83R23352 SCL-D
By: Bonnen of Galveston H.B. No. 2359
Substitute the following for H.B. No. 2359:
By: Bonnen of Galveston C.S.H.B. No. 2359
A BILL TO BE ENTITLED
AN ACT
relating to health care compensation under certain health benefit
or managed care plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1451.153(a), Insurance Code, is amended
to read as follows:
(a) A managed care plan may not:
(1) discriminate against a health care practitioner
because the practitioner is an optometrist, therapeutic
optometrist, or ophthalmologist;
(2) restrict or discourage a plan participant from
obtaining covered vision or medical eye care services or procedures
from a participating optometrist, therapeutic optometrist, or
ophthalmologist solely because the practitioner is an optometrist,
therapeutic optometrist, or ophthalmologist;
(3) exclude an optometrist, therapeutic optometrist,
or ophthalmologist as a participating practitioner in the plan
because the optometrist, therapeutic optometrist, or
ophthalmologist does not have medical staff privileges at a
hospital or at a particular hospital;
(4) exclude an optometrist, therapeutic optometrist,
or ophthalmologist as a participating practitioner in the plan
because the services or procedures provided by the optometrist,
therapeutic optometrist, or ophthalmologist may be provided by
another type of health care practitioner; [or]
(5) as a condition for a therapeutic optometrist or
ophthalmologist to be included in one or more of the plan's medical
panels, require the therapeutic optometrist or ophthalmologist to
be included in, or to accept the terms of payment under or for, a
particular vision panel in which the therapeutic optometrist or
ophthalmologist does not otherwise wish to be included;
(6) use different contractual terms and conditions or
administrative procedures for an optometrist, therapeutic
optometrist, or ophthalmologist solely because the practitioner is
an optometrist, therapeutic optometrist, or ophthalmologist;
(7) use, within a geographic area, different
contractual fee schedules or reimbursement amounts for an
optometrist, therapeutic optometrist, or ophthalmologist solely
because the practitioner is an optometrist, therapeutic
optometrist, or ophthalmologist; or
(8) use different claim adjudication methodologies or
procedures for an optometrist, therapeutic optometrist, or
ophthalmologist solely because the practitioner is an optometrist,
therapeutic optometrist, or ophthalmologist.
SECTION 2. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1470 to read as follows:
CHAPTER 1470. DISCLOSURE OF PAYMENT AND COMPENSATION METHODOLOGY
Sec. 1470.001. DEFINITIONS. In this chapter, unless the
context otherwise requires:
(1) "Edit" means a practice or procedure under which
an adjustment is made regarding procedure codes that results in:
(A) payment for some, but not all, of the health
care procedures performed under a procedure code;
(B) payment made under a different procedure
code;
(C) a reduced payment as a result of services
provided to a patient that are claimed under more than one procedure
code on the same service date;
(D) a reduced payment related to a modifier used
with a procedure code; or
(E) a reduced payment based on multiple units of
the same procedure code billed for a single date of service.
(2) "Health benefit plan issuer" means:
(A) an insurance company, association,
organization, group hospital service corporation, health
maintenance organization, or pharmacy benefit manager that
delivers or issues for delivery an individual, group, blanket, or
franchise insurance policy or insurance agreement, a group hospital
service contract, or an evidence of coverage that provides health
insurance or health care benefits and includes:
(i) a life, health, or accident insurance
company operating under Chapter 841 or 982;
(ii) a general casualty insurance company
operating under Chapter 861;
(iii) a fraternal benefit society operating
under Chapter 885;
(iv) a mutual life insurance company
operating under Chapter 882;
(v) a local mutual aid association
operating under Chapter 886;
(vi) a statewide mutual assessment company
operating under Chapter 881;
(vii) a mutual assessment company or mutual
assessment life, health, and accident association operating under
Chapter 887;
(viii) a mutual insurance company operating
under Chapter 883 that writes coverage other than life insurance;
(ix) a Lloyd's plan operating under Chapter
941;
(x) a reciprocal exchange operating under
Chapter 942;
(xi) a stipulated premium insurance company
operating under Chapter 884;
(xii) an exchange operating under Chapter
942;
(xiii) a Medicare supplemental policy as
defined by Section 1882(g)(1), Social Security Act (42 U.S.C.
Section 1395ss(g)(1));
(xiv) a health maintenance organization
operating under Chapter 843;
(xv) a multiple employer welfare
arrangement that holds a certificate of authority under Chapter
846; and
(xvi) an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844; and
(B) a nongovernmental entity issuing or
administering medical benefits provided under a workers'
compensation insurance policy or otherwise under Title 5, Labor
Code, but excluding benefits provided through self-insurance.
(3) "Health care contract" means a contract entered
into or renewed between a health care contractor and a physician or
health care provider for the delivery of health care services to
others.
(4) "Health care contractor" means an individual or
entity that has as a business purpose contracting with physicians
or health care providers for the delivery of health care services.
The term includes a health benefit plan issuer, an administrator
regulated under Chapter 4151, and a pharmacy benefit manager that
administers or manages prescription drug benefits.
(5) "Health care provider" means an individual or
entity that furnishes goods or services under a license,
certificate, registration, or other authority issued by this state
to diagnose, prevent, alleviate, or cure a human illness or injury.
The term includes a physician or a hospital, ambulatory surgical
center, outpatient imaging facility, or other health care facility.
(6) "Physician" means:
(A) an individual licensed to engage in the
practice of medicine in this state; or
(B) an entity organized under Subchapter B,
Chapter 162, Occupations Code.
(7) "Procedure code" means an alphanumeric code used
to identify a specific health procedure performed by a health care
provider. The term includes:
(A) the American Medical Association's Current
Procedural Terminology code, also known as the "CPT code";
(B) the Centers for Medicare and Medicaid
Services Healthcare Common Procedure Coding System; and
(C) other analogous codes published by national
organizations and recognized by the commissioner.
(8) "Same service" means health care procedures
performed or billed under the same procedure code.
Sec. 1470.002. DEFINITION OF MATERIAL CHANGE. For purposes
of this chapter, "material change" means a change to a contract that
decreases the health care provider's payment or compensation.
Sec. 1470.003. APPLICABILITY OF CHAPTER. (a) This chapter
does not apply to an employment contract or arrangement between
health care providers.
(b) Notwithstanding Subsection (a), this chapter applies to
contracts for health care services between a medical group and
other medical groups.
Sec. 1470.004. RULEMAKING AUTHORITY. The commissioner may
adopt reasonable rules as necessary to implement the purposes and
provisions of this chapter.
Sec. 1470.005. DISCLOSURE TO DEPARTMENT. A health care
contract may not preclude the use of the contract or disclosure of
the contract to the department to enforce this chapter or other
state law. The information is confidential and privileged and is
not subject to Chapter 552, Government Code, or to subpoena, except
to the extent necessary to enable the commissioner to enforce this
chapter or other state law.
Sec. 1470.006. REQUIRED DISCLOSURE AND PERMISSIBLE RANGE OF
PAYMENT AND COMPENSATION. (a) Each health care contract must
include a disclosure form that states, in plain language, payment
and compensation terms. The form must include information
sufficient for a health care provider to determine the compensation
or payment for the provider's services.
(b) The disclosure form under Subsection (a) must include:
(1) the manner of payment, such as fee-for-service,
capitation, or risk sharing;
(2) the effect of edits, if any, on payment or
compensation; and
(3) a fee schedule that shows:
(A) the compensation or payments to the health
care provider for procedure codes reasonably expected to be billed
by the health care provider for services provided under all
contracts used by the health care contractor; and
(B) the range of compensation or payments to
different health care providers performing the same service for
procedure codes reasonably expected to be billed by the health care
provider for services provided under all contracts used by the
health care contractor and, on request, the range of compensation
or payments for other procedure codes used by, or which may be used
by, the health care provider.
(c) A health care contractor may not pay an amount of
compensation or payments to a health care provider that is less than
85 percent of the amount paid for the same service to another health
care provider that holds the same license, certificate, or other
authority, regardless of the location of the health care providers
and of whether the health care providers are performing services
under the same contract.
(d) A health care contractor may satisfy the requirement
under Subsection (b)(2) regarding the effect of edits by providing
a clearly understandable, readily available mechanism that allows a
health care provider to determine the effect of an edit on payment
or compensation before a service is provided or a claim is
submitted.
(e) The fee schedule described by Subsection (b)(3) must
include, as applicable, service or procedure codes and the
associated payment or compensation for each code. The fee schedule
may be provided electronically.
(f) A health care contractor shall provide the fee schedule
described by Subsection (b)(3) to an affected health care provider
when a material change related to payment or compensation occurs.
Additionally, a health care provider may request that a written fee
schedule be provided up to twice annually, and the health care
contractor must provide the written fee schedule promptly.
(g) If applicable, a health care contractor, in the
disclosure form described by Subsection (a), shall inform an
affected health care provider of the prohibited payment and
contracting practices described by Sections 1451.153(a)(6), (7),
and (8).
Sec. 1470.007. ENFORCEMENT. (a) The commissioner shall
adopt rules as necessary to enforce the provisions of this chapter.
(b) A violation of Section 1470.006 is a deceptive act or
practice in insurance under Subchapter B, Chapter 541.
Sec. 1470.008. WAIVER OF FEDERAL LAW. If the commissioner
determines that a waiver of federal law or other federal
authorization would facilitate implementation of this chapter, the
commissioner may request the waiver or authorization.
SECTION 3. Section 1451.153(a), Insurance Code, as amended
by this Act, and Chapter 1470, Insurance Code, as added by this Act,
apply only to a health care contract that is entered into or renewed
on or after January 1, 2014. A health care contract entered into
before January 1, 2014, 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, 2013.