| 1 | 1 | | 81R5893 PMO-D |
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| 2 | 2 | | By: Jackson H.B. No. 1929 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | A BILL TO BE ENTITLED |
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| 6 | 6 | | AN ACT |
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| 7 | 7 | | relating to payment of claims of certain out-of-network physicians |
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| 8 | 8 | | and health care providers. |
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| 9 | 9 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 10 | 10 | | SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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| 11 | 11 | | by adding Chapter 1458 to read as follows: |
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| 12 | 12 | | CHAPTER 1458. PAYMENT OF OUT-OF-NETWORK PROVIDER |
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| 13 | 13 | | Sec. 1458.001. DEFINITIONS. In this chapter: |
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| 14 | 14 | | (1) "Enrollee" means an individual who is eligible to |
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| 15 | 15 | | receive health care services under a managed care plan. |
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| 16 | 16 | | (2) "Health care provider" means: |
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| 17 | 17 | | (A) an individual who is licensed to provide |
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| 18 | 18 | | health care services; or |
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| 19 | 19 | | (B) a hospital, emergency clinic, outpatient |
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| 20 | 20 | | clinic, or other facility providing health care services. |
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| 21 | 21 | | (3) "Managed care plan" means a health benefit plan |
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| 22 | 22 | | under which health care services are provided to enrollees through |
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| 23 | 23 | | contracts with health care providers and that requires those |
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| 24 | 24 | | enrollees to use health care providers participating in the plan |
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| 25 | 25 | | and procedures covered by the plan. The term includes a health |
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| 26 | 26 | | benefit plan issued by: |
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| 27 | 27 | | (A) a health maintenance organization; |
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| 28 | 28 | | (B) a preferred provider benefit plan issuer; or |
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| 29 | 29 | | (C) any other entity that issues a health benefit |
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| 30 | 30 | | plan, including an insurance company. |
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| 31 | 31 | | (4) "Out-of-network provider" means a health care |
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| 32 | 32 | | provider who is not a participating provider. |
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| 33 | 33 | | (5) "Participating provider" means a health care |
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| 34 | 34 | | provider who has contracted with a health benefit plan issuer to |
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| 35 | 35 | | provide services to enrollees. |
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| 36 | 36 | | Sec. 1458.002. CONDITION FOR PAYMENT AT IN-NETWORK RATE. A |
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| 37 | 37 | | managed care plan must pay an out-of-network health care provider |
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| 38 | 38 | | that provides a service to an enrollee at the rate the plan pays a |
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| 39 | 39 | | participating provider for the health care service only if the |
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| 40 | 40 | | enrollee: |
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| 41 | 41 | | (1) makes a reasonable effort to locate and obtain the |
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| 42 | 42 | | health care service from a participating provider; and |
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| 43 | 43 | | (2) is unable, after that reasonable effort, to locate |
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| 44 | 44 | | and obtain the health care service from a participating provider. |
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| 45 | 45 | | Sec. 1458.003. RULES. The commissioner shall adopt rules |
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| 46 | 46 | | necessary to implement this chapter, including a rule to identify |
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| 47 | 47 | | criteria used to determine whether an enrollee made reasonable |
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| 48 | 48 | | efforts to locate and obtain adequate health care services from a |
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| 49 | 49 | | participating provider. |
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| 50 | 50 | | SECTION 2. This Act applies only to an insurance policy or |
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| 51 | 51 | | contract or evidence of coverage that is delivered, issued for |
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| 52 | 52 | | delivery, or renewed on or after January 1, 2010. An insurance |
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| 53 | 53 | | policy or contract or evidence of coverage delivered, issued for |
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| 54 | 54 | | delivery, or renewed before January 1, 2010, is governed by the law |
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| 55 | 55 | | as it existed immediately before the effective date of this Act, and |
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| 56 | 56 | | that law is continued in effect for that purpose. |
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| 57 | 57 | | SECTION 3. This Act takes effect September 1, 2009. |
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