Texas 2013 - 83rd Regular

Texas House Bill HB2359 Compare Versions

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1	1	83R23352 SCL-D
2	2	By: Bonnen of Galveston H.B. No. 2359
3	3	Substitute the following for H.B. No. 2359:
4	4	By: Bonnen of Galveston C.S.H.B. No. 2359
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to health care compensation under certain health benefit
10	10	or managed care plans.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 1451.153(a), Insurance Code, is amended
13	13	to read as follows:
14	14	(a) A managed care plan may not:
15	15	(1) discriminate against a health care practitioner
16	16	because the practitioner is an optometrist, therapeutic
17	17	optometrist, or ophthalmologist;
18	18	(2) restrict or discourage a plan participant from
19	19	obtaining covered vision or medical eye care services or procedures
20	20	from a participating optometrist, therapeutic optometrist, or
21	21	ophthalmologist solely because the practitioner is an optometrist,
22	22	therapeutic optometrist, or ophthalmologist;
23	23	(3) exclude an optometrist, therapeutic optometrist,
24	24	or ophthalmologist as a participating practitioner in the plan
25	25	because the optometrist, therapeutic optometrist, or
26	26	ophthalmologist does not have medical staff privileges at a
27	27	hospital or at a particular hospital;
28	28	(4) exclude an optometrist, therapeutic optometrist,
29	29	or ophthalmologist as a participating practitioner in the plan
30	30	because the services or procedures provided by the optometrist,
31	31	therapeutic optometrist, or ophthalmologist may be provided by
32	32	another type of health care practitioner; [or]
33	33	(5) as a condition for a therapeutic optometrist or
34	34	ophthalmologist to be included in one or more of the plan's medical
35	35	panels, require the therapeutic optometrist or ophthalmologist to
36	36	be included in, or to accept the terms of payment under or for, a
37	37	particular vision panel in which the therapeutic optometrist or
38	38	ophthalmologist does not otherwise wish to be included;
39	39	(6) use different contractual terms and conditions or
40	40	administrative procedures for an optometrist, therapeutic
41	41	optometrist, or ophthalmologist solely because the practitioner is
42	42	an optometrist, therapeutic optometrist, or ophthalmologist;
43	43	(7) use, within a geographic area, different
44	44	contractual fee schedules or reimbursement amounts for an
45	45	optometrist, therapeutic optometrist, or ophthalmologist solely
46	46	because the practitioner is an optometrist, therapeutic
47	47	optometrist, or ophthalmologist; or
48	48	(8) use different claim adjudication methodologies or
49	49	procedures for an optometrist, therapeutic optometrist, or
50	50	ophthalmologist solely because the practitioner is an optometrist,
51	51	therapeutic optometrist, or ophthalmologist.
52	52	SECTION 2. Subtitle F, Title 8, Insurance Code, is amended
53	53	by adding Chapter 1470 to read as follows:
54	54	CHAPTER 1470. DISCLOSURE OF PAYMENT AND COMPENSATION METHODOLOGY
55	55	Sec. 1470.001. DEFINITIONS. In this chapter, unless the
56	56	context otherwise requires:
57	57	(1) "Edit" means a practice or procedure under which
58	58	an adjustment is made regarding procedure codes that results in:
59	59	(A) payment for some, but not all, of the health
60	60	care procedures performed under a procedure code;
61	61	(B) payment made under a different procedure
62	62	code;
63	63	(C) a reduced payment as a result of services
64	64	provided to a patient that are claimed under more than one procedure
65	65	code on the same service date;
66	66	(D) a reduced payment related to a modifier used
67	67	with a procedure code; or
68	68	(E) a reduced payment based on multiple units of
69	69	the same procedure code billed for a single date of service.
70	70	(2) "Health benefit plan issuer" means:
71	71	(A) an insurance company, association,
72	72	organization, group hospital service corporation, health
73	73	maintenance organization, or pharmacy benefit manager that
74	74	delivers or issues for delivery an individual, group, blanket, or
75	75	franchise insurance policy or insurance agreement, a group hospital
76	76	service contract, or an evidence of coverage that provides health
77	77	insurance or health care benefits and includes:
78	78	(i) a life, health, or accident insurance
79	79	company operating under Chapter 841 or 982;
80	80	(ii) a general casualty insurance company
81	81	operating under Chapter 861;
82	82	(iii) a fraternal benefit society operating
83	83	under Chapter 885;
84	84	(iv) a mutual life insurance company
85	85	operating under Chapter 882;
86	86	(v) a local mutual aid association
87	87	operating under Chapter 886;
88	88	(vi) a statewide mutual assessment company
89	89	operating under Chapter 881;
90	90	(vii) a mutual assessment company or mutual
91	91	assessment life, health, and accident association operating under
92	92	Chapter 887;
93	93	(viii) a mutual insurance company operating
94	94	under Chapter 883 that writes coverage other than life insurance;
95	95	(ix) a Lloyd's plan operating under Chapter
96	96	941;
97	97	(x) a reciprocal exchange operating under
98	98	Chapter 942;
99	99	(xi) a stipulated premium insurance company
100	100	operating under Chapter 884;
101	101	(xii) an exchange operating under Chapter
102	102	942;
103	103	(xiii) a Medicare supplemental policy as
104	104	defined by Section 1882(g)(1), Social Security Act (42 U.S.C.
105	105	Section 1395ss(g)(1));
106	106	(xiv) a health maintenance organization
107	107	operating under Chapter 843;
108	108	(xv) a multiple employer welfare
109	109	arrangement that holds a certificate of authority under Chapter
110	110	846; and
111	111	(xvi) an approved nonprofit health
112	112	corporation that holds a certificate of authority under Chapter
113	113	844; and
114	114	(B) a nongovernmental entity issuing or
115	115	administering medical benefits provided under a workers'
116	116	compensation insurance policy or otherwise under Title 5, Labor
117	117	Code, but excluding benefits provided through self-insurance.
118	118	(3) "Health care contract" means a contract entered
119	119	into or renewed between a health care contractor and a physician or
120	120	health care provider for the delivery of health care services to
121	121	others.
122	122	(4) "Health care contractor" means an individual or
123	123	entity that has as a business purpose contracting with physicians
124	124	or health care providers for the delivery of health care services.
125	125	The term includes a health benefit plan issuer, an administrator
126	126	regulated under Chapter 4151, and a pharmacy benefit manager that
127	127	administers or manages prescription drug benefits.
128	128	(5) "Health care provider" means an individual or
129	129	entity that furnishes goods or services under a license,
130	130	certificate, registration, or other authority issued by this state
131	131	to diagnose, prevent, alleviate, or cure a human illness or injury.
132	132	The term includes a physician or a hospital, ambulatory surgical
133	133	center, outpatient imaging facility, or other health care facility.
134	134	(6) "Physician" means:
135	135	(A) an individual licensed to engage in the
136	136	practice of medicine in this state; or
137	137	(B) an entity organized under Subchapter B,
138	138	Chapter 162, Occupations Code.
139	139	(7) "Procedure code" means an alphanumeric code used
140	140	to identify a specific health procedure performed by a health care
141	141	provider. The term includes:
142	142	(A) the American Medical Association's Current
143	143	Procedural Terminology code, also known as the "CPT code";
144	144	(B) the Centers for Medicare and Medicaid
145	145	Services Healthcare Common Procedure Coding System; and
146	146	(C) other analogous codes published by national
147	147	organizations and recognized by the commissioner.
148	148	(8) "Same service" means health care procedures
149	149	performed or billed under the same procedure code.
150	150	Sec. 1470.002. DEFINITION OF MATERIAL CHANGE. For purposes
151	151	of this chapter, "material change" means a change to a contract that
152	152	decreases the health care provider's payment or compensation.
153	153	Sec. 1470.003. APPLICABILITY OF CHAPTER. (a) This chapter
154	154	does not apply to an employment contract or arrangement between
155	155	health care providers.
156	156	(b) Notwithstanding Subsection (a), this chapter applies to
157	157	contracts for health care services between a medical group and
158	158	other medical groups.
159	159	Sec. 1470.004. RULEMAKING AUTHORITY. The commissioner may
160	160	adopt reasonable rules as necessary to implement the purposes and
161	161	provisions of this chapter.
162	162	Sec. 1470.005. DISCLOSURE TO DEPARTMENT. A health care
163	163	contract may not preclude the use of the contract or disclosure of
164	164	the contract to the department to enforce this chapter or other
165	165	state law. The information is confidential and privileged and is
166	166	not subject to Chapter 552, Government Code, or to subpoena, except
167	167	to the extent necessary to enable the commissioner to enforce this
168	168	chapter or other state law.
169	169	Sec. 1470.006. REQUIRED DISCLOSURE AND PERMISSIBLE RANGE OF
170	170	PAYMENT AND COMPENSATION. (a) Each health care contract must
171	171	include a disclosure form that states, in plain language, payment
172	172	and compensation terms. The form must include information
173	173	sufficient for a health care provider to determine the compensation
174	174	or payment for the provider's services.
175	175	(b) The disclosure form under Subsection (a) must include:
176	176	(1) the manner of payment, such as fee-for-service,
177	177	capitation, or risk sharing;
178	178	(2) the effect of edits, if any, on payment or
179	179	compensation; and
180	180	(3) a fee schedule that shows:
181	181	(A) the compensation or payments to the health
182	182	care provider for procedure codes reasonably expected to be billed
183	183	by the health care provider for services provided under all
184	184	contracts used by the health care contractor; and
185	185	(B) the range of compensation or payments to
186	186	different health care providers performing the same service for
187	187	procedure codes reasonably expected to be billed by the health care
188	188	provider for services provided under all contracts used by the
189	189	health care contractor and, on request, the range of compensation
190	190	or payments for other procedure codes used by, or which may be used
191	191	by, the health care provider.
192	192	(c) A health care contractor may not pay an amount of
193	193	compensation or payments to a health care provider that is less than
194	194	85 percent of the amount paid for the same service to another health
195	195	care provider that holds the same license, certificate, or other
196	196	authority, regardless of the location of the health care providers
197	197	and of whether the health care providers are performing services
198	198	under the same contract.
199	199	(d) A health care contractor may satisfy the requirement
200	200	under Subsection (b)(2) regarding the effect of edits by providing
201	201	a clearly understandable, readily available mechanism that allows a
202	202	health care provider to determine the effect of an edit on payment
203	203	or compensation before a service is provided or a claim is
204	204	submitted.
205	205	(e) The fee schedule described by Subsection (b)(3) must
206	206	include, as applicable, service or procedure codes and the
207	207	associated payment or compensation for each code. The fee schedule
208	208	may be provided electronically.
209	209	(f) A health care contractor shall provide the fee schedule
210	210	described by Subsection (b)(3) to an affected health care provider
211	211	when a material change related to payment or compensation occurs.
212	212	Additionally, a health care provider may request that a written fee
213	213	schedule be provided up to twice annually, and the health care
214	214	contractor must provide the written fee schedule promptly.
215	215	(g) If applicable, a health care contractor, in the
216	216	disclosure form described by Subsection (a), shall inform an
217	217	affected health care provider of the prohibited payment and
218	218	contracting practices described by Sections 1451.153(a)(6), (7),
219	219	and (8).
220	220	Sec. 1470.007. ENFORCEMENT. (a) The commissioner shall
221	221	adopt rules as necessary to enforce the provisions of this chapter.
222	222	(b) A violation of Section 1470.006 is a deceptive act or
223	223	practice in insurance under Subchapter B, Chapter 541.
224	224	Sec. 1470.008. WAIVER OF FEDERAL LAW. If the commissioner
225	225	determines that a waiver of federal law or other federal
226	226	authorization would facilitate implementation of this chapter, the
227	227	commissioner may request the waiver or authorization.
228	228	SECTION 3. Section 1451.153(a), Insurance Code, as amended
229	229	by this Act, and Chapter 1470, Insurance Code, as added by this Act,
230	230	apply only to a health care contract that is entered into or renewed
231	231	on or after January 1, 2014. A health care contract entered into
232	232	before January 1, 2014, is governed by the law as it existed
233	233	immediately before the effective date of this Act, and that law is
234	234	continued in effect for that purpose.
235	235	SECTION 4. This Act takes effect September 1, 2013.