81R8858 PMO-D
By: Isett H.B. No. 3459
A BILL TO BE ENTITLED
AN ACT
relating to pricing for health care services and supplies and
reimbursement for those services or supplies under certain health
benefit plans; imposing penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle A, Title 8, Insurance Code, is amended
by adding Chapter 1225 to read as follows:
CHAPTER 1225. PRICING FOR HEALTH CARE SERVICES AND SUPPLIES;
REIMBURSEMENT RATES
Sec. 1225.001. DEFINITION. In this chapter, "health care
provider" includes a physician, health care practitioner, and
health care facility.
Sec. 1225.002. APPLICABILITY OF CHAPTER. (a) This chapter
does not apply to the provision of a health care service or supply
to a:
(1) patient for which a health care provider has
accepted assignment for the health care service or supply from
Medicaid or Medicare or any other federal, state, or local
government-sponsored indigent health care program;
(2) financially or medically indigent person who
qualifies for indigent health care services based on:
(A) a sliding fee scale; or
(B) a written charity care policy established by
a health care provider; or
(3) person who is not covered by a health benefit plan
that provides benefits for the services and qualifies for services
for the uninsured based on a written policy established by a health
care provider.
(b) This chapter does not apply to payments made for a
health care service or supply on a capitation basis.
(c) This chapter does not permit the establishment of health
care provider policies or contracts that violate any other state or
federal law.
Sec. 1225.003. PRICING INFORMATION; AVAILABILITY. (a)
Each health care provider shall compile a list of the price charged
by the provider for each service or supply provided by the health
care provider. If the health care provider bundles together prices
for multiple services or supplies provided by the provider during
one treatment by or visit to the provider, the provider shall
include any price bundles used by the provider in the list compiled
under this subsection.
(b) A health care provider shall provide a copy of the price
list described by Subsection (a) to any patient of the health care
provider who requests a copy of the list.
Sec. 1225.004. POSTING REQUIRED. (a) Each health care
provider shall post in any general waiting area maintained by the
provider, including any waiting areas of off-site or on-site
registration, a clear and conspicuous notice that advises patients
of the availability of the price list described by Section
1225.003.
(b) If a health care provider maintains an Internet website,
the provider shall post the price list described by Section
1225.003 on the provider's website.
Sec. 1225.005. OVERPAYMENT; REFUNDS. (a) A health care
provider that receives payment for a health care service or supply
provided to a patient by the provider that exceeds the price of
those products or services published in the price list described by
Section 1225.003 shall, not later than the 30th day after the date
the overpayment is discovered by the provider, refund to the payor
the amount of the overpayment. This section does not apply to an
overpayment subject to Section 843.350 or 1301.132.
(b) The health care provider shall refund the overpayment
described by Subsection (a) by:
(1) crediting the patient's account to pay a copayment
amount, deductible, or other charge that the patient owes to the
provider; or
(2) funding an established qualified account of the
patient such as a savings account or medical reimbursement account
dedicated to the payment of a future medical expense.
Sec. 1225.006. DISCIPLINARY ACTIONS AND ADMINISTRATIVE
PENALTY. A violation of this chapter is grounds for disciplinary
action or the imposition of an administrative penalty by the entity
that licenses the health care provider that violates this chapter.
Sec. 1225.007. FRAUDULENT INSURANCE ACT. An offense under
this chapter is a fraudulent insurance act under Chapter 701.
Sec. 1225.008. CHARGING DIFFERENT PRICES; OFFENSE. (a) A
health care provider commits an offense if the provider knowingly
charges different prices for providing the same health care service
or supply.
(b) It is a defense to prosecution under this section that
the health care provider refunded the overpayment as required by
Section 843.350, 1225.005, or 1301.132, as applicable.
(c) An offense under this section is a Class B misdemeanor.
Sec. 1225.009. ESTABLISHMENT OF RATES. (a) The department
shall analyze reimbursement payments made by health benefit plan
issuers to a health care provider for specific health care services
or supplies in each health service region established by the
Department of State Health Services under Section 121.007, Health
and Safety Code.
(b) For each region analyzed under Subsection (a), and for
each health care service or supply, the commissioner shall
determine the 25th quartile of the reimbursement payment.
(c) The amount determined for each health care service or
supply for each region by the department under Subsection (b) is the
maximum amount that a health benefit plan issuer may reimburse a
health care provider for the health care service or supply.
Sec. 1225.010. EXCEPTION. For good cause shown, the
commissioner may by rule except from the maximum reimbursement rate
established under Section 1225.009 a payment made:
(1) to a tertiary care facility as defined by Section
46.001, Health and Safety Code; or
(2) for tertiary medical services as defined by
Section 46.001, Health and Safety Code, or a supply related to those
services.
SECTION 2. A health care provider shall compile the price
list and post the notice required by Chapter 1225, Insurance Code,
as added by this Act, not later than January 1, 2010.
SECTION 3. This Act applies only to an insurance policy,
contract, or evidence of coverage that is delivered, issued for
delivery, or renewed on or after January 1, 2010. A policy,
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 4. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2009.