83R22015 SCL-D
By: Bonnen of Galveston, et al. H.B. No. 2360
Substitute the following for H.B. No. 2360:
By: Bonnen of Galveston C.S.H.B. No. 2360
A BILL TO BE ENTITLED
AN ACT
relating to the disclosure of health care prices and related
information.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. 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, health maintenance organization, or pharmacy benefit
manager that delivers or issues for delivery an individual, group,
blanket, or franchise insurance policy or insurance agreement 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 Medicaid managed care program
operated under Chapter 533, Government Code;
(xv) a health maintenance organization
operating under Chapter 843;
(xvi) a multiple employer welfare
arrangement that holds a certificate of authority under Chapter
846; and
(xvii) an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844;
(B) the state Medicaid program operated under
Chapter 32, Human Resources Code, or the state child health plan or
health benefits plan for children under Chapter 62 or 63, Health and
Safety Code;
(C) the Employees Retirement System of Texas or
another entity issuing or administering a basic coverage plan under
Chapter 1551;
(D) the Teacher Retirement System of Texas or
another entity issuing or administering a basic plan under Chapter
1575 or a primary care coverage plan under Chapter 1579;
(E) The Texas A&M University System or The
University of Texas System or another entity issuing or
administering basic coverage under Chapter 1601; and
(F) an entity issuing or administering medical
benefits provided under a workers' compensation insurance policy or
otherwise under Title 5, Labor Code.
(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 does not include a physician, hospital, 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 Health Care Common Procedure Coding System; and
(C) other analogous codes published by national
organizations and recognized by the commissioner.
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 or physician's payment or
compensation.
Sec. 1470.003. APPLICABILITY OF CHAPTER. (a) Except as
otherwise provided by Subsection (c), this chapter applies only to
contracts between a health care contractor and:
(1) a physician; or
(2) a health care provider who has filed a form
described by Section 118.002, Occupations Code, with the
commissioner.
(b) This chapter does not apply to an employment contract or
arrangement between health care providers or physicians.
(c) 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 THIRD PARTY. A health care
contract may not preclude the use of the contract or disclosure of
the contract to a third party to enforce this chapter or other state
or federal law. The third party is bound by any applicable
confidentiality requirements, including those stated in the
contract.
Sec. 1470.006. REQUIRED DISCLOSURE OF PAYMENT AND
COMPENSATION TERMS. (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 or physician to determine the
compensation or payment for the provider's or physician'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 methodology used to compute any fee schedule,
such as the use of a relative value unit system and conversion
factor, percentage of Medicare payment system, or percentage of
billed charges;
(3) the fee schedule for procedure codes reasonably
expected to be billed by the health care provider or physician for
services provided under the contract and, on request, the fee
schedule for other procedure codes used by, or that may be used by,
the health care provider or physician; and
(4) the effect of edits, if any, on payment or
compensation.
(c) As applicable, the methodology disclosure under
Subsection (b)(2) must include:
(1) the name of any relative value system used;
(2) the version, edition, or publication date of that
system;
(3) any applicable conversion or geographic factors;
and
(4) the date by which compensation or fee schedules
may be changed by the methodology, if allowed under the contract.
(d) 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.
(e) A health care contractor shall provide the fee schedule
described by Subsection (b)(3) to an affected health care provider
or physician when a material change related to payment or
compensation occurs. Additionally, a health care provider or
physician 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.
(f) A health care contractor may satisfy the requirement
under Subsection (b)(4) regarding the effect of edits by providing
a clearly understandable, readily available mechanism that allows a
health care provider or physician to determine the effect of an
edit on payment or compensation before a service is provided or a
claim is submitted.
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.
SECTION 2. Subtitle A, Title 3, Occupations Code, is
amended by adding Chapter 118 to read as follows:
CHAPTER 118. DISCLOSURE OF HEALTH CARE PRICES
Sec. 118.001. DEFINITIONS. In this chapter:
(1) "Consumer" means an individual who seeks or
acquires health care goods, including drugs or devices, or services
from a health care provider or physician.
(2) "Health care contractor" has the meaning assigned
by Section 1470.001, Insurance Code.
(3) "Health care good" or "health care service" means
a good or service, as applicable, to diagnose, prevent, alleviate,
cure, or heal a health condition, sickness, or injury that is
provided to a consumer by a physician or health care provider.
(4) "Health care provider" means a person who
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
does not include a physician, hospital, or other health care
facility.
Sec. 118.002. APPLICABILITY. (a) This chapter applies
only to:
(1) a physician; and
(2) a health care provider who elects to comply with
this chapter and files a form evidencing that election with the
commissioner of insurance.
(b) The commissioner of insurance shall adopt a form to be
used to comply with Subsection (a).
Sec. 118.003. DISCLOSURE OF HEALTH CARE PRICES. (a) A
health care provider who elects to comply with this chapter and a
physician must disclose to a consumer before the commencement of a
health care service or the transfer of a health care good, including
a drug or device, the price of the service or good.
(b) The disclosure may be made through the health care
provider's or physician's Internet website or in writing given to
the consumer before the commencement of the health care service or
the transfer of the health care good. If the disclosure was given
through the provider's or physician's Internet website, the
provider or physician shall inform the consumer in writing, before
the commencement of the service or transfer of the good, that health
care prices are disclosed on the website.
Sec. 118.004. FAILURE TO DISCLOSE. (a) A health care
provider or physician who fails to disclose the information as
described by this section cannot recover a fee, a deductible, a
copayment, or any other payment or obligation from the consumer
related to a health care service or good for which the provider or
physician did not disclose the price.
(b) Notwithstanding Subsection (a), a health care provider
or physician may recover the amount of a payment or other obligation
owed to the provider or physician from a consumer if the cause of
the failure to disclose was a health care contractor's failure to
disclose information under Section 1470.005, Insurance Code.
SECTION 3. (a) Chapter 1470, Insurance Code, as added by
this Act, applies 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.
(b) Chapter 118, Occupations Code, as added by this Act,
applies only to a health care service that is commenced or a health
care good that is transferred on or after the effective date of this
Act. A health care service that is commenced or a health care good
that is transferred before the effective date of this Act 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 4. This Act takes effect September 1, 2013.