Texas 2013 - 83rd Regular

Texas House Bill HB2360 Compare Versions

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1	1	83R22015 SCL-D
2	2	By: Bonnen of Galveston, et al. H.B. No. 2360
3	3	Substitute the following for H.B. No. 2360:
4	4	By: Bonnen of Galveston C.S.H.B. No. 2360
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the disclosure of health care prices and related
10	10	information.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
13	13	by adding Chapter 1470 to read as follows:
14	14	CHAPTER 1470. DISCLOSURE OF PAYMENT AND COMPENSATION METHODOLOGY
15	15	Sec. 1470.001. DEFINITIONS. In this chapter, unless the
16	16	context otherwise requires:
17	17	(1) "Edit" means a practice or procedure under which
18	18	an adjustment is made regarding procedure codes that results in:
19	19	(A) payment for some, but not all, of the health
20	20	care procedures performed under a procedure code;
21	21	(B) payment made under a different procedure
22	22	code;
23	23	(C) a reduced payment as a result of services
24	24	provided to a patient that are claimed under more than one procedure
25	25	code on the same service date;
26	26	(D) a reduced payment related to a modifier used
27	27	with a procedure code; or
28	28	(E) a reduced payment based on multiple units of
29	29	the same procedure code billed for a single date of service.
30	30	(2) "Health benefit plan issuer" means:
31	31	(A) an insurance company, association,
32	32	organization, health maintenance organization, or pharmacy benefit
33	33	manager that delivers or issues for delivery an individual, group,
34	34	blanket, or franchise insurance policy or insurance agreement or an
35	35	evidence of coverage that provides health insurance or health care
36	36	benefits and includes:
37	37	(i) a life, health, or accident insurance
38	38	company operating under Chapter 841 or 982;
39	39	(ii) a general casualty insurance company
40	40	operating under Chapter 861;
41	41	(iii) a fraternal benefit society operating
42	42	under Chapter 885;
43	43	(iv) a mutual life insurance company
44	44	operating under Chapter 882;
45	45	(v) a local mutual aid association
46	46	operating under Chapter 886;
47	47	(vi) a statewide mutual assessment company
48	48	operating under Chapter 881;
49	49	(vii) a mutual assessment company or mutual
50	50	assessment life, health, and accident association operating under
51	51	Chapter 887;
52	52	(viii) a mutual insurance company operating
53	53	under Chapter 883 that writes coverage other than life insurance;
54	54	(ix) a Lloyd's plan operating under Chapter
55	55	941;
56	56	(x) a reciprocal exchange operating under
57	57	Chapter 942;
58	58	(xi) a stipulated premium insurance company
59	59	operating under Chapter 884;
60	60	(xii) an exchange operating under Chapter
61	61	942;
62	62	(xiii) a Medicare supplemental policy as
63	63	defined by Section 1882(g)(1), Social Security Act (42 U.S.C.
64	64	Section 1395ss(g)(1));
65	65	(xiv) a Medicaid managed care program
66	66	operated under Chapter 533, Government Code;
67	67	(xv) a health maintenance organization
68	68	operating under Chapter 843;
69	69	(xvi) a multiple employer welfare
70	70	arrangement that holds a certificate of authority under Chapter
71	71	846; and
72	72	(xvii) an approved nonprofit health
73	73	corporation that holds a certificate of authority under Chapter
74	74	844;
75	75	(B) the state Medicaid program operated under
76	76	Chapter 32, Human Resources Code, or the state child health plan or
77	77	health benefits plan for children under Chapter 62 or 63, Health and
78	78	Safety Code;
79	79	(C) the Employees Retirement System of Texas or
80	80	another entity issuing or administering a basic coverage plan under
81	81	Chapter 1551;
82	82	(D) the Teacher Retirement System of Texas or
83	83	another entity issuing or administering a basic plan under Chapter
84	84	1575 or a primary care coverage plan under Chapter 1579;
85	85	(E) The Texas A&M University System or The
86	86	University of Texas System or another entity issuing or
87	87	administering basic coverage under Chapter 1601; and
88	88	(F) an entity issuing or administering medical
89	89	benefits provided under a workers' compensation insurance policy or
90	90	otherwise under Title 5, Labor Code.
91	91	(3) "Health care contract" means a contract entered
92	92	into or renewed between a health care contractor and a physician or
93	93	health care provider for the delivery of health care services to
94	94	others.
95	95	(4) "Health care contractor" means an individual or
96	96	entity that has as a business purpose contracting with physicians
97	97	or health care providers for the delivery of health care services.
98	98	The term includes a health benefit plan issuer, an administrator
99	99	regulated under Chapter 4151, and a pharmacy benefit manager that
100	100	administers or manages prescription drug benefits.
101	101	(5) "Health care provider" means an individual or
102	102	entity that furnishes goods or services under a license,
103	103	certificate, registration, or other authority issued by this state
104	104	to diagnose, prevent, alleviate, or cure a human illness or injury.
105	105	The term does not include a physician, hospital, or other health
106	106	care facility.
107	107	(6) "Physician" means:
108	108	(A) an individual licensed to engage in the
109	109	practice of medicine in this state; or
110	110	(B) an entity organized under Subchapter B,
111	111	Chapter 162, Occupations Code.
112	112	(7) "Procedure code" means an alphanumeric code used
113	113	to identify a specific health procedure performed by a health care
114	114	provider. The term includes:
115	115	(A) the American Medical Association's Current
116	116	Procedural Terminology code, also known as the "CPT code";
117	117	(B) the Centers for Medicare and Medicaid
118	118	Services Health Care Common Procedure Coding System; and
119	119	(C) other analogous codes published by national
120	120	organizations and recognized by the commissioner.
121	121	Sec. 1470.002. DEFINITION OF MATERIAL CHANGE. For purposes
122	122	of this chapter, "material change" means a change to a contract that
123	123	decreases the health care provider's or physician's payment or
124	124	compensation.
125	125	Sec. 1470.003. APPLICABILITY OF CHAPTER. (a) Except as
126	126	otherwise provided by Subsection (c), this chapter applies only to
127	127	contracts between a health care contractor and:
128	128	(1) a physician; or
129	129	(2) a health care provider who has filed a form
130	130	described by Section 118.002, Occupations Code, with the
131	131	commissioner.
132	132	(b) This chapter does not apply to an employment contract or
133	133	arrangement between health care providers or physicians.
134	134	(c) Notwithstanding Subsection (a), this chapter applies to
135	135	contracts for health care services between a medical group and
136	136	other medical groups.
137	137	Sec. 1470.004. RULEMAKING AUTHORITY. The commissioner may
138	138	adopt reasonable rules as necessary to implement the purposes and
139	139	provisions of this chapter.
140	140	Sec. 1470.005. DISCLOSURE TO THIRD PARTY. A health care
141	141	contract may not preclude the use of the contract or disclosure of
142	142	the contract to a third party to enforce this chapter or other state
143	143	or federal law. The third party is bound by any applicable
144	144	confidentiality requirements, including those stated in the
145	145	contract.
146	146	Sec. 1470.006. REQUIRED DISCLOSURE OF PAYMENT AND
147	147	COMPENSATION TERMS. (a) Each health care contract must include a
148	148	disclosure form that states, in plain language, payment and
149	149	compensation terms. The form must include information sufficient
150	150	for a health care provider or physician to determine the
151	151	compensation or payment for the provider's or physician's services.
152	152	(b) The disclosure form under Subsection (a) must include:
153	153	(1) the manner of payment, such as fee-for-service,
154	154	capitation, or risk sharing;
155	155	(2) the methodology used to compute any fee schedule,
156	156	such as the use of a relative value unit system and conversion
157	157	factor, percentage of Medicare payment system, or percentage of
158	158	billed charges;
159	159	(3) the fee schedule for procedure codes reasonably
160	160	expected to be billed by the health care provider or physician for
161	161	services provided under the contract and, on request, the fee
162	162	schedule for other procedure codes used by, or that may be used by,
163	163	the health care provider or physician; and
164	164	(4) the effect of edits, if any, on payment or
165	165	compensation.
166	166	(c) As applicable, the methodology disclosure under
167	167	Subsection (b)(2) must include:
168	168	(1) the name of any relative value system used;
169	169	(2) the version, edition, or publication date of that
170	170	system;
171	171	(3) any applicable conversion or geographic factors;
172	172	and
173	173	(4) the date by which compensation or fee schedules
174	174	may be changed by the methodology, if allowed under the contract.
175	175	(d) The fee schedule described by Subsection (b)(3) must
176	176	include, as applicable, service or procedure codes and the
177	177	associated payment or compensation for each code. The fee schedule
178	178	may be provided electronically.
179	179	(e) A health care contractor shall provide the fee schedule
180	180	described by Subsection (b)(3) to an affected health care provider
181	181	or physician when a material change related to payment or
182	182	compensation occurs. Additionally, a health care provider or
183	183	physician may request that a written fee schedule be provided up to
184	184	twice annually, and the health care contractor must provide the
185	185	written fee schedule promptly.
186	186	(f) A health care contractor may satisfy the requirement
187	187	under Subsection (b)(4) regarding the effect of edits by providing
188	188	a clearly understandable, readily available mechanism that allows a
189	189	health care provider or physician to determine the effect of an
190	190	edit on payment or compensation before a service is provided or a
191	191	claim is submitted.
192	192	Sec. 1470.007. ENFORCEMENT. (a) The commissioner shall
193	193	adopt rules as necessary to enforce the provisions of this chapter.
194	194	(b) A violation of Section 1470.006 is a deceptive act or
195	195	practice in insurance under Subchapter B, Chapter 541.
196	196	SECTION 2. Subtitle A, Title 3, Occupations Code, is
197	197	amended by adding Chapter 118 to read as follows:
198	198	CHAPTER 118. DISCLOSURE OF HEALTH CARE PRICES
199	199	Sec. 118.001. DEFINITIONS. In this chapter:
200	200	(1) "Consumer" means an individual who seeks or
201	201	acquires health care goods, including drugs or devices, or services
202	202	from a health care provider or physician.
203	203	(2) "Health care contractor" has the meaning assigned
204	204	by Section 1470.001, Insurance Code.
205	205	(3) "Health care good" or "health care service" means
206	206	a good or service, as applicable, to diagnose, prevent, alleviate,
207	207	cure, or heal a health condition, sickness, or injury that is
208	208	provided to a consumer by a physician or health care provider.
209	209	(4) "Health care provider" means a person who
210	210	furnishes goods or services under a license, certificate,
211	211	registration, or other authority issued by this state to diagnose,
212	212	prevent, alleviate, or cure a human illness or injury. The term
213	213	does not include a physician, hospital, or other health care
214	214	facility.
215	215	Sec. 118.002. APPLICABILITY. (a) This chapter applies
216	216	only to:
217	217	(1) a physician; and
218	218	(2) a health care provider who elects to comply with
219	219	this chapter and files a form evidencing that election with the
220	220	commissioner of insurance.
221	221	(b) The commissioner of insurance shall adopt a form to be
222	222	used to comply with Subsection (a).
223	223	Sec. 118.003. DISCLOSURE OF HEALTH CARE PRICES. (a) A
224	224	health care provider who elects to comply with this chapter and a
225	225	physician must disclose to a consumer before the commencement of a
226	226	health care service or the transfer of a health care good, including
227	227	a drug or device, the price of the service or good.
228	228	(b) The disclosure may be made through the health care
229	229	provider's or physician's Internet website or in writing given to
230	230	the consumer before the commencement of the health care service or
231	231	the transfer of the health care good. If the disclosure was given
232	232	through the provider's or physician's Internet website, the
233	233	provider or physician shall inform the consumer in writing, before
234	234	the commencement of the service or transfer of the good, that health
235	235	care prices are disclosed on the website.
236	236	Sec. 118.004. FAILURE TO DISCLOSE. (a) A health care
237	237	provider or physician who fails to disclose the information as
238	238	described by this section cannot recover a fee, a deductible, a
239	239	copayment, or any other payment or obligation from the consumer
240	240	related to a health care service or good for which the provider or
241	241	physician did not disclose the price.
242	242	(b) Notwithstanding Subsection (a), a health care provider
243	243	or physician may recover the amount of a payment or other obligation
244	244	owed to the provider or physician from a consumer if the cause of
245	245	the failure to disclose was a health care contractor's failure to
246	246	disclose information under Section 1470.005, Insurance Code.
247	247	SECTION 3. (a) Chapter 1470, Insurance Code, as added by
248	248	this Act, applies only to a health care contract that is entered
249	249	into or renewed on or after January 1, 2014. A health care contract
250	250	entered into before January 1, 2014, is governed by the law as it
251	251	existed immediately before the effective date of this Act, and that
252	252	law is continued in effect for that purpose.
253	253	(b) Chapter 118, Occupations Code, as added by this Act,
254	254	applies only to a health care service that is commenced or a health
255	255	care good that is transferred on or after the effective date of this
256	256	Act. A health care service that is commenced or a health care good
257	257	that is transferred before the effective date of this Act is
258	258	governed by the law in effect immediately before the effective date
259	259	of this Act, and that law is continued in effect for that purpose.
260	260	SECTION 4. This Act takes effect September 1, 2013.