Texas 2015 - 84th Regular

Texas House Bill HB3727 Compare Versions

Only one version of the bill is available at this time.

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1	1	By: Bonnen of Galveston H.B. No. 3727
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to the provision of health care payment information and
7	7	related information for health care services, supplies, and
8	8	procedures; authorizing enforcement and penalties.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
11	11	by adding Chapter 1470 to read as follows:
12	12	CHAPTER 1470. DISCLOSURE OF PAYMENT AND COMPENSATION
13	13	METHODOLOGY
14	14	Sec. 1470.001. DEFINITIONS. In this chapter, unless the
15	15	context otherwise requires:
16	16	(1) "Edit" means a practice or procedure under which
17	17	an adjustme
18	18	nt 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, group hospital service corporation, health
33	33	maintenance organization, or pharmacy benefit manager that
34	34	delivers or issues for delivery an individual, group, blanket, or
35	35	franchise insurance policy or insurance agreement, a group hospital
36	36	service contract, or an evidence of coverage that provides health
37	37	insurance or health care benefits and includes:
38	38	(i) a life, health, or accident insurance
39	39	company operating under Chapter 841 or 982;
40	40	(ii) a general casualty insurance company
41	41	operating under Chapter 861;
42	42	(iii) a fraternal benefit society operating
43	43	under Chapter 885;
44	44	(iv) a mutual life insurance company
45	45	operating under Chapter 882;
46	46	(v) a local mutual aid association
47	47	operating under Chapter 886;
48	48	(vi) a statewide mutual assessment company
49	49	operating under Chapter 881;
50	50	(vii) a mutual assessment company or mutual
51	51	assessment life, health, and accident association operating under
52	52	Chapter 887;
53	53	(viii) a mutual insurance company operating
54	54	under Chapter 883 that writes coverage other than life insurance;
55	55	(ix) a Lloyd's plan operating under Chapter
56	56	941;
57	57	(x) a reciprocal exchange operating under
58	58	Chapter 942;
59	59	(xi) a stipulated premium insurance company
60	60	operating under Chapter 884;
61	61	(xii) an exchange operating under Chapter
62	62	942;
63	63	(xiii) a Medicare supplemental policy as
64	64	defined by Section 1882(g)(1), Social Security Act (42 U.S.C.
65	65	Section 1395ss(g)(1);
66	66	(xiv) a Medicaid managed care program
67	67	operated under Chapter 533, Government Code;
68	68	(xv) a health maintenance organization
69	69	operating under Chapter 843;
70	70	(xvi) a multiple employer welfare
71	71	arrangement that holds a certificate of authority under Chapter
72	72	846; and
73	73	(xvii) an approved nonprofit health
74	74	corporation that holds a certificate of authority under Chapter
75	75	844;
76	76	(B) the state Medicaid program operated under
77	77	Chapter 32, Human Resources Code, or the state child health plan or
78	78	health benefits plan for children under Chapter 62 or 63, Health and
79	79	Safety Code;
80	80	(C) the Employees Retirement System of Texas or
81	81	another entity issuing or administering a basic coverage plan under
82	82	Chapter 1551;
83	83	(D) the Teacher Retirement System of Texas or
84	84	another entity issuing or administering a basic plan under Chapter
85	85	1575 or a primary care coverage plan under Chapter 1579;
86	86	(E) The Texas A&M University System or The
87	87	University of Texas System or another entity issuing or
88	88	administering basic coverage under Chapter 1601; and
89	89	(F) an entity issuing or administering medical
90	90	benefits provided under a workers' compensation insurance policy or
91	91	otherwise under Title 5, Labor Code.
92	92	(3) "Health care contract" means a contract entered
93	93	into or renewed between a health care contractor and a physician or
94	94	health care provider for the delivery of health care services to
95	95	others.
96	96	(4) "Health care contractor" means an individual or
97	97	entity that has as a business purpose contracting with physicians
98	98	or health care providers for the delivery of health care services.
99	99	The term includes a health benefit plan issuer, an administrator
100	100	regulated under Chapter 4151, and a pharmacy benefit manager that
101	101	administers or manages prescription drug benefits.
102	102	(5) "Health care provider" means an individual or
103	103	entity that furnishes goods or services under a license,
104	104	certificate, registration, or other authority issued by this state
105	105	to diagnose, prevent, alleviate, or cure a human illness or injury.
106	106	The term includes a physician or a hospital or other health care
107	107	facility.
108	108	(6) "Physician" means:
109	109	(A) an individual licensed to engage in the
110	110	practice of medicine in this state; or
111	111	(B) an entity organized under Subchapter B,
112	112	Chapter 162, Occupations Code.
113	113	(7) "Procedure code" means an alphanumeric code used
114	114	to identify a specific health procedure performed by a health care
115	115	provider. The term includes:
116	116	(A) the American Medical Association's Current
117	117	Procedural Terminology code, also known as the "CPT code";
118	118	(B) the Centers for Medicare and Medicaid
119	119	Services Health Care Common Procedure Coding System; and
120	120	(C) other analogous codes published by national
121	121	organizations and recognized by the commissioner.
122	122	Sec. 1470.002. DEFINITION OF MATERIAL CHANGE. For purposes
123	123	of this chapter, "material change" means a change to a contract that
124	124	decreases the health care provider's payment or compensation.
125	125	Sec. 1470.003. APPLICABILITY OF CHAPTER. This chapter does
126	126	not apply to an employment contract or arrangement between health
127	127	care providers.
128	128	Sec. 1470.004. RULEMAKING AUTHORITY. The commissioner may
129	129	adopt reasonable rules as necessary to implement the purposes and
130	130	provisions of this chapter.
131	131	Sec. 1470.005. REQUIRED DISCLOSURE OF PAYMENT AND
132	132	COMPENSATION TERMS. (a) Each health care contract must include a
133	133	disclosure form that states, in plain language, payment and
134	134	compensation terms for the provision of health care services,
135	135	supplies or procedures. The form must include information
136	136	sufficient for a health care provider to determine the compensation
137	137	or payment for the provider's services.
138	138	(b) The disclosure form under Subsection (a) must include:
139	139	(1) the manner of payment, such as fee-for-service,
140	140	capitation, or risk sharing;
141	141	(2) the methodology used to compute any fee schedule,
142	142	such as the use of a relative value unit system and conversion
143	143	factor, percentage of Medicare payment system, or percentage of
144	144	billed charges;
145	145	(3) the fee schedule for procedure codes reasonably
146	146	expected to be billed by the health care provider for services
147	147	provided under the contract and, on request, the fee schedule for
148	148	other procedure codes used by, or that may be used by, the health
149	149	care provider; and
150	150	(4) the effect of edits, if any, on payment or
151	151	compensation.
152	152	(c) As applicable, the methodology disclosure under
153	153	Subsection (b)(2) must include:
154	154	(1) the name of any relative value system used;
155	155	(2) the version, edition, or publication date of that
156	156	system;
157	157	(3) any applicable conversion or geographic factors;
158	158	and
159	159	(4) the date by which compensation or fee schedules
160	160	may be changed by the methodology, if allowed under the contract.
161	161	(d) The fee schedule described by Subsection (b)(3) must
162	162	include, as applicable, service or procedure codes and the
163	163	associated payment or compensation for each code. The fee schedule
164	164	may be provided electronically.
165	165	(e) A health care contractor shall provide the fee schedule
166	166	described by Subsection (b)(3) to an affected health care provider
167	167	when a material change related to payment or compensation occurs.
168	168	Additionally, a health care provider may request that a written fee
169	169	schedule be provided up to twice annually, and the health care
170	170	contractor must provide the written fee schedule within 10 business
171	171	days.
172	172	(f) A health care contractor may satisfy the requirement
173	173	under Subsection (b)(4) regarding the effect of edits by providing
174	174	a clearly understandable, readily available mechanism that allows a
175	175	health care provider to determine the effect of an edit on payment
176	176	or compensation before a service is provided or a claim is
177	177	submitted.
178	178	Sec. 1470.006. ENFORCEMENT. (a) The commissioner shall
179	179	adopt rules as necessary to enforce the provisions of this chapter,
180	180	including the imposition of administrative penalties.
181	181	(b) A violation of Section 1470.005 is a deceptive act or
182	182	practice in insurance under Subchapter B, Chapter 541.
183	183	SECTION 2. Chapter 1470, Insurance Code, as added by this
184	184	Act, applies only to a health care contract that is entered into or
185	185	renewed on or after January 1, 2016. A health care contract entered
186	186	into before January 1, 2014, is governed by the law as it existed
187	187	immediately before the effective date of this Act, and that law is
188	188	continued in effect for that purpose.
189	189	SECTION 3. This Act takes effect September 1, 2015.