Texas 2009 - 81st Regular

Texas House Bill HB2431 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	81R9831 PMO-F
2	2	By: Smith of Tarrant H.B. No. 2431
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to mediation of out-of-network health benefit claim
8	8	disputes between enrollees and health benefit plan issuers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
11	11	by adding Chapter 1467 to read as follows:
12	12	CHAPTER 1467. OUT-OF-NETWORK CLAIM SETTLEMENT MEDIATION
13	13	Sec. 1467.001. DEFINITIONS. In this chapter:
14	14	(1) "Billing code" means the American Medical
15	15	Association's Current Procedural Terminology (CPT) code, the
16	16	Healthcare Common Procedure Coding System (HCPCS), a revenue code,
17	17	or any other code used by physicians or health care providers to
18	18	obtain reimbursement.
19	19	(2) "Enrollee" means an individual who is eligible to
20	20	receive benefits through a health benefit plan.
21	21	(3) "Fee array" means a schedule of the billing codes
22	22	relevant to a claim settlement dispute that are used by a health
23	23	benefit plan issuer in paying the claim. For each billing code, the
24	24	fee array is composed of:
25	25	(A) the highest fee paid by the health benefit
26	26	plan issuer for a particular medical service, health care service,
27	27	or medical supply for the code during the preceding 12 calendar
28	28	months;
29	29	(B) the lowest fee paid by the health benefit
30	30	plan issuer for the particular medical service, health care
31	31	service, or medical supply for the code during the preceding 12
32	32	calendar months; and
33	33	(C) the median fee paid by the health benefit
34	34	plan issuer for the particular medical service, health care
35	35	service, or medical supply for the code during the preceding 12
36	36	calendar months.
37	37	(4) "Mediation" means a process in which an impartial
38	38	mediator facilitates and promotes a voluntary agreement between the
39	39	parties to settle a health benefit claim.
40	40	(5) "Mediator" means an impartial person who is
41	41	appointed to conduct a mediation under this chapter.
42	42	(6) "Party" means a health benefit plan issuer or an
43	43	enrollee who participates in a mediation conducted under this
44	44	chapter.
45	45	Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter
46	46	applies to any health benefit plan that:
47	47	(1) provides benefits for medical or surgical expenses
48	48	incurred as a result of a health condition, accident, or sickness,
49	49	including an individual, group, blanket, or franchise insurance
50	50	policy or insurance agreement, a group hospital service contract,
51	51	or an individual or group evidence of coverage that is offered by:
52	52	(A) an insurance company;
53	53	(B) a group hospital service corporation
54	54	operating under Chapter 842;
55	55	(C) a fraternal benefit society operating under
56	56	Chapter 885;
57	57	(D) a stipulated premium company operating under
58	58	Chapter 884;
59	59	(E) a health maintenance organization operating
60	60	under Chapter 843;
61	61	(F) a multiple employer welfare arrangement that
62	62	holds a certificate of authority under Chapter 846;
63	63	(G) an approved nonprofit health corporation
64	64	that holds a certificate of authority under Chapter 844; or
65	65	(H) an entity not authorized under this code or
66	66	another insurance law of this state that contracts directly for
67	67	health care services on a risk-sharing basis, including a
68	68	capitation basis; or
69	69	(2) provides health and accident coverage through a
70	70	risk pool created under Chapter 172, Local Government Code,
71	71	notwithstanding Section 172.014, Local Government Code, or any
72	72	other law.
73	73	Sec. 1467.003. AVAILABILITY OF MEDIATION; PUBLIC INSURANCE
74	74	COUNSEL. (a) An enrollee may request mediation of a settlement of
75	75	an out-of-network health benefit claim if:
76	76	(1) the health benefit plan issuer does not determine
77	77	the financial responsibility of the issuer and enrollee based
78	78	solely on the amount submitted on the claim by an out-of-network
79	79	health care provider; and
80	80	(2) the amount for which the enrollee is responsible,
81	81	including the amount unpaid by the issuer, is greater than $500.
82	82	(b) The public insurance counsel may request mediation on
83	83	behalf of an enrollee under this chapter.
84	84	Sec. 1467.004. MEDIATOR QUALIFICATIONS. (a) Except as
85	85	provided by Subsection (b), to qualify for an appointment as a
86	86	mediator under this chapter a person must have completed at least 40
87	87	classroom hours of training in dispute resolution techniques in a
88	88	course conducted by an alternative dispute resolution organization
89	89	or other dispute resolution organization approved by the
90	90	commissioner.
91	91	(b) A person not qualified under Subsection (a) may be
92	92	appointed as a mediator on agreement of the parties.
93	93	(c) A person may not mediate a claim settlement dispute if
94	94	the person has been employed by, consulted for, or otherwise had a
95	95	business relationship with, the health benefit plan issuer during
96	96	the seven years immediately preceding the request for mediation.
97	97	Sec. 1467.005. APPOINTMENT OF MEDIATOR; FEES. (a) A
98	98	mediation shall be conducted by one mediator.
99	99	(b) The mediator shall be appointed by the commissioner
100	100	through a random assignment from a list of qualified mediators
101	101	maintained by the department.
102	102	(c) Notwithstanding Subsection (b), a person other than a
103	103	mediator appointed by the commissioner may conduct the mediation on
104	104	agreement of the parties and notice to the commissioner.
105	105	(d) The health benefit plan issuer shall pay all costs of
106	106	the mediation, including the mediator's fees.
107	107	Sec. 1467.006. REQUEST AND PRELIMINARY PROCEDURES FOR
108	108	MANDATORY MEDIATION. (a) An enrollee may request mandatory
109	109	mediation under this chapter.
110	110	(b) A request for mandatory mediation must be provided on a
111	111	form prescribed by the commissioner, and must include:
112	112	(1) the name of the enrollee requesting mediation;
113	113	(2) a brief description of the claim to be mediated;
114	114	(3) contact information, including a telephone
115	115	number, for the requesting enrollee and the enrollee's counsel, if
116	116	the enrollee retains counsel;
117	117	(4) whether the public insurance counsel will
118	118	participate in the mediation; and
119	119	(5) any other information the commissioner may require
120	120	by rule.
121	121	(c) Except on agreement of the parties, a mandatory
122	122	mediation must take place within 30 miles of the enrollee's
123	123	residence.
124	124	(d) Not later than the 60th day after the date of the
125	125	appointment of a mediator, the health benefit plan issuer, for use
126	126	by the parties in the mediation, shall file with the mediator the
127	127	fee array for the billing codes or diagnosis-related groups related
128	128	to the disputed claim settlement, together with all bundling logic
129	129	and claims processing policies for the codes. The mediator shall
130	130	provide a copy of the fee array to the enrollee and, if the office of
131	131	public insurance counsel is involved, to the public insurance
132	132	counsel, not later than the 30th day before the date on which the
133	133	mediation is scheduled to occur.
134	134	Sec. 1467.007. CONDUCT OF MEDIATION; CONFIDENTIALITY. (a)
135	135	A mediator may not impose the mediator's judgment on a party about
136	136	an issue that is a subject of the mediation.
137	137	(b) A mediation session is under the control of the
138	138	mediator.
139	139	(c) Except as provided by Sections 1467.008, 1467.009, and
140	140	1467.010, the mediator must hold in strict confidence all
141	141	information provided by or communication with a party.
142	142	(d) A party must have an opportunity to speak and state the
143	143	party's position.
144	144	(e) Legal counsel may be present to represent and advise
145	145	clients about legal rights and the implication of a suggested
146	146	solution.
147	147	(f) Except on the agreement of the parties, a mediation may
148	148	not last more than eight hours.
149	149	(g) Except at the request of an enrollee, a mediation shall
150	150	be held not later than the 180th day after the date of the request
151	151	for mediation.
152	152	(h) Other than to enforce this chapter, a mediator may not
153	153	be called as a witness in a proceeding related to the claim
154	154	settlement.
155	155	Sec. 1467.008. MEDIATION AGREEMENT. (a) If the parties
156	156	reach a tentative agreement, the mediator shall provide information
157	157	to prepare a proposed mediation agreement.
158	158	(b) After the parties approve the details of the proposed
159	159	agreement, the parties shall agree on a person to prepare the final
160	160	document. The parties may select the mediator to prepare the final
161	161	document.
162	162	(c) A party that does not reach an agreement may request
163	163	another mediation session which another party may decline. The
164	164	request for another session may be made in writing or orally to the
165	165	mediator and may include a request for extension of time.
166	166	(d) Notwithstanding any other law, if the parties agree that
167	167	they cannot reach a final mediated agreement, the mediator shall
168	168	report to the commissioner that the mediation failed to produce an
169	169	agreement.
170	170	(e) If the parties reach a mediated agreement, the mediator
171	171	shall send a copy of the final mediated agreement to the
172	172	commissioner.
173	173	Sec. 1467.009. BAD FAITH. (a) For purposes of this chapter,
174	174	bad faith negotiation is a failure to:
175	175	(1) attend the mediation;
176	176	(2) provide information that the mediator indicates to
177	177	a party is necessary to facilitate an agreement; or
178	178	(3) send a designated representative to the mediation
179	179	with full authority to enter into a mediated agreement.
180	180	(b) Failure to reach an agreement is not in itself proof of
181	181	bad faith negotiation.
182	182	(c) The mediator may terminate a mediation immediately if a
183	183	party fails to negotiate in good faith.
184	184	(d) Notwithstanding any other law, a mediator shall report
185	185	bad faith negotiation by a health benefit plan issuer to the
186	186	commissioner following the conclusion or termination of the
187	187	mediation.
188	188	(e) On appropriate proof, the commissioner shall impose on a
189	189	health benefit plan issuer that is reported under Subsection (d)
190	190	the maximum administrative penalty allowed under Chapter 84.
191	191	Sec. 1467.010. CONSUMER PROTECTION; RULES. (a) The
192	192	commissioner, a designee from the department's consumer protection
193	193	division, or any other person designated by the commissioner, may
194	194	attend a mediation held under this chapter.
195	195	(b) The commissioner shall adopt rules regulating the
196	196	investigation and review of a complaint filed with the department
197	197	that relates to the settlement of an out-of-network health benefit
198	198	claim. The rules adopted under this section must:
199	199	(1) distinguish among complaints for out-of-network
200	200	coverage or payment and give priority to investigating allegations
201	201	of delayed medical care;
202	202	(2) develop a form for filing a complaint and
203	203	establish an outreach effort to inform consumers of the
204	204	availability of the mediation process under this chapter;
205	205	(3) ensure an enrollee who files a complaint about
206	206	additional out-of-network billing is informed that the enrollee can
207	207	request mediation of the amount paid by the health benefit plan
208	208	issuer; and
209	209	(4) ensure that a complaint is not dismissed without
210	210	appropriate consideration.
211	211	(c) The department shall maintain information:
212	212	(1) on each complaint filed with the department that
213	213	concerns an activity regulated by this chapter; and
214	214	(2) related to an out-of-network claim that is the
215	215	basis of an enrollee complaint, including:
216	216	(A) the type of services that gave rise to the
217	217	dispute;
218	218	(B) the type and specialty of the physician or
219	219	other health care provider that provided the out-of-network
220	220	service;
221	221	(C) the county and metropolitan area in which the
222	222	health care service was provided;
223	223	(D) whether the medical or health care service
224	224	was for emergency care; and
225	225	(E) any other information about the health
226	226	benefit plan issuer the commissioner by rule may require.
227	227	(d) The information collected and maintained by the
228	228	department under Subsection (c)(2) is public information as defined
229	229	in Section 552.002, Government Code, and may not include personal
230	230	identifiable information.
231	231	(e) An enrollee's request for mediation does not prohibit
232	232	the department from investigating a dispute or pursuing
233	233	disciplinary actions against a health benefit plan issuer.
234	234	(f) The commissioner shall adopt other rules as necessary to
235	235	implement this chapter.
236	236	Sec. 1467.011. REMEDIES NOT EXCLUSIVE. The remedies
237	237	provided by this chapter are in addition to any other defense,
238	238	remedy, or procedure provided by law or at common law.
239	239	Sec. 1467.012. ATTORNEY-CLIENT RELATIONSHIP NOT CREATED.
240	240	In bringing or participating in a mediation under this chapter, the
241	241	public insurance counsel acts in the name of the state and does not
242	242	establish an attorney-client relationship with a party, including
243	243	an enrollee whose claim is the basis for the request for mediation
244	244	or who filed a complaint with the office of public insurance
245	245	counsel.
246	246	SECTION 2. This Act applies only to a claim filed with a
247	247	health benefit plan issuer on or after the effective date of this
248	248	Act. A claim filed before the effective date of this Act is
249	249	governed by the law as it existed immediately before the effective
250	250	date of this Act, and that law is continued in effect for that
251	251	purpose.
252	252	SECTION 3. This Act takes effect immediately if it receives
253	253	a vote of two-thirds of all the members elected to each house, as
254	254	provided by Section 39, Article III, Texas Constitution. If this
255	255	Act does not receive the vote necessary for immediate effect, this
256	256	Act takes effect September 1, 2009.