83R3617 AJA-D
By: Van de Putte, Deuell S.B. No. 800
A BILL TO BE ENTITLED
AN ACT
relating to the disclosure of the calculation of out-of-network
payments by the issuers of preferred provider benefit plans and by
health maintenance organizations.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter F, Chapter 843, Insurance Code, is
amended by adding Section 843.212 to read as follows:
Sec. 843.212. CALCULATION OF NONPARTICIPATING PROVIDER
PAYMENTS. (a) In this section, "usual charge for out-of-network
health care services" means the 99th percentile of the actual
charges charged by a physician or provider that does not
participate in a health maintenance organization's delivery
network for a particular health care service in a particular
service area covered by the delivery network, as reported in a
benchmarking database maintained by a nonprofit organization that
is not affiliated with a health maintenance organization or other
health benefit plan issuer, a holding company of a health benefit
plan issuer, or a trade association in the field of insurance or
health benefits.
(b) A health maintenance organization shall disclose to
each enrollee and, if applicable, each group contract holder the
methodology used by the health maintenance organization to
calculate payment under the health plan for health care services
provided by a physician or provider that does not participate in the
health maintenance organization's delivery network. The
disclosure required by this section must:
(1) express the payment amount in terms of a
percentage of the usual charge for out-of-network health care
services that will be paid to the physician or provider; and
(2) include examples of the anticipated out-of-pocket
payment responsibility for frequently billed health care services
provided by physicians or providers that do not participate in the
health maintenance organization's delivery network.
(c) A health maintenance organization shall, at the request
of an enrollee, provide the enrollee with information, in writing
or through publication on an Internet website, that allows the
enrollee to determine the anticipated out-of-pocket payment
responsibility for a specific health care service provided by a
physician or provider that does not participate in the health
maintenance organization's delivery network based on:
(1) the methodology used by the health maintenance
organization to calculate payment under the health plan for health
care services provided by physicians and providers that do not
participate in the health maintenance organization's delivery
network; and
(2) the usual charge for out-of-network health care
services.
SECTION 2. Subchapter A, Chapter 1301, Insurance Code, is
amended by adding Section 1301.010 to read as follows:
Sec. 1301.010. CALCULATION OF NONPREFERRED PROVIDER
PAYMENTS. (a) In this section, "usual charge for out-of-network
health care services" means the 99th percentile of the actual
charges charged by a nonpreferred provider for a particular health
care service in a particular service area covered by the preferred
provider benefit plan, as reported in a benchmarking database
maintained by a nonprofit organization that is not affiliated with
an insurer or other health benefit plan issuer, a holding company of
a health benefit plan issuer, or a trade association in the field of
insurance or health benefits.
(b) An insurer offering a preferred provider benefit plan
shall disclose to each insured and, if applicable, each group
policy holder the methodology used by the insurer to calculate
payment under the plan for health care services provided by
nonpreferred providers. The disclosure required by this section
must:
(1) express the payment amount in terms of a
percentage of the usual charge for out-of-network health care
services that will be paid to the provider; and
(2) include examples of the anticipated out-of-pocket
payment responsibility for frequently billed health care services
provided by nonpreferred providers.
(c) An insurer offering a preferred provider benefit plan
shall, at the request of an insured, provide the insured with
information, in writing or through publication on an Internet
website, that allows the insured to determine the anticipated
out-of-pocket payment responsibility for a specific health care
service provided by a nonpreferred provider based on:
(1) the methodology used by the insurer to calculate
payment under the plan for health care services provided by
nonpreferred providers; and
(2) the usual charge for out-of-network health care
services.
SECTION 3. The change in law made by this Act applies only
to a health plan contract or health insurance policy that is
delivered, issued for delivery, or renewed on or after January 1,
2014. A health plan contract or health insurance policy that is
delivered, issued for delivery, or renewed before January 1, 2014,
is covered 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.