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A BILL TO BE ENTITLED
|
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AN ACT
|
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relating to consumer protections against certain medical and health |
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care billing by certain out-of-network providers; authorizing a |
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fee. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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ARTICLE 1. ELIMINATION OF SURPRISE BILLING FOR CERTAIN HEALTH |
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BENEFIT PLANS |
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SECTION 1.01. Subtitle G, Title 5, Insurance Code, is |
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amended by adding Chapter 752 to read as follows: |
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CHAPTER 752. ENFORCEMENT OF BALANCE BILLING PROHIBITIONS |
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Sec. 752.0001. INJUNCTION FOR BALANCE BILLING. (a) If the |
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attorney general believes that an individual or entity has |
|
exhibited a pattern of intentionally violating a law that prohibits |
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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. |
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(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. |
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Sec. 752.0002. ENFORCEMENT BY REGULATORY AGENCY. (a) An |
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appropriate regulatory agency that licenses, certifies, or |
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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; [and] |
|
(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 [a nonpreferred] |
|
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 [nonpreferred] provider at |
|
the usual and customary rate or at a rate agreed to by the issuer and |
|
the out-of-network [nonpreferred] provider for the provision of the |
|
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; |
|
[and] |
|
(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) [(2-b)] "Emergency care provider" means a |
|
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 [preferred provider benefit plan or a] |
|
health benefit plan subject to this chapter [under Chapter 1551,
|
|
1575, or 1579]. |
|
(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 [insurer
|
|
offering a preferred provider benefit plan or the] administrator |
|
and an out-of-network [a facility-based] provider [or emergency
|
|
care provider] or the provider's representative to settle a health |
|
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 [an
|
|
insurer] offering a health [a preferred provider] benefit plan, an |
|
administrator, or an out-of-network [a facility-based provider or
|
|
emergency care] provider or the provider's representative who |
|
participates in a mediation or arbitration conducted under this |
|
chapter. [The enrollee is also considered a party to the
|
|
mediation.] |
|
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 [an administrator
|
|
of a health benefit plan, other than] a health maintenance |
|
organization operating under Chapter 843 [plan, under Chapter 1551,
|
|
1575, or 1579]. |
|
(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 [an insurer offering a preferred
|
|
provider] benefit plan issuer or administrator from, at any time, |
|
offering a reformed claim settlement; or |
|
(2) an out-of-network [a facility-based provider or
|
|
emergency care] provider from, at any time, offering a reformed |
|
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 [MEDIATION] |
|
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 |
|
[MEDIATION; EXCEPTION]. |
|
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 [An enrollee] may request arbitration [mediation] of a |
|
settlement of an out-of-network health benefit claim through a |
|
portal on the department's Internet website if: |
|
(1) there is an [the] amount billed by the provider and |
|
unpaid by the issuer [for which the enrollee is responsible to a
|
|
facility-based provider or emergency care provider,] after |
|
copayments, deductibles, and coinsurance for which an enrollee may |
|
not be billed [, including the amount unpaid by the administrator or
|
|
insurer, is greater than $500]; and |
|
(2) the health benefit claim is for: |
|
(A) emergency care; [or] |
|
(B) a health care or medical service or supply |
|
provided by a facility-based provider in a facility that is a |
|
participating [preferred] provider; |
|
(C) an out-of-network laboratory service; or |
|
(D) an out-of-network diagnostic imaging service |
|
[that has a contract with the administrator]. |
|
(b) If a person [Except as provided by Subsections (c) and
|
|
(d), if an enrollee] requests arbitration [mediation] under this |
|
subchapter, the out-of-network [facility-based] provider [or
|
|
emergency care provider,] or the provider's representative, and the |
|
health benefit plan issuer [insurer or the administrator, as
|
|
appropriate,] shall participate in the arbitration [mediation]. |
|
(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 [MEDIATION] |
|
Sec. 1467.101. BAD FAITH. (a) The following conduct |
|
constitutes bad faith participation [mediation] for purposes of |
|
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 [an] |
|
agreement; [or] |
|
(3) failing to designate a representative |
|
participating in the arbitration or mediation with full authority |
|
to enter into any [mediated] agreement; or |
|
(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 [mediation]. |
|
Sec. 1467.102. PENALTIES. (a) Bad faith participation or |
|
otherwise failing to comply with Subchapter B [mediation, by a
|
|
party other than the enrollee,] is grounds for imposition of an |
|
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 [mediation], the regulatory agency that issued the license or |
|
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 [and
|
|
establish an outreach effort to inform enrollees of the
|
|
availability of the claims dispute resolution process under this
|
|
chapter]; and |
|
(3) ensure that a complaint is not dismissed without |
|
appropriate consideration[;
|
|
[(4)
ensure that enrollees are informed of the
|
|
availability of mandatory mediation; and
|
|
[(5)
require the administrator to include a notice of
|
|
the claims dispute resolution process available under this chapter
|
|
with the explanation of benefits sent to an enrollee]. |
|
(b) The department and the Texas Medical Board or other |
|
appropriate regulatory agency shall maintain information[:
|
|
[(1)] on each complaint filed that concerns a claim, |
|
arbitration, or mediation subject to this chapter[; and
|
|
[(2)
related to a claim that is the basis of an
|
|
enrollee complaint], including: |
|
(1) [(A)] the type of services or supplies that gave |
|
rise to the dispute; |
|
(2) [(B)] the type and specialty, if any, of the |
|
out-of-network [facility-based] provider [or emergency care
|
|
provider] who provided the out-of-network service or supply; |
|
(3) [(C)] the county and metropolitan area in which |
|
the health care or medical service or supply was provided; |
|
(4) [(D)] whether the health care or medical service |
|
or supply was for emergency care; and |
|
(5) [(E)] any other information about: |
|
(A) [(i)] the health benefit plan issuer |
|
[insurer] or administrator that the commissioner by rule requires; |
|
or |
|
(B) [(ii)] the out-of-network [facility-based] |
|
provider [or emergency care provider] that the Texas Medical Board |
|
or other appropriate regulatory agency by rule requires. |
|
(c) The information collected and maintained [by the
|
|
department and the Texas Medical Board and other appropriate
|
|
regulatory agencies] under Subsection (b) [(b)(2)] is public |
|
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. [The term includes a network
|
|
operated by:
|
|
[(A) a health maintenance organization;
|
|
[(B) a preferred provider benefit plan issuer; or
|
|
[(C)
another entity that issues a health benefit
|
|
plan, including an insurance company.] |
|
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) [a health maintenance organization operating
|
|
under Chapter 843;
|
|
[(F)] a multiple employer welfare arrangement |
|
that holds a certificate of authority under Chapter 846; |
|
(F) [(G)] an approved nonprofit health |
|
corporation that holds a certificate of authority under Chapter |
|
844; or |
|
(G) [(H)] an entity not authorized under this |
|
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; [or] |
|
(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. |