81R5892 PMO-D
By: Jackson H.B. No. 1930
A BILL TO BE ENTITLED
AN ACT
relating to health services provided to health benefit plan
enrollees by certain out-of-network health care providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1456.001, Insurance Code, is amended by
adding Subdivisions (5-a) and (5-b) to read as follows:
(5-a) "Out-of-network provider" means a health care
practitioner who has not contracted with a health benefit plan
issuer to provide services to enrollees.
(5-b) "Participating provider" means a health care
practitioner who has contracted with a health benefit plan issuer
to provide services to enrollees.
SECTION 2. Chapter 1456, Insurance Code, is amended by
adding Section 1456.0041 to read as follows:
Sec. 1456.0041. REQUIRED DISCLOSURE: OUT-OF-NETWORK
PROVIDER BILLING. (a) A participating provider shall provide
written notice to an enrollee if the participating provider:
(1) refers an enrollee to an out-of-network provider;
(2) has granted clinical privileges to a surgeon, a
radiologist, an anesthesiologist, a pathologist, or another
physician who is an out-of-network provider who is to provide
services to the enrollee as a patient of the facility; or
(3) otherwise arranges for health care services for
the enrollee through an out-of-network provider.
(b) The notice required by this section must substantially
comply with requirements adopted under Subsection (i) and must
disclose that the out-of-network provider:
(1) is not a participating provider for the enrollee's
managed care plan; and
(2) may charge the enrollee the balance of the
provider's fee for services received by the enrollee that is not
fully paid or reimbursed by the enrollee's managed care plan.
(c) The notice must include a signature line for the
enrollee to sign to acknowledge that the enrollee has received the
notice.
(d) An out-of-network provider may elect to provide the
notice required by this section.
(e) A health care provider that provides notice under this
section shall maintain a copy of the notice, signed by the enrollee,
in the provider's records.
(f) The notice required by this section must be provided to
an enrollee:
(1) before services are provided to the enrollee by an
out-of-network provider; and
(2) to the extent practicable, sufficiently in advance
of the time the services are to be provided to allow the enrollee to
select a participating provider to provide the services.
(g) If notice is not provided as required by this section,
the out-of-network provider may not charge the enrollee for any
portion of that provider's fee that is not paid or reimbursed by the
enrollee's managed care plan.
(h) A health care provider is not required to provide the
notice required by this section, and Subsection (g) does not apply,
if the enrollee's treating physician reasonably determines, in the
physician's medical judgment, that an emergency exists and there is
insufficient time to provide that notice.
(i) The commissioner shall adopt rules as necessary to
implement this chapter, including a rule prescribing the form of
the notice required by this section.
SECTION 3. This Act applies only to a managed care plan that
is delivered, issued for delivery, or renewed on or after January 1,
2010. A managed care plan that is 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 4. This Act takes effect September 1, 2009.