81R5893 PMO-D
By: Jackson H.B. No. 1929
A BILL TO BE ENTITLED
AN ACT
relating to payment of claims of certain out-of-network physicians
and health care providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1458 to read as follows:
CHAPTER 1458. PAYMENT OF OUT-OF-NETWORK PROVIDER
Sec. 1458.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible to
receive health care services under a managed care plan.
(2) "Health care provider" means:
(A) an individual who is licensed to provide
health care services; or
(B) a hospital, emergency clinic, outpatient
clinic, or other facility providing health care services.
(3) "Managed care plan" 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 health
benefit plan issued by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) any other entity that issues a health benefit
plan, including an insurance company.
(4) "Out-of-network provider" means a health care
provider who is not a participating provider.
(5) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer to
provide services to enrollees.
Sec. 1458.002. CONDITION FOR PAYMENT AT IN-NETWORK RATE. A
managed care plan must pay an out-of-network health care provider
that provides a service to an enrollee at the rate the plan pays a
participating provider for the health care service only if the
enrollee:
(1) makes a reasonable effort to locate and obtain the
health care service from a participating provider; and
(2) is unable, after that reasonable effort, to locate
and obtain the health care service from a participating provider.
Sec. 1458.003. RULES. The commissioner shall adopt rules
necessary to implement this chapter, including a rule to identify
criteria used to determine whether an enrollee made reasonable
efforts to locate and obtain adequate health care services from a
participating provider.
SECTION 2. This Act applies only to an insurance policy or
contract or evidence of coverage that is delivered, issued for
delivery, or renewed on or after January 1, 2010. An insurance
policy or contract or evidence of coverage delivered, issued for
delivery, or renewed before January 1, 2010, is governed by the law
as it existed immediately before the effective date of this Act, and
that law is continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2009.