses, including court costs and | ||
witness fees, incurred in bringing the action. | ||
Sec. 752.0002. ENFORCEMENT BY REGULATORY AGENCY. (a) An | ||
appropriate regulatory agency that licenses, certifies, or | ||
otherwise authorizes a physician, health care practitioner, health | ||
care facility, or other health care provider to practice or operate | ||
in this state may take disciplinary action against the physician, | ||
practitioner, facility, or provider if the physician, | ||
practitioner, facility, or provider violates a law that prohibits | ||
the physician, practitioner, facility, or provider from billing an | ||
insured, participant, or enrollee in an amount greater than an | ||
applicable copayment, coinsurance, or deductible under the | ||
insured's, participant's, or enrollee's managed care plan or that | ||
imposes a requirement related to that prohibition. | ||
(b) A regulatory agency described by Subsection (a) may | ||
adopt rules as necessary to implement this section. Section | ||
2001.0045, Government Code, does not apply to rules adopted under | ||
this subsection. | ||
SECTION 1.02. Subchapter A, Chapter 1271, Insurance Code, | ||
is amended by adding Section 1271.008 to read as follows: | ||
Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A | ||
health maintenance organization shall provide written notice in | ||
accordance with this subsection in an explanation of benefits | ||
provided to the enrollee and the physician or provider in | ||
connection with a health care service or supply that is subject to | ||
Section 1271.155, 1271.157, or 1271.158. The notice must include: | ||
(1) a statement of the billing prohibition under | ||
Section 1271.155, 1271.157, or 1271.158, as applicable; | ||
(2) the amount the physician or provider may bill the | ||
enrollee under the enrollee's health benefit plan; and | ||
(3) for an explanation of benefits provided to the | ||
physician or provider, information required by commissioner rule | ||
advising the physician or provider of the availability of the | ||
out-of-network claim dispute resolution process under Chapter | ||
1467. | ||
(b) A physician or provider that provides a service or | ||
supply described by Subsection (a) shall provide notice of the | ||
prohibitions described by Subsection (a)(1) in an invoice for the | ||
service or supply provided to an enrollee. | ||
SECTION 1.03. Section 1271.155, Insurance Code, is amended | ||
by amending Subsection (b) and adding Subsection (f) to read as | ||
follows: | ||
(b) A health care plan of a health maintenance organization | ||
must provide the following coverage of emergency care: | ||
(1) a medical screening examination or other | ||
evaluation required by state or federal law necessary to determine | ||
whether an emergency medical condition exists shall be provided to | ||
covered enrollees in a hospital emergency facility or comparable | ||
facility; | ||
(2) necessary emergency care shall be provided to | ||
covered enrollees, including the treatment and stabilization of an | ||
emergency medical condition; [ |
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(3) services originated in a hospital emergency | ||
facility, freestanding emergency medical care facility, or | ||
comparable emergency facility following treatment or stabilization | ||
of an emergency medical condition shall be provided to covered | ||
enrollees as approved by the health maintenance organization, | ||
subject to Subsections (c) and (d); and | ||
(4) supplies related to a service described by this | ||
subsection shall be provided to covered enrollees. | ||
(f) For emergency care subject to this section or a supply | ||
related to that care, a non-network physician or provider or a | ||
person asserting a claim as an agent or assignee of the physician or | ||
provider may not bill an enrollee in, and the enrollee does not have | ||
financial responsibility for, an amount greater than an applicable | ||
copayment, coinsurance, or deductible under the enrollee's health | ||
care plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the health maintenance organization; or | ||
(B) a modified amount as determined under the | ||
health maintenance organization's internal dispute resolution | ||
process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the physician or provider under Chapter 1467. | ||
SECTION 1.04. Subchapter D, Chapter 1271, Insurance Code, | ||
is amended by adding Sections 1271.157 and 1271.158 to read as | ||
follows: | ||
Sec. 1271.157. NON-NETWORK FACILITY-BASED PROVIDERS. | ||
(a) In this section, "facility-based provider" means a physician | ||
or provider who provides health care services to patients of a | ||
health care facility. | ||
(b) Except as provided by Subsection (d), a health | ||
maintenance organization shall pay for a health care service | ||
performed for or a supply related to that service provided to an | ||
enrollee by a non-network physician or provider who is a | ||
facility-based provider at the usual and customary rate or at an | ||
agreed rate if the provider performed the service at a health care | ||
facility that is a network provider. | ||
(c) Except as provided by Subsection (d), a non-network | ||
facility-based provider or a person asserting a claim as an agent or | ||
assignee of the provider may not bill an enrollee receiving a health | ||
care service or supply described by Subsection (b) in, and the | ||
enrollee does not have financial responsibility for, an amount | ||
greater than an applicable copayment, coinsurance, or deductible | ||
under the enrollee's health care plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the health maintenance organization; or | ||
(B) a modified amount as determined under the | ||
health maintenance organization's internal dispute resolution | ||
process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(d) This section does not apply to a nonemergency health | ||
care service that an enrollee elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each non-network physician or provider providing the service; | ||
and | ||
(2) with notice of the enrollee's potential financial | ||
responsibility from each non-network physician or provider | ||
providing the service. | ||
Sec. 1271.158. NON-NETWORK DIAGNOSTIC IMAGING PROVIDER OR | ||
LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic | ||
imaging provider" and "laboratory service provider" have the | ||
meanings assigned by Section 1467.001. | ||
(b) Except as provided by Subsection (d), a health | ||
maintenance organization shall pay for a health care service | ||
performed by or a supply related to that service provided by a | ||
non-network diagnostic imaging provider or laboratory service | ||
provider at the usual and customary rate or at an agreed rate if the | ||
provider performed the service in connection with a health care | ||
service performed by a network physician or provider. | ||
(c) Except as provided by Subsection (d), a non-network | ||
diagnostic imaging provider or laboratory service provider or a | ||
person asserting a claim as an agent or assignee of the provider may | ||
not bill an enrollee receiving a health care service or supply | ||
described by Subsection (b) in, and the enrollee does not have | ||
financial responsibility for, an amount greater than an applicable | ||
copayment, coinsurance, or deductible under the enrollee's health | ||
care plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the health maintenance organization; or | ||
(B) a modified amount as determined under the | ||
health maintenance organization's internal dispute resolution | ||
process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(d) This section does not apply to a nonemergency health | ||
care service that an enrollee elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each non-network provider providing the service; and | ||
(2) with notice of the enrollee's potential financial | ||
responsibility from each non-network physician or provider | ||
providing the service. | ||
SECTION 1.05. Section 1301.0053, Insurance Code, is amended | ||
to read as follows: | ||
Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS: | ||
EMERGENCY CARE. (a) If an out-of-network [ |
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provider provides emergency care as defined by Section 1301.155 to | ||
an enrollee in an exclusive provider benefit plan, the issuer of the | ||
plan shall reimburse the out-of-network [ |
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the usual and customary rate or at a rate agreed to by the issuer and | ||
the out-of-network [ |
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services and any supply related to those services. | ||
(b) For emergency care subject to this section or a supply | ||
related to that care, an out-of-network provider or a person | ||
asserting a claim as an agent or assignee of the provider may not | ||
bill an insured in, and the insured does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the insured's exclusive provider | ||
benefit plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the insurer; or | ||
(B) a modified amount as determined under the | ||
insurer's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
SECTION 1.06. Subchapter A, Chapter 1301, Insurance Code, | ||
is amended by adding Section 1301.010 to read as follows: | ||
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An | ||
insurer shall provide written notice in accordance with this | ||
subsection in an explanation of benefits provided to the insured | ||
and the physician or health care provider in connection with a | ||
health care service or supply that is subject to Section 1301.0053, | ||
1301.155, 1301.164, or 1301.165. The notice must include: | ||
(1) a statement of the billing prohibition under | ||
Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable; | ||
(2) the amount the physician or provider may bill the | ||
insured under the insured's preferred provider benefit plan; and | ||
(3) for an explanation of benefits provided to the | ||
physician or provider, information required by commissioner rule | ||
advising the physician or provider of the availability of the | ||
out-of-network claim dispute resolution process under Chapter | ||
1467. | ||
(b) A physician or health care provider that provides a | ||
service or supply described by Subsection (a) shall provide notice | ||
of the prohibitions described by Subsection (a)(1) in an invoice | ||
for the service or supply provided to an insured. | ||
SECTION 1.07. Section 1301.155, Insurance Code, is amended | ||
by amending Subsection (b) and adding Subsection (c) to read as | ||
follows: | ||
(b) If an insured cannot reasonably reach a preferred | ||
provider, an insurer shall provide reimbursement for the following | ||
emergency care services at the usual and customary rate or at an | ||
agreed rate and at the preferred level of benefits until the insured | ||
can reasonably be expected to transfer to a preferred provider: | ||
(1) a medical screening examination or other | ||
evaluation required by state or federal law to be provided in the | ||
emergency facility of a hospital that is necessary to determine | ||
whether a medical emergency condition exists; | ||
(2) necessary emergency care services, including the | ||
treatment and stabilization of an emergency medical condition; | ||
[ |
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(3) services originating in a hospital emergency | ||
facility or freestanding emergency medical care facility following | ||
treatment or stabilization of an emergency medical condition; and | ||
(4) supplies related to a service described by this | ||
subsection. | ||
(c) For emergency care subject to this section or a supply | ||
related to that care, an out-of-network provider or a person | ||
asserting a claim as an agent or assignee of the provider may not | ||
bill an insured in, and the insured does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the insured's preferred provider | ||
benefit plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the insurer; or | ||
(B) a modified amount as determined under the | ||
insurer's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
SECTION 1.08. Subchapter D, Chapter 1301, Insurance Code, | ||
is amended by adding Sections 1301.164 and 1301.165 to read as | ||
follows: | ||
Sec. 1301.164. OUT-OF-NETWORK FACILITY-BASED PROVIDERS. | ||
(a) In this section, "facility-based provider" means a physician | ||
or health care provider who provides health care services to | ||
patients of a health care facility. | ||
(b) Except as provided by Subsection (d), an insurer shall | ||
pay for a health care service performed for or a supply related to | ||
that service provided to an insured by an out-of-network provider | ||
who is a facility-based provider at the usual and customary rate or | ||
at an agreed rate if the provider performed the service at a health | ||
care facility that is a preferred provider. | ||
(c) Except as provided by Subsection (d), an out-of-network | ||
provider who is a facility-based provider or a person asserting a | ||
claim as an agent or assignee of the provider may not bill an | ||
insured receiving a health care service or supply described by | ||
Subsection (b) in, and the insured does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the insured's preferred provider | ||
benefit plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the insurer; or | ||
(B) a modified amount as determined under the | ||
insurer's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(d) This section does not apply to a nonemergency health | ||
care service that an insured elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the insured's potential financial | ||
responsibility from each out-of-network provider providing the | ||
service. | ||
Sec. 1301.165. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER | ||
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic | ||
imaging provider" and "laboratory service provider" have the | ||
meanings assigned by Section 1467.001. | ||
(b) Except as provided by Subsection (d), an insurer shall | ||
pay for a medical care or health care service performed by or a | ||
supply related to that service provided by an out-of-network | ||
provider who is a diagnostic imaging provider or laboratory service | ||
provider at the usual and customary rate or at an agreed rate if the | ||
provider performed the service in connection with a medical care or | ||
health care service performed by a preferred provider. | ||
(c) Except as provided by Subsection (d), an out-of-network | ||
provider who is a diagnostic imaging provider or laboratory service | ||
provider or a person asserting a claim as an agent or assignee of | ||
the provider may not bill an insured receiving a medical care or | ||
health care service or supply described by Subsection (b) in, and | ||
the insured does not have financial responsibility for, an amount | ||
greater than an applicable copayment, coinsurance, or deductible | ||
under the insured's preferred provider benefit plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the insurer; or | ||
(B) the modified amount as determined under the | ||
insurer's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(d) This section does not apply to a nonemergency health | ||
care service that an insured elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the insured's potential financial | ||
responsibility from each out-of-network provider providing the | ||
service. | ||
SECTION 1.09. Section 1551.003, Insurance Code, is amended | ||
by adding Subdivision (15) to read as follows: | ||
(15) "Usual and customary rate" means the relevant | ||
allowable amount as described by the applicable master benefit plan | ||
document or policy. | ||
SECTION 1.10. Subchapter A, Chapter 1551, Insurance Code, | ||
is amended by adding Section 1551.015 to read as follows: | ||
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. | ||
(a) The administrator of a managed care plan provided under the | ||
group benefits program shall provide written notice in accordance | ||
with this subsection in an explanation of benefits provided to the | ||
participant and the physician or health care provider in connection | ||
with a health care service or supply that is subject to Section | ||
1551.228, 1551.229, or 1551.230. The notice must include: | ||
(1) a statement of the billing prohibition under | ||
Section 1551.228, 1551.229, or 1551.230, as applicable; | ||
(2) the amount the physician or provider may bill the | ||
participant under the participant's managed care plan; and | ||
(3) for an explanation of benefits provided to the | ||
physician or provider, information required by commissioner rule | ||
advising the physician or provider of the availability of the | ||
out-of-network claim dispute resolution process under Chapter | ||
1467. | ||
(b) A physician or health care provider that provides a | ||
service or supply described by Subsection (a) shall provide notice | ||
of the prohibitions described by Subsection (a)(1) in an invoice | ||
for the service or supply provided to a participant. | ||
SECTION 1.11. Subchapter E, Chapter 1551, Insurance Code, | ||
is amended by adding Sections 1551.228, 1551.229, and 1551.230 to | ||
read as follows: | ||
Sec. 1551.228. EMERGENCY CARE COVERAGE. (a) In this | ||
section, "emergency care" has the meaning assigned by Section | ||
1301.155. | ||
(b) A managed care plan provided under the group benefits | ||
program must provide out-of-network emergency care coverage for | ||
participants in accordance with this section. | ||
(c) The coverage must require the administrator of the plan | ||
to pay for emergency care performed by or a supply related to that | ||
care provided by an out-of-network provider at the usual and | ||
customary rate or at an agreed rate. | ||
(d) For emergency care subject to this section or a supply | ||
related to that care, an out-of-network provider or a person | ||
asserting a claim as an agent or assignee of the provider may not | ||
bill a participant in, and the participant does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the participant's managed care | ||
plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
Sec. 1551.229. OUT-OF-NETWORK FACILITY-BASED PROVIDER | ||
COVERAGE. (a) In this section, "facility-based provider" means a | ||
physician or health care provider who provides health care services | ||
to patients of a health care facility. | ||
(b) A managed care plan provided under the group benefits | ||
program must provide out-of-network facility-based provider | ||
coverage for participants in accordance with this section. | ||
(c) Except as provided by Subsection (e), the coverage must | ||
require the administrator of the plan to pay for a health care | ||
service performed for or a supply related to that service provided | ||
to a participant by an out-of-network provider who is a | ||
facility-based provider at the usual and customary rate or at an | ||
agreed rate if the provider performed the service at a health care | ||
facility that is a participating provider. | ||
(d) Except as provided by Subsection (e), an out-of-network | ||
provider who is a facility-based provider or a person asserting a | ||
claim as an agent or assignee of the provider may not bill a | ||
participant receiving a health care service or supply described by | ||
Subsection (c) in, and the participant does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the participant's managed care | ||
plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(e) This section does not apply to a nonemergency health | ||
care service that a participant elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the participant's potential | ||
financial responsibility from each out-of-network provider | ||
providing the service. | ||
Sec. 1551.230. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER | ||
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic | ||
imaging provider" and "laboratory service provider" have the | ||
meanings assigned by Section 1467.001. | ||
(b) A managed care plan provided under the group benefits | ||
program must provide out-of-network diagnostic imaging provider | ||
and laboratory service provider coverage for participants in | ||
accordance with this section. | ||
(c) Except as provided by Subsection (e), the coverage must | ||
require the administrator of the plan to pay for a health care | ||
service performed for or a supply related to that service provided | ||
to a participant by an out-of-network provider who is a diagnostic | ||
imaging provider or laboratory service provider at the usual and | ||
customary rate or at an agreed rate if the provider performed the | ||
service in connection with a health care service performed by a | ||
participating provider. | ||
(d) Except as provided by Subsection (e), an out-of-network | ||
provider who is a diagnostic imaging provider or laboratory service | ||
provider or a person asserting a claim as an agent or assignee of | ||
the provider may not bill a participant receiving a health care | ||
service or supply described by Subsection (c) in, and the | ||
participant does not have financial responsibility for, an amount | ||
greater than an applicable copayment, coinsurance, or deductible | ||
under the participant's managed care plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) the modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(e) This section does not apply to a nonemergency health | ||
care service that a participant elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the participant's potential | ||
financial responsibility from each out-of-network provider | ||
providing the service. | ||
SECTION 1.12. Section 1575.002, Insurance Code, is amended | ||
by adding Subdivision (8) to read as follows: | ||
(8) "Usual and customary rate" means the relevant | ||
allowable amount as described by the applicable master benefit plan | ||
document or policy. | ||
SECTION 1.13. Subchapter A, Chapter 1575, Insurance Code, | ||
is amended by adding Section 1575.009 to read as follows: | ||
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. | ||
(a) The administrator of a managed care plan provided under the | ||
group program shall provide written notice in accordance with this | ||
subsection in an explanation of benefits provided to the enrollee | ||
and the physician or health care provider in connection with a | ||
health care service or supply that is subject to Section 1575.171, | ||
1575.172, or 1575.173. The notice must include: | ||
(1) a statement of the billing prohibition under | ||
Section 1575.171, 1575.172, or 1575.173, as applicable; | ||
(2) the amount the physician or provider may bill the | ||
enrollee under the enrollee's managed care plan; and | ||
(3) for an explanation of benefits provided to the | ||
physician or provider, information required by commissioner rule | ||
advising the physician or provider of the availability of the | ||
out-of-network claim dispute resolution process under Chapter | ||
1467. | ||
(b) A physician or health care provider that provides a | ||
service or supply described by Subsection (a) shall provide notice | ||
of the prohibitions described by Subsection (a)(1) in an invoice | ||
for the service or supply provided to an enrollee. | ||
SECTION 1.14. Subchapter D, Chapter 1575, Insurance Code, | ||
is amended by adding Sections 1575.171, 1575.172, and 1575.173 to | ||
read as follows: | ||
Sec. 1575.171. EMERGENCY CARE COVERAGE. (a) In this | ||
section, "emergency care" has the meaning assigned by Section | ||
1301.155. | ||
(b) A managed care plan provided under the group program | ||
must provide out-of-network emergency care coverage in accordance | ||
with this section. | ||
(c) The coverage must require the administrator of the plan | ||
to pay for emergency care performed by or a supply related to that | ||
care provided by an out-of-network provider at the usual and | ||
customary rate or at an agreed rate. | ||
(d) For emergency care subject to this section or a supply | ||
related to that care, an out-of-network provider or a person | ||
asserting a claim as an agent or assignee of the provider may not | ||
bill an enrollee in, and the enrollee does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the enrollee's managed care plan | ||
that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
Sec. 1575.172. OUT-OF-NETWORK FACILITY-BASED PROVIDER | ||
COVERAGE. (a) In this section, "facility-based provider" means a | ||
physician or health care provider who provides health care services | ||
to patients of a health care facility. | ||
(b) A managed care plan provided under the group program | ||
must provide out-of-network facility-based provider coverage for | ||
enrollees in accordance with this section. | ||
(c) Except as provided by Subsection (e), the coverage must | ||
require the administrator of the plan to pay for a health care | ||
service performed for or a supply related to that service provided | ||
to an enrollee by an out-of-network provider who is a | ||
facility-based provider at the usual and customary rate or at an | ||
agreed rate if the provider performed the service at a health care | ||
facility that is a participating provider. | ||
(d) Except as provided by Subsection (e), an out-of-network | ||
provider who is a facility-based provider or a person asserting a | ||
claim as an agent or assignee of the provider may not bill an | ||
enrollee receiving a health care service or supply described by | ||
Subsection (c) in, and the enrollee does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the enrollee's managed care plan | ||
that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(e) This section does not apply to a nonemergency health | ||
care service that an enrollee elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the enrollee's potential financial | ||
responsibility from each out-of-network provider providing the | ||
service. | ||
Sec. 1575.173. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER | ||
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic | ||
imaging provider" and "laboratory service provider" have the | ||
meanings assigned by Section 1467.001. | ||
(b) A managed care plan provided under the group program | ||
must provide out-of-network diagnostic imaging provider and | ||
laboratory service provider coverage for enrollees in accordance | ||
with this section. | ||
(c) Except as provided by Subsection (e), the coverage must | ||
require the administrator of the plan to pay for a health care | ||
service performed for or a supply related to that service provided | ||
to an enrollee by an out-of-network provider who is a diagnostic | ||
imaging provider or laboratory service provider at the usual and | ||
customary rate or at an agreed rate if the provider performed the | ||
service in connection with a health care service performed by a | ||
participating provider. | ||
(d) Except as provided by Subsection (e), an out-of-network | ||
provider who is a diagnostic imaging provider or laboratory service | ||
provider or a person asserting a claim as an agent or assignee of | ||
the provider may not bill an enrollee receiving a health care | ||
service or supply described by Subsection (c) in, and the enrollee | ||
does not have financial responsibility for, an amount greater than | ||
an applicable copayment, coinsurance, or deductible under the | ||
enrollee's managed care plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) the modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(e) This section does not apply to a nonemergency health | ||
care service that an enrollee elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the enrollee's potential financial | ||
responsibility from each out-of-network provider providing the | ||
service. | ||
SECTION 1.15. Subchapter A, Chapter 1579, Insurance Code, | ||
is amended by adding Section 1579.009 to read as follows: | ||
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. | ||
(a) The administrator of a managed care plan provided under this | ||
chapter shall provide written notice in accordance with this | ||
subsection in an explanation of benefits provided to the enrollee | ||
and the physician or health care provider in connection with a | ||
health care service or supply that is subject to Section 1579.109, | ||
1579.110, or 1579.111. The notice must include: | ||
(1) a statement of the billing prohibition under | ||
Section 1579.109, 1579.110, or 1579.111, as applicable; | ||
(2) the amount the physician or provider may bill the | ||
enrollee under the enrollee's managed care plan; and | ||
(3) for an explanation of benefits provided to the | ||
physician or provider, information required by commissioner rule | ||
advising the physician or provider of the availability of the | ||
out-of-network claim dispute resolution process under Chapter | ||
1467. | ||
(b) A physician or health care provider that provides a | ||
service or supply described by Subsection (a) shall provide notice | ||
of the prohibitions described by Subsection (a)(1) in an invoice | ||
for the service or supply provided to an enrollee. | ||
SECTION 1.16. Subchapter C, Chapter 1579, Insurance Code, | ||
is amended by adding Sections 1579.109, 1579.110, and 1579.111 to | ||
read as follows: | ||
Sec. 1579.109. EMERGENCY CARE COVERAGE. (a) In this | ||
section, "emergency care" has the meaning assigned by Section | ||
1301.155. | ||
(b) A managed care plan provided under this chapter must | ||
provide out-of-network emergency care coverage in accordance with | ||
this section. | ||
(c) The coverage must require the administrator of the plan | ||
to pay for emergency care performed by or a supply related to that | ||
care provided by an out-of-network provider at the usual and | ||
customary rate or at an agreed rate. | ||
(d) For emergency care subject to this section or a supply | ||
related to that care, an out-of-network provider or a person | ||
asserting a claim as an agent or assignee of the provider may not | ||
bill an enrollee in, and the enrollee does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the enrollee's managed care plan | ||
that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
Sec. 1579.110. OUT-OF-NETWORK FACILITY-BASED PROVIDER | ||
COVERAGE. (a) In this section, "facility-based provider" means a | ||
physician or health care provider who provides health care services | ||
to patients of a health care facility. | ||
(b) A managed care plan provided under this chapter must | ||
provide out-of-network facility-based provider coverage to | ||
enrollees in accordance with this section. | ||
(c) Except as provided by Subsection (e), the coverage must | ||
require the administrator of the plan to pay for a health care | ||
service performed for or a supply related to that service provided | ||
to an enrollee by an out-of-network provider who is a | ||
facility-based provider at the usual and customary rate or at an | ||
agreed rate if the provider performed the service at a health care | ||
facility that is a participating provider. | ||
(d) Except as provided by Subsection (e), an out-of-network | ||
provider who is a facility-based provider or a person asserting a | ||
claim as an agent or assignee of the provider may not bill an | ||
enrollee receiving a health care service or supply described by | ||
Subsection (c) in, and the enrollee does not have financial | ||
responsibility for, an amount greater than an applicable copayment, | ||
coinsurance, or deductible under the enrollee's managed care plan | ||
that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) does not include any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(e) This section does not apply to a nonemergency health | ||
care service that an enrollee elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the enrollee's potential financial | ||
responsibility from each out-of-network provider providing the | ||
service. | ||
Sec. 1579.111. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER | ||
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic | ||
imaging provider" and "laboratory service provider" have the | ||
meanings assigned by Section 1467.001. | ||
(b) A managed care plan provided under this chapter must | ||
provide out-of-network diagnostic imaging provider and laboratory | ||
service provider coverage for enrollees in accordance with this | ||
section. | ||
(c) Except as provided by Subsection (e), the coverage must | ||
require the administrator of the plan to pay for a health care | ||
service performed for or a supply related to that service provided | ||
to an enrollee by an out-of-network provider who is a diagnostic | ||
imaging provider or laboratory service provider at the usual and | ||
customary rate or at an agreed rate if the provider performed the | ||
service in connection with a health care service performed by a | ||
participating provider. | ||
(d) Except as provided by Subsection (e), an out-of-network | ||
provider who is a diagnostic imaging provider or laboratory service | ||
provider or a person asserting a claim through the provider may not | ||
bill an enrollee receiving a health care service or supply | ||
described by Subsection (c) in, and the enrollee does not have | ||
financial responsibility for, an amount greater than an applicable | ||
copayment, coinsurance, or deductible under the enrollee's managed | ||
care plan that: | ||
(1) is based on: | ||
(A) the amount initially determined payable by | ||
the administrator; or | ||
(B) a modified amount as determined under the | ||
administrator's internal dispute resolution process; and | ||
(2) is not based on any additional amount determined | ||
to be owed to the provider under Chapter 1467. | ||
(e) This section does not apply to a nonemergency health | ||
care service that an enrollee elects to receive: | ||
(1) in writing in advance of the service with respect | ||
to each out-of-network provider providing the service; and | ||
(2) with notice of the enrollee's potential financial | ||
responsibility from each out-of-network provider providing the | ||
service. | ||
ARTICLE 2. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION | ||
SECTION 2.01. Section 1467.001, Insurance Code, is amended | ||
by adding Subdivisions (1-a), (2-c), (2-d), (4-b), and (6-a) and | ||
amending Subdivisions (2-a), (2-b), (3), (5), and (7) to read as | ||
follows: | ||
(1-a) "Arbitration" means a process in which an | ||
impartial arbiter issues a binding determination in a dispute | ||
between a health benefit plan issuer and an out-of-network provider | ||
or the provider's representative to settle a health benefit claim. | ||
(2-a) "Diagnostic imaging provider" means a health | ||
care provider who performs a diagnostic imaging service on a | ||
patient for a fee or interprets imaging produced by a diagnostic | ||
imaging service. | ||
(2-b) "Diagnostic imaging service" means magnetic | ||
resonance imaging, computed tomography, positron emission | ||
tomography, or any hybrid technology that combines any of those | ||
imaging modalities. | ||
(2-c) "Emergency care" has the meaning assigned by | ||
Section 1301.155. | ||
(2-d) [ |
||
physician, health care practitioner, facility, or other health care | ||
provider who provides and bills an enrollee, administrator, or | ||
health benefit plan for emergency care. | ||
(3) "Enrollee" means an individual who is eligible to | ||
receive benefits through a [ |
||
health benefit plan subject to this chapter [ |
||
|
||
(4-b) "Laboratory service provider" means an | ||
accredited facility in which a specimen taken from a human body is | ||
interpreted and pathological diagnoses are made or a person who | ||
makes an interpretation of or diagnosis based on a specimen or | ||
information provided by a laboratory based on a specimen. | ||
(5) "Mediation" means a process in which an impartial | ||
mediator facilitates and promotes agreement between the [ |
||
|
||
and an out-of-network [ |
||
|
||
benefit claim of an enrollee. | ||
(6-a) "Out-of-network provider" means a diagnostic | ||
imaging provider, emergency care provider, facility-based | ||
provider, or laboratory service provider that is not a | ||
participating provider for a health benefit plan. | ||
(7) "Party" means a health benefit plan issuer [ |
||
|
||
administrator, or an out-of-network [ |
||
|
||
participates in a mediation or arbitration conducted under this | ||
chapter. [ |
||
|
||
SECTION 2.02. Sections 1467.002, 1467.003, and 1467.005, | ||
Insurance Code, are amended to read as follows: | ||
Sec. 1467.002. APPLICABILITY OF CHAPTER. (a) This | ||
chapter, other than Subchapter B-1, applies to: | ||
(1) a preferred provider benefit plan, including an | ||
exclusive provider benefit plan, offered by an insurer under | ||
Chapter 1301; and | ||
(2) a health benefit plan offered by [ |
||
|
||
organization operating under Chapter 843 [ |
||
|
||
(b) This chapter, other than Subchapter B, applies to an | ||
administrator of a health benefit plan, other than a health | ||
maintenance organization plan, under Chapter 1551, 1575, or 1579. | ||
Sec. 1467.003. RULES. (a) The commissioner, the Texas | ||
Medical Board, any other appropriate regulatory agency, and the | ||
chief administrative law judge shall adopt rules as necessary to | ||
implement their respective powers and duties under this chapter. | ||
(b) Section 2001.0045, Government Code, does not apply to a | ||
rule adopted under this chapter. | ||
Sec. 1467.005. REFORM. This chapter may not be construed to | ||
prohibit: | ||
(1) a health [ |
||
|
||
offering a reformed claim settlement; or | ||
(2) an out-of-network [ |
||
|
||
charge for health care or medical services or supplies. | ||
SECTION 2.03. Subchapter A, Chapter 1467, Insurance Code, | ||
is amended by adding Section 1467.006 to read as follows: | ||
Sec. 1467.006. BENCHMARKING DATABASE. (a) The | ||
commissioner shall select an organization to maintain a | ||
benchmarking database that contains information necessary to | ||
calculate, with respect to a health care or medical service or | ||
supply, for each geographical area in this state: | ||
(1) the 80th percentile of billed amounts of all | ||
physicians or health care providers; and | ||
(2) the 50th percentile of rates paid to participating | ||
providers. | ||
(b) The commissioner may not select under Subsection (a) an | ||
organization that is financially affiliated with a health benefit | ||
plan issuer. | ||
SECTION 2.04. The heading to Subchapter B, Chapter 1467, | ||
Insurance Code, is amended to read as follows: | ||
SUBCHAPTER B. MANDATORY BINDING ARBITRATION [ |
||
SECTION 2.05. Subchapter B, Chapter 1467, Insurance Code, | ||
is amended by adding Sections 1467.050 and 1467.0505 to read as | ||
follows: | ||
Sec. 1467.050. ESTABLISHMENT AND ADMINISTRATION OF | ||
ARBITRATION PROGRAM. (a) The commissioner shall establish and | ||
administer an arbitration program to resolve disputes over | ||
out-of-network provider amounts in accordance with this | ||
subchapter. | ||
(b) The commissioner: | ||
(1) shall adopt rules, forms, and procedures necessary | ||
for the implementation and administration of the arbitration | ||
program, including the establishment of a portal on the | ||
department's Internet website through which a request for | ||
arbitration under Section 1467.051 may be submitted; and | ||
(2) shall maintain a list of qualified arbitrators for | ||
the program. | ||
Sec. 1467.0505. ISSUE TO BE ADDRESSED; BASIS FOR | ||
DETERMINATION. (a) The only issue that an arbitrator may | ||
determine under this subchapter is the reasonable amount for the | ||
health care or medical services or supplies provided to the | ||
enrollee by an out-of-network provider. | ||
(b) The determination must, at a minimum, take into account: | ||
(1) whether there is a gross disparity between the fee | ||
billed by the out-of-network provider and: | ||
(A) fees paid to the out-of-network provider for | ||
the same services or supplies rendered by the provider to other | ||
enrollees for which the provider is an out-of-network provider; and | ||
(B) fees paid by the health benefit plan issuer | ||
to reimburse similarly qualified out-of-network providers for the | ||
same services or supplies in the same region; | ||
(2) the level of training, education, and experience | ||
of the out-of-network provider; | ||
(3) the out-of-network provider's usual billed amount | ||
for comparable services or supplies with regard to other enrollees | ||
for which the provider is an out-of-network provider; | ||
(4) the circumstances and complexity of the enrollee's | ||
particular case, including the time and place of the provision of | ||
the service or supply; | ||
(5) individual enrollee characteristics; | ||
(6) the 80th percentile of all billed amounts for the | ||
service or supply performed by a health care provider in the same or | ||
similar specialty and provided in the same geographical area as | ||
reported in a benchmarking database described by Section 1467.006; | ||
and | ||
(7) the 50th percentile of rates for the service or | ||
supply paid to participating providers in the same or similar | ||
specialty and provided in the same geographical area as reported in | ||
a benchmarking database described by Section 1467.006. | ||
SECTION 2.06. The heading to Section 1467.051, Insurance | ||
Code, is amended to read as follows: | ||
Sec. 1467.051. AVAILABILITY OF MANDATORY ARBITRATION | ||
[ |
||
SECTION 2.07. Section 1467.051, Insurance Code, is amended | ||
by amending Subsections (a) and (b) and adding Subsections (e), | ||
(f), and (g) to read as follows: | ||
(a) An out-of-network provider or health benefit plan | ||
issuer [ |
||
settlement of an out-of-network health benefit claim through a | ||
portal on the department's Internet website if: | ||
(1) there is an [ |
||
unpaid by the issuer [ |
||
|
||
copayments, deductibles, and coinsurance for which an enrollee may | ||
not be billed [ |
||
|
||
(2) the health benefit claim is for: | ||
(A) emergency care; [ |
||
(B) a health care or medical service or supply | ||
provided by a facility-based provider in a facility that is a | ||
participating [ |
||
(C) an out-of-network laboratory service; or | ||
(D) an out-of-network diagnostic imaging service | ||
[ |
||
(b) If a person [ |
||
|
||
subchapter, the out-of-network [ |
||
|
||
health benefit plan issuer [ |
||
|
||
(e) The person who requests the arbitration shall provide | ||
written notice on the date the arbitration is requested in the form | ||
and manner prescribed by commissioner rule to: | ||
(1) the department; and | ||
(2) each other party. | ||
(f) In an effort to settle the claim before arbitration, all | ||
parties must participate in an informal settlement teleconference | ||
not later than the 30th day after the date on which the arbitration | ||
is requested. A health benefit plan issuer shall make a reasonable | ||
effort to arrange the teleconference. | ||
(g) The parties may agree to submit multiple claims to | ||
arbitration in one proceeding. | ||
SECTION 2.08. Subchapter B, Chapter 1467, Insurance Code, | ||
is amended by adding Section 1467.0515 to read as follows: | ||
Sec. 1467.0515. EFFECT OF ARBITRATION AND APPLICABILITY OF | ||
OTHER LAW. (a) Notwithstanding Section 1467.004, an | ||
out-of-network provider or health benefit plan issuer may not file | ||
suit for an out-of-network claim subject to this chapter until the | ||
conclusion of the arbitration on the issue of the amount to be paid | ||
in the out-of-network claim dispute. | ||
(b) An arbitration conducted under this subchapter is not | ||
subject to Title 7, Civil Practice and Remedies Code. | ||
SECTION 2.09. Subchapter B, Chapter 1467, Insurance Code, | ||
is amended by adding Sections 1467.0535, 1467.0545, 1467.0555, and | ||
1467.0565 to read as follows: | ||
Sec. 1467.0535. SELECTION AND APPROVAL OF ARBITRATOR. | ||
(a) If the parties do not select an arbitrator by mutual agreement | ||
on or before the 30th day after the date the arbitration is | ||
requested, the party requesting the arbitration shall notify the | ||
commissioner, and the commissioner shall select an arbitrator from | ||
the commissioner's list of approved arbitrators. | ||
(b) In approving an individual as an arbitrator, the | ||
commissioner shall ensure that the individual does not have a | ||
conflict of interest that would adversely impact the individual's | ||
independence and impartiality in rendering a decision in an | ||
arbitration. A conflict of interest includes current or recent | ||
ownership or employment of the individual or a close family member | ||
in a health benefit plan issuer or out-of-network provider that may | ||
be involved in the arbitration. | ||
(c) The commissioner shall immediately terminate the | ||
approval of an arbitrator who no longer meets the requirements | ||
under this subchapter and rules adopted under this subchapter to | ||
serve as an arbitrator. | ||
Sec. 1467.0545. PROCEDURES. (a) The arbitrator shall set | ||
a date for submission of all information to be considered by the | ||
arbitrator. | ||
(b) A party may not engage in discovery in connection with | ||
the arbitration. | ||
(c) On agreement of all parties, any deadline under this | ||
subchapter may be extended. | ||
(d) Unless otherwise agreed to by the parties, an | ||
arbitrator: | ||
(1) may not consider medical records that were not | ||
presented to the health benefit plan issuer during an appeals | ||
process offered by the issuer or administrator to resolve an | ||
out-of-network claim; | ||
(2) may not review a claim arising from an adverse | ||
determination by a utilization review agent under Chapter 4201 that | ||
may be reviewed by an independent review organization; and | ||
(3) may not determine whether a health benefit plan | ||
covers a particular health care or medical service or supply. | ||
(e) The parties shall evenly split and pay the arbitrator's | ||
fees and expenses. | ||
Sec. 1467.0555. DECISION. (a) Not later than the 75th day | ||
after the date the arbitration is requested, an arbitrator shall | ||
provide the parties with a written decision in which the | ||
arbitrator: | ||
(1) determines whether the billed amount or the | ||
initial payment made by the health benefit plan issuer is the | ||
closest to the reasonable amount for the services or supplies | ||
determined in accordance with Section 1467.0505(b), provided that: | ||
(A) the provider may revise the billed amount to | ||
correct a billing error before the completion of an appeal process | ||
offered by the issuer or administrator to resolve an out-of-network | ||
claim; and | ||
(B) the health benefit plan issuer may increase | ||
the initial payment under the appeal process offered by the issuer | ||
or administrator to resolve an out-of-network claim; and | ||
(2) selects the amount described by Subdivision (1) as | ||
the binding award amount. | ||
(b) An arbitrator may not modify the binding award amount | ||
selected under Subsection (a). | ||
Sec. 1467.0565. EFFECT OF DECISION. (a) An arbitrator's | ||
decision under Section 1467.0555 is binding. | ||
(b) Not later than the 90th day after the date of an | ||
arbitrator's decision under Section 1467.0555, a party not | ||
satisfied with the decision may file an action to determine the | ||
payment due to an out-of-network provider. | ||
(c) In an action filed under Subsection (b), the court shall | ||
determine whether the arbitrator's decision is proper based on a | ||
substantial evidence standard of review. | ||
(d) A health benefit plan issuer shall pay to an | ||
out-of-network provider any additional amount necessary to satisfy | ||
a binding award or a court's determination in an action filed under | ||
Subsection (b), as applicable. | ||
SECTION 2.10. Chapter 1467, Insurance Code, is amended by | ||
adding Subchapter B-1 to read as follows: | ||
SUBCHAPTER B-1. MANDATORY MEDIATION | ||
Sec. 1467.081. AVAILABILITY OF MANDATORY MEDIATION. | ||
(a) An out-of-network provider or administrator may request | ||
mediation of a settlement of an out-of-network health benefit claim | ||
arising from a health benefit plan to which this subchapter applies | ||
if: | ||
(1) there is an amount billed by the provider and | ||
unpaid by the administrator after copayments, deductibles, and | ||
coinsurance for which an enrollee may not be billed; and | ||
(2) the health benefit claim is for: | ||
(A) emergency care; | ||
(B) a health care or medical service or supply | ||
provided by a facility-based provider in a facility that is a | ||
participating provider; | ||
(C) an out-of-network laboratory service; or | ||
(D) an out-of-network diagnostic imaging | ||
service. | ||
(b) If a person requests mediation under this subchapter, | ||
the out-of-network provider, or the provider's representative, and | ||
the administrator shall participate in the mediation. | ||
Sec. 1467.082. MEDIATOR QUALIFICATIONS. (a) Except as | ||
provided by Subsection (b), to qualify for an appointment as a | ||
mediator under this subchapter a person must have completed at | ||
least 40 classroom hours of training in dispute resolution | ||
techniques in a course conducted by an alternative dispute | ||
resolution organization or other dispute resolution organization | ||
approved by the chief administrative law judge. | ||
(b) A person not qualified under Subsection (a) may be | ||
appointed as a mediator on agreement of the parties. | ||
(c) A person may not act as mediator for a claim settlement | ||
dispute if the person has been employed by, consulted for, or | ||
otherwise had a business relationship with an administrator of a | ||
health benefit plan that is subject to this subchapter or a | ||
physician, health care practitioner, or other health care provider | ||
during the three years immediately preceding the request for | ||
mediation. | ||
Sec. 1467.083. APPOINTMENT OF MEDIATOR; FEES. (a) A | ||
mediation shall be conducted by one mediator. | ||
(b) The chief administrative law judge shall appoint the | ||
mediator through a random assignment from a list of qualified | ||
mediators maintained by the State Office of Administrative | ||
Hearings. | ||
(c) Notwithstanding Subsection (b), a person other than a | ||
mediator appointed by the chief administrative law judge may | ||
conduct the mediation on agreement of all of the parties and notice | ||
to the chief administrative law judge. | ||
(d) The mediator's fees shall be split evenly and paid by | ||
the administrator and the out-of-network provider. | ||
Sec. 1467.084. REQUEST AND PRELIMINARY PROCEDURES FOR | ||
MANDATORY MEDIATION. (a) An out-of-network provider or | ||
administrator may request mandatory mediation under this | ||
subchapter. | ||
(b) A request for mandatory mediation must be provided to | ||
the department on a form prescribed by the commissioner and must | ||
include: | ||
(1) the name of the person requesting mediation; | ||
(2) a brief description of the claim to be mediated; | ||
(3) contact information, including a telephone | ||
number, for the requesting person and the person's counsel, if the | ||
person retains counsel; | ||
(4) the name of the out-of-network provider and name | ||
of the administrator; and | ||
(5) any other information the commissioner may require | ||
by rule. | ||
(c) On receipt of a request for mediation, the department | ||
shall notify the out-of-network provider or the administrator of | ||
the request. | ||
(d) In an effort to settle the claim before mediation, all | ||
parties must participate in an informal settlement teleconference | ||
not later than the 30th day after the date on which a person submits | ||
a request for mediation under this subchapter. | ||
(e) A dispute to be mediated under this subchapter that does | ||
not settle as a result of a teleconference conducted under | ||
Subsection (d) must be conducted in the county in which the health | ||
care or medical services were rendered. | ||
Sec. 1467.085. CONDUCT OF MEDIATION; CONFIDENTIALITY. | ||
(a) A mediator may not impose the mediator's judgment on a party | ||
about an issue that is a subject of the mediation. | ||
(b) A mediation session is under the control of the | ||
mediator. | ||
(c) Except as provided by this chapter, the mediator must | ||
hold in strict confidence all information provided to the mediator | ||
by a party and all communications of the mediator with a party. | ||
(d) A party must have an opportunity during the mediation to | ||
speak and state the party's position. | ||
(e) Except on the agreement of the participating parties, a | ||
mediation may not last more than four hours. | ||
(f) A mediation shall be held not later than the 180th day | ||
after the date of the request for mediation. | ||
(g) A health care or medical service or supply provided by | ||
an out-of-network provider may not be summarily disallowed. This | ||
subsection does not require an administrator to pay for an | ||
uncovered service or supply. | ||
(h) A mediator may not testify in a proceeding, other than a | ||
proceeding to enforce this chapter, related to the mediation | ||
agreement. | ||
Sec. 1467.086. MATTERS CONSIDERED IN MEDIATION; AGREED | ||
RESOLUTION. (a) In a mediation under this subchapter, the parties | ||
shall evaluate whether: | ||
(1) the amount charged by the out-of-network provider | ||
for the health care or medical service or supply is excessive; and | ||
(2) the amount paid by the administrator represents | ||
the usual and customary rate for the health care or medical service | ||
or supply or is unreasonably low. | ||
(b) The out-of-network provider may present information | ||
regarding the amount charged for the health care or medical service | ||
or supply. The administrator may present information regarding the | ||
amount paid by the administrator. | ||
(c) Nothing in this chapter prohibits mediation of more than | ||
one claim between the parties during a mediation. | ||
(d) The goal of the mediation is to reach an agreement | ||
between the out-of-network provider and the administrator as to the | ||
amount paid by the administrator to the provider and the amount | ||
charged by the provider. | ||
Sec. 1467.087. NO AGREED RESOLUTION. (a) The mediator of | ||
an unsuccessful mediation under this subchapter shall report the | ||
outcome of the mediation to the department, the Texas Medical Board | ||
or other appropriate regulatory agency, and the chief | ||
administrative law judge. | ||
(b) The chief administrative law judge shall enter an order | ||
of referral of a matter reported under Subsection (a) to a special | ||
judge under Chapter 151, Civil Practice and Remedies Code, that: | ||
(1) names the special judge on whom the parties agreed | ||
or appoints the special judge if the parties did not agree on a | ||
judge; | ||
(2) states the issues to be referred and the time and | ||
place on which the parties agree for the trial; | ||
(3) requires each party to pay the party's | ||
proportionate share of the special judge's fee; and | ||
(4) certifies that the parties have waived the right | ||
to trial by jury. | ||
(c) A trial by the special judge selected or appointed as | ||
described by Subsection (b) must proceed under Chapter 151, Civil | ||
Practice and Remedies Code, except that the special judge's verdict | ||
is not relevant or material to any other billing dispute and has no | ||
precedential value. | ||
(d) Notwithstanding any other provision of this section, | ||
Section 151.012, Civil Practice and Remedies Code, does not apply | ||
to a mediation under this subchapter. | ||
Sec. 1467.088. CONTINUATION OF MEDIATION. After a referral | ||
is made under Section 1467.087, the out-of-network provider and the | ||
administrator may elect to continue the mediation to further | ||
determine their responsibilities. | ||
Sec. 1467.089. MEDIATION AGREEMENT. The mediator shall | ||
prepare a confidential mediation agreement and order that states | ||
any agreement reached by the parties under Section 1467.088. | ||
Sec. 1467.090. REPORT OF MEDIATOR. The mediator shall | ||
report to the commissioner and the Texas Medical Board or other | ||
appropriate regulatory agency: | ||
(1) the names of the parties to the mediation; and | ||
(2) whether the parties reached an agreement or the | ||
mediator made a referral under Section 1467.087. | ||
SECTION 2.11. Subchapter C, Chapter 1467, Insurance Code, | ||
is amended to read as follows: | ||
SUBCHAPTER C. BAD FAITH PARTICIPATION [ |
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Sec. 1467.101. BAD FAITH. (a) The following conduct | ||
constitutes bad faith participation [ |
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this chapter: | ||
(1) failing to participate in the informal settlement | ||
teleconference under Section 1467.051(f), arbitration under | ||
Subchapter B, or mediation under Subchapter B-1; | ||
(2) failing to provide information the arbitrator or | ||
mediator believes is necessary to facilitate a decision or [ |
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agreement; [ |
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(3) failing to designate a representative | ||
participating in the arbitration or mediation with full authority | ||
to enter into any [ |
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(4) failing to appear for the arbitration or | ||
mediation. | ||
(b) Failure to reach an agreement under Subchapter B-1 is | ||
not conclusive proof of bad faith participation [ |
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Sec. 1467.102. PENALTIES. (a) Bad faith participation or | ||
otherwise failing to comply with Subchapter B [ |
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administrative penalty by the regulatory agency that issued a | ||
license or certificate of authority to the party who committed the | ||
violation. | ||
(b) Except for good cause shown, on a report of a mediator | ||
and appropriate proof of bad faith participation under Subchapter | ||
B-1 [ |
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certificate of authority shall impose an administrative penalty. | ||
SECTION 2.12. Sections 1467.151(a), (b), and (c), Insurance | ||
Code, are amended to read as follows: | ||
(a) The commissioner and the Texas Medical Board or other | ||
regulatory agency, as appropriate, shall adopt rules regulating the | ||
investigation and review of a complaint filed that relates to the | ||
settlement of an out-of-network health benefit claim that is | ||
subject to this chapter. The rules adopted under this section must: | ||
(1) distinguish among complaints for out-of-network | ||
coverage or payment and give priority to investigating allegations | ||
of delayed health care or medical care; | ||
(2) develop a form for filing a complaint [ |
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(3) ensure that a complaint is not dismissed without | ||
appropriate consideration[ |
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[ |
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[ |
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(b) The department and the Texas Medical Board or other | ||
appropriate regulatory agency shall maintain information[ |
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[ |
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arbitration, or mediation subject to this chapter[ |
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[ |
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(1) [ |
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rise to the dispute; | ||
(2) [ |
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out-of-network [ |
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(3) [ |
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the health care or medical service or supply was provided; | ||
(4) [ |
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or supply was for emergency care; and | ||
(5) [ |
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(A) [ |
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[ |
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or | ||
(B) [ |
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provider [ |
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or other appropriate regulatory agency by rule requires. | ||
(c) The information collected and maintained [ |
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information as defined by Section 552.002, Government Code, and may | ||
not include personally identifiable information or health care or | ||
medical information. | ||
ARTICLE 3. CONFORMING AMENDMENTS | ||
SECTION 3.01. Section 1456.001(6), Insurance Code, is | ||
amended to read as follows: | ||
(6) "Provider network" means a health benefit plan | ||
under which health care services are provided to enrollees through | ||
contracts with health care providers and that requires those | ||
enrollees to use health care providers participating in the plan | ||
and procedures covered by the plan. [ |
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[ |
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[ |
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SECTION 3.02. Sections 1456.002(a) and (c), Insurance Code, | ||
are amended to read as follows: | ||
(a) This chapter applies to any health benefit plan that: | ||
(1) provides benefits for medical or surgical expenses | ||
incurred as a result of a health condition, accident, or sickness, | ||
including an individual, group, blanket, or franchise insurance | ||
policy or insurance agreement, a group hospital service contract, | ||
or an individual or group evidence of coverage that is offered by: | ||
(A) an insurance company; | ||
(B) a group hospital service corporation | ||
operating under Chapter 842; | ||
(C) a fraternal benefit society operating under | ||
Chapter 885; | ||
(D) a stipulated premium company operating under | ||
Chapter 884; | ||
(E) [ |
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[ |
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that holds a certificate of authority under Chapter 846; | ||
(F) [ |
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corporation that holds a certificate of authority under Chapter | ||
844; or | ||
(G) [ |
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code or another insurance law of this state that contracts directly | ||
for health care services on a risk-sharing basis, including a | ||
capitation basis; or | ||
(2) provides health and accident coverage through a | ||
risk pool created under Chapter 172, Local Government Code, | ||
notwithstanding Section 172.014, Local Government Code, or any | ||
other law. | ||
(c) This chapter does not apply to: | ||
(1) Medicaid managed care programs operated under | ||
Chapter 533, Government Code; | ||
(2) Medicaid programs operated under Chapter 32, Human | ||
Resources Code; [ |
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(3) the state child health plan operated under Chapter | ||
62 or 63, Health and Safety Code; or | ||
(4) a health benefit plan subject to Section 1271.157, | ||
1301.164, 1551.229, 1575.172, or 1579.110. | ||
SECTION 3.03. The following provisions of the Insurance | ||
Code are repealed: | ||
(1) Section 1456.004(c); | ||
(2) Sections 1467.051(c) and (d); | ||
(3) Section 1467.0511; | ||
(4) Section 1467.052; | ||
(5) Section 1467.053; | ||
(6) Section 1467.054; | ||
(7) Section 1467.055; | ||
(8) Section 1467.056; | ||
(9) Section 1467.057; | ||
(10) Section 1467.058; | ||
(11) Section 1467.059; | ||
(12) Section 1467.060; and | ||
(13) Section 1467.151(d). | ||
ARTICLE 4. STUDY | ||
SECTION 4.01. Subchapter A, Chapter 38, Insurance Code, is | ||
amended by adding Section 38.004 to read as follows: | ||
Sec. 38.004. BALANCE BILLING PROHIBITION REPORT. (a) The | ||
department shall, each biennium, conduct a study on the impacts of | ||
S.B. No. 1264, Acts of the 86th Legislature, Regular Session, 2019, | ||
on Texas consumers and health coverage in this state, including: | ||
(1) trends in billed amounts for health care or | ||
medical services or supplies, especially emergency services, | ||
laboratory services, diagnostic imaging services, and | ||
facility-based services; | ||
(2) comparison of the total amount spent on | ||
out-of-network emergency services, laboratory services, diagnostic | ||
imaging services, and facility-based services by calendar year and | ||
provider type or physician specialty; | ||
(3) trends and changes in network participation by | ||
providers of emergency services, laboratory services, diagnostic | ||
imaging services, and facility-based services by provider type or | ||
physician specialty, including whether any terminations were | ||
initiated by a health benefit plan issuer, administrator, or | ||
provider; | ||
(4) the number of complaints, completed | ||
investigations, and disciplinary sanctions for billing by | ||
providers of emergency services, laboratory services, diagnostic | ||
imaging services, or facility-based services of insureds, | ||
enrollees, or plan participants for amounts greater than the | ||
insured's, enrollee's, or participant's responsibility under an | ||
applicable managed care plan, including an applicable copayment, | ||
coinsurance, or deductible; | ||
(5) trends in amounts paid to out-of-network | ||
providers; | ||
(6) trends in the usual and customary rate for health | ||
care or medical services or supplies, especially emergency | ||
services, laboratory services, diagnostic imaging services, and | ||
facility-based services; and | ||
(7) the effectiveness of the claim dispute resolution | ||
process under Chapter 1467. | ||
(b) In conducting the study described by Subsection (a), the | ||
department shall collect settlement data and verdicts or | ||
arbitration awards from parties to arbitration under Chapter 1467. | ||
(c) The department: | ||
(1) shall collect data quarterly from a health benefit | ||
plan issuer or administrator subject to Chapter 1467 to conduct the | ||
study required by this section; and | ||
(2) may utilize any reliable external resource or | ||
entity to acquire information reasonably necessary to prepare the | ||
report required by Subsection (d). | ||
(d) Not later than December 1 of each even-numbered year, | ||
the department shall prepare and submit a written report on the | ||
results of the study under this section, including the department's | ||
findings, to the legislature. | ||
ARTICLE 5. TRANSITION AND EFFECTIVE DATE | ||
SECTION 5.01. The changes in law made by this Act apply only | ||
to a health care or medical service or supply provided on or after | ||
January 1, 2020. A health care or medical service or supply | ||
provided before January 1, 2020, is governed by the law in effect | ||
immediately before the effective date of this Act, and that law is | ||
continued in effect for that purpose. | ||
SECTION 5.02. The Texas Department of Insurance, the | ||
Employees Retirement System of Texas, the Teacher Retirement System | ||
of Texas, and any other state agency subject to this Act are | ||
required to implement a provision of this Act only if the | ||
legislature appropriates money specifically for that purpose. If | ||
the legislature does not appropriate money specifically for that | ||
purpose, those agencies may, but are not required to, implement a | ||
provision of this Act using other appropriations available for that | ||
purpose. | ||
SECTION 5.03. This Act takes effect September 1, 2019. |