82R7932 AJA-F
By: Uresti S.B. No. 1495
A BILL TO BE ENTITLED
AN ACT
relating to payment of out-of-network ambulatory surgery benefits
by certain health benefit plans.
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 BENEFITS FOR AMBULATORY
SURGERY AND PROCEDURES
Sec. 1458.001. DEFINITIONS. In this chapter:
(1) "Ambulatory surgery or procedure" means a surgery
or procedure provided in accordance with the medical standard of
care to an ambulatory patient in an ambulatory surgical center or
hospital outpatient department in this state.
(2) "Ambulatory surgical center" means a facility
licensed under Chapter 243, Health and Safety Code.
(3) "Fair market value" means the marketplace value
within a geozip area for the facility services for an ambulatory
surgery or procedure based on payment information, excluding
payments discounted under a governmental or nongovernmental health
benefit plan.
(4) "Geozip area" means an area that includes all zip
codes with the identical first three digits.
(5) "Hospital" includes a public or private
institution licensed under Chapter 241 or 577, Health and Safety
Code.
(6) "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 or provides
incentives for 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;
(C) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; or
(D) any other entity that issues a health benefit
plan, including:
(i) an insurance company;
(ii) a group hospital service corporation
operating under Chapter 842;
(iii) a fraternal benefit society operating
under Chapter 885;
(iv) a stipulated premium company operating
under Chapter 884; or
(v) a multiple employer welfare arrangement
that holds a certificate of authority under Chapter 846.
(7) "Out-of-network provider," with respect to a
managed care plan, means a provider who is not a preferred or
participating provider of the plan.
(8) "Usual and customary charge" with respect to an
ambulatory surgery or procedure facility fee means the fair market
value of the facility fee for the ambulatory surgery or procedure
within the geozip area in which the surgery or procedure is
performed.
Sec. 1458.002. PAYMENT OF USUAL AND CUSTOMARY CHARGE
REQUIRED. A managed care plan that provides a benefit for an
ambulatory surgery or procedure provided by an ambulatory surgical
center or hospital that is an out-of-network provider with respect
to the plan must pay a benefit for the facility fee for the surgery
or procedure that is computed based on the usual and customary
charge with respect to the facility fee.
SECTION 2. Chapter 1458, Insurance Code, as added by this
Act, applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2012. A health benefit
plan delivered, issued for delivery, or renewed before January 1,
2012, is governed by the law in effect 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, 2011.