Texas 2017 - 85th Regular

Texas House Bill HB1566 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	85R21367 SMT-F
2	2	By: Frullo H.B. No. 1566
3	3	Substitute the following for H.B. No. 1566:
4	4	By: Phillips C.S.H.B. No. 1566
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to mediation of the settlement of certain out-of-network
10	10	health benefit claims involving balance billing.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 1467.001, Insurance Code, is amended by
13	13	amending Subdivisions (1), (3), (4), (5), and (7) and adding
14	14	Subdivisions (2-a), (2-b), (3-a), and (4-a) to read as follows:
15	15	(1) "Administrator" means:
16	16	(A) an administering firm for a health benefit
17	17	plan providing coverage under Chapter 1551, 1575, or 1579; and
18	18	(B) if applicable, the claims administrator for
19	19	the health benefit plan.
20	20	(2-a) "Emergency care" has the meaning assigned by
21	21	Section 1301.155.
22	22	(2-b) "Emergency care provider" means a physician,
23	23	health care practitioner, facility, or other health care provider
24	24	who provides and bills an enrollee, administrator, or health
25	25	benefit plan for emergency care.
26	26	(3) "Enrollee" means an individual who is eligible to
27	27	receive benefits through a preferred provider benefit plan or a
28	28	health benefit plan under Chapter 1551, 1575, or 1579.
29	29	(3-a) "Facility" has the meaning assigned by Section
30	30	324.001, Health and Safety Code.
31	31	(4) "Facility-based provider [physician]" means a
32	32	physician, health care practitioner, or other health care provider
33	33	[radiologist, an anesthesiologist, a pathologist, an emergency
34	34	department physician, a neonatologist, or an assistant surgeon:
35	35	[(A) to whom the facility has granted clinical
36	36	privileges; and
37	37	[(B)] who provides health care or medical
38	38	services to patients of a [the] facility [under those clinical
39	39	privileges].
40	40	(4-a) "Health care practitioner" means an individual
41	41	who is licensed to provide health care services.
42	42	(5) "Mediation" means a process in which an impartial
43	43	mediator facilitates and promotes agreement between the insurer
44	44	offering a preferred provider benefit plan or the administrator and
45	45	a facility-based provider or emergency care provider [physician] or
46	46	the provider's [physician's] representative to settle a health
47	47	benefit claim of an enrollee.
48	48	(7) "Party" means an insurer offering a preferred
49	49	provider benefit plan, an administrator, or a facility-based
50	50	provider or emergency care provider [physician] or the provider's
51	51	[physician's] representative who participates in a mediation
52	52	conducted under this chapter. The enrollee is also considered a
53	53	party to the mediation.
54	54	SECTION 2. Section 1467.002, Insurance Code, is amended to
55	55	read as follows:
56	56	Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter
57	57	applies to:
58	58	(1) a preferred provider benefit plan offered by an
59	59	insurer under Chapter 1301; and
60	60	(2) an administrator of a health benefit plan, other
61	61	than a health maintenance organization plan, under Chapter 1551,
62	62	1575, or 1579.
63	63	SECTION 3. Section 1467.003, Insurance Code, is amended to
64	64	read as follows:
65	65	Sec. 1467.003. RULES. The commissioner, the Texas Medical
66	66	Board, any other appropriate regulatory agency, and the chief
67	67	administrative law judge shall adopt rules as necessary to
68	68	implement their respective powers and duties under this chapter.
69	69	SECTION 4. Section 1467.005, Insurance Code, is amended to
70	70	read as follows:
71	71	Sec. 1467.005. REFORM. This chapter may not be construed to
72	72	prohibit:
73	73	(1) an insurer offering a preferred provider benefit
74	74	plan or administrator from, at any time, offering a reformed claim
75	75	settlement; or
76	76	(2) a facility-based provider or emergency care
77	77	provider [physician] from, at any time, offering a reformed charge
78	78	for health care or medical services or supplies.
79	79	SECTION 5. Section 1467.051, Insurance Code, is amended to
80	80	read as follows:
81	81	Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION;
82	82	EXCEPTION. (a) An enrollee may request mediation of a settlement
83	83	of an out-of-network health benefit claim if:
84	84	(1) the amount for which the enrollee is responsible
85	85	to a facility-based provider or emergency care provider
86	86	[physician], after copayments, deductibles, and coinsurance,
87	87	including the amount unpaid by the administrator or insurer, is
88	88	greater than $500; and
89	89	(2) the health benefit claim is for:
90	90	(A) emergency care; or
91	91	(B) a health care or medical service or supply
92	92	provided by a facility-based provider [physician] in a facility
93	93	[hospital] that is a preferred provider or that has a contract with
94	94	the administrator.
95	95	(b) Except as provided by Subsections (c) and (d), if an
96	96	enrollee requests mediation under this subchapter, the
97	97	facility-based provider or emergency care provider, [physician] or
98	98	the provider's [physician's] representative, and the insurer or the
99	99	administrator, as appropriate, shall participate in the mediation.
100	100	(c) Except in the case of an emergency and if requested by
101	101	the enrollee, a facility-based provider [physician] shall, before
102	102	providing a health care or medical service or supply, provide a
103	103	complete disclosure to an enrollee that:
104	104	(1) explains that the facility-based provider
105	105	[physician] does not have a contract with the enrollee's health
106	106	benefit plan;
107	107	(2) discloses projected amounts for which the enrollee
108	108	may be responsible; and
109	109	(3) discloses the circumstances under which the
110	110	enrollee would be responsible for those amounts.
111	111	(d) A facility-based provider [physician] who makes a
112	112	disclosure under Subsection (c) and obtains the enrollee's written
113	113	acknowledgment of that disclosure may not be required to mediate a
114	114	billed charge under this subchapter if the amount billed is less
115	115	than or equal to the maximum amount projected in the disclosure.
116	116	SECTION 6. Subchapter B, Chapter 1467, Insurance Code, is
117	117	amended by adding Section 1467.0511 to read as follows:
118	118	Sec. 1467.0511. NOTICE AND INFORMATION PROVIDED TO
119	119	ENROLLEE. (a) A bill sent to an enrollee by a facility-based
120	120	provider or emergency care provider or an explanation of benefits
121	121	sent to an enrollee by an insurer or administrator for an
122	122	out-of-network health benefit claim eligible for mediation under
123	123	this chapter must contain, in not less than 10-point boldface type,
124	124	a conspicuous, plain-language explanation of the mediation process
125	125	available under this chapter, including information on how to
126	126	request mediation and a statement that is substantially similar to
127	127	the following:
128	128	"You may be able to reduce some of your out-of-pocket costs
129	129	for an out-of-network medical or health care claim that is eligible
130	130	for mediation by contacting the Texas Department of Insurance at
131	131	(website) and (phone number)."
132	132	(b) If an enrollee contacts an insurer, administrator,
133	133	facility-based provider, or emergency care provider about a bill
134	134	that may be eligible for mediation under this chapter, the insurer,
135	135	administrator, facility-based provider, or emergency care provider
136	136	is encouraged to:
137	137	(1) inform the enrollee about mediation under this
138	138	chapter; and
139	139	(2) provide the enrollee with the department's
140	140	toll-free telephone number and Internet website address.
141	141	SECTION 7. Section 1467.052(c), Insurance Code, is amended
142	142	to read as follows:
143	143	(c) A person may not act as mediator for a claim settlement
144	144	dispute if the person has been employed by, consulted for, or
145	145	otherwise had a business relationship with an insurer offering the
146	146	preferred provider benefit plan or a physician, health care
147	147	practitioner, or other health care provider during the three years
148	148	immediately preceding the request for mediation.
149	149	SECTION 8. Section 1467.053(d), Insurance Code, is amended
150	150	to read as follows:
151	151	(d) The mediator's fees shall be split evenly and paid by
152	152	the insurer or administrator and the facility-based provider or
153	153	emergency care provider [physician].
154	154	SECTION 9. Sections 1467.054(b), (c), and (e), Insurance
155	155	Code, are amended to read as follows:
156	156	(b) A request for mandatory mediation must be provided to
157	157	the department on a form prescribed by the commissioner and must
158	158	include:
159	159	(1) the name of the enrollee requesting mediation;
160	160	(2) a brief description of the claim to be mediated;
161	161	(3) contact information, including a telephone
162	162	number, for the requesting enrollee and the enrollee's counsel, if
163	163	the enrollee retains counsel;
164	164	(4) the name of the facility-based provider or
165	165	emergency care provider [physician] and name of the insurer or
166	166	administrator; and
167	167	(5) any other information the commissioner may require
168	168	by rule.
169	169	(c) On receipt of a request for mediation, the department
170	170	shall notify the facility-based provider or emergency care provider
171	171	[physician] and insurer or administrator of the request.
172	172	(e) A dispute to be mediated under this chapter that does
173	173	not settle as a result of a teleconference conducted under
174	174	Subsection (d) must be conducted in the county in which the health
175	175	care or medical services were rendered.
176	176	SECTION 10. Sections 1467.055(d), (h), and (i), Insurance
177	177	Code, are amended to read as follows:
178	178	(d) If the enrollee is participating in the mediation in
179	179	person, at the beginning of the mediation the mediator shall inform
180	180	the enrollee that if the enrollee is not satisfied with the mediated
181	181	agreement, the enrollee may file a complaint with:
182	182	(1) the Texas Medical Board or other appropriate
183	183	regulatory agency against the facility-based provider or emergency
184	184	care provider [physician] for improper billing; and
185	185	(2) the department for unfair claim settlement
186	186	practices.
187	187	(h) On receipt of notice from the department that an
188	188	enrollee has made a request for mediation that meets the
189	189	requirements of this chapter, the facility-based provider or
190	190	emergency care provider [physician] may not pursue any collection
191	191	effort against the enrollee who has requested mediation for amounts
192	192	other than copayments, deductibles, and coinsurance before the
193	193	earlier of:
194	194	(1) the date the mediation is completed; or
195	195	(2) the date the request to mediate is withdrawn.
196	196	(i) A health care or medical service or supply provided by a
197	197	facility-based provider or emergency care provider [physician] may
198	198	not be summarily disallowed. This subsection does not require an
199	199	insurer or administrator to pay for an uncovered service or supply.
200	200	SECTION 11. Sections 1467.056(a), (b), and (d), Insurance
201	201	Code, are amended to read as follows:
202	202	(a) In a mediation under this chapter, the parties shall:
203	203	(1) evaluate whether:
204	204	(A) the amount charged by the facility-based
205	205	provider or emergency care provider [physician] for the health care
206	206	or medical service or supply is excessive; and
207	207	(B) the amount paid by the insurer or
208	208	administrator represents the usual and customary rate for the
209	209	health care or medical service or supply or is unreasonably low; and
210	210	(2) as a result of the amounts described by
211	211	Subdivision (1), determine the amount, after copayments,
212	212	deductibles, and coinsurance are applied, for which an enrollee is
213	213	responsible to the facility-based provider or emergency care
214	214	provider [physician].
215	215	(b) The facility-based provider or emergency care provider
216	216	[physician] may present information regarding the amount charged
217	217	for the health care or medical service or supply. The insurer or
218	218	administrator may present information regarding the amount paid by
219	219	the insurer or administrator.
220	220	(d) The goal of the mediation is to reach an agreement among
221	221	the enrollee, the facility-based provider or emergency care
222	222	provider [physician], and the insurer or administrator, as
223	223	applicable, as to the amount paid by the insurer or administrator to
224	224	the facility-based provider or emergency care provider
225	225	[physician], the amount charged by the facility-based provider or
226	226	emergency care provider [physician], and the amount paid to the
227	227	facility-based provider or emergency care provider [physician] by
228	228	the enrollee.
229	229	SECTION 12. Section 1467.057(a), Insurance Code, is amended
230	230	to read as follows:
231	231	(a) The mediator of an unsuccessful mediation under this
232	232	chapter shall report the outcome of the mediation to the
233	233	department, the Texas Medical Board or other appropriate regulatory
234	234	agency, and the chief administrative law judge.
235	235	SECTION 13. Section 1467.058, Insurance Code, is amended to
236	236	read as follows:
237	237	Sec. 1467.058. CONTINUATION OF MEDIATION. After a referral
238	238	is made under Section 1467.057, the facility-based provider or
239	239	emergency care provider [physician] and the insurer or
240	240	administrator may elect to continue the mediation to further
241	241	determine their responsibilities. Continuation of mediation under
242	242	this section does not affect the amount of the billed charge to the
243	243	enrollee.
244	244	SECTION 14. Section 1467.059, Insurance Code, is amended to
245	245	read as follows:
246	246	Sec. 1467.059. MEDIATION AGREEMENT. The mediator shall
247	247	prepare a confidential mediation agreement and order that states:
248	248	(1) the total amount for which the enrollee will be
249	249	responsible to the facility-based provider or emergency care
250	250	provider [physician], after copayments, deductibles, and
251	251	coinsurance; and
252	252	(2) any agreement reached by the parties under Section
253	253	1467.058.
254	254	SECTION 15. Section 1467.060, Insurance Code, is amended to
255	255	read as follows:
256	256	Sec. 1467.060. REPORT OF MEDIATOR. The mediator shall
257	257	report to the commissioner and the Texas Medical Board or other
258	258	appropriate regulatory agency:
259	259	(1) the names of the parties to the mediation; and
260	260	(2) whether the parties reached an agreement or the
261	261	mediator made a referral under Section 1467.057.
262	262	SECTION 16. Section 1467.151, Insurance Code, is amended to
263	263	read as follows:
264	264	Sec. 1467.151. CONSUMER PROTECTION; RULES. (a) The
265	265	commissioner and the Texas Medical Board or other regulatory
266	266	agency, as appropriate, shall adopt rules regulating the
267	267	investigation and review of a complaint filed that relates to the
268	268	settlement of an out-of-network health benefit claim that is
269	269	subject to this chapter. The rules adopted under this section must:
270	270	(1) distinguish among complaints for out-of-network
271	271	coverage or payment and give priority to investigating allegations
272	272	of delayed health care or medical care;
273	273	(2) develop a form for filing a complaint and
274	274	establish an outreach effort to inform enrollees of the
275	275	availability of the claims dispute resolution process under this
276	276	chapter;
277	277	(3) ensure that a complaint is not dismissed without
278	278	appropriate consideration;
279	279	(4) ensure that enrollees are informed of the
280	280	availability of mandatory mediation; and
281	281	(5) require the administrator to include a notice of
282	282	the claims dispute resolution process available under this chapter
283	283	with the explanation of benefits sent to an enrollee.
284	284	(b) The department and the Texas Medical Board or other
285	285	appropriate regulatory agency shall maintain information:
286	286	(1) on each complaint filed that concerns a claim or
287	287	mediation subject to this chapter; and
288	288	(2) related to a claim that is the basis of an enrollee
289	289	complaint, including:
290	290	(A) the type of services that gave rise to the
291	291	dispute;
292	292	(B) the type and specialty, if any, of the
293	293	facility-based provider or emergency care provider [physician] who
294	294	provided the out-of-network service;
295	295	(C) the county and metropolitan area in which the
296	296	health care or medical service or supply was provided;
297	297	(D) whether the health care or medical service or
298	298	supply was for emergency care; and
299	299	(E) any other information about:
300	300	(i) the insurer or administrator that the
301	301	commissioner by rule requires; or
302	302	(ii) the facility-based provider or
303	303	emergency care provider [physician] that the Texas Medical Board or
304	304	other appropriate regulatory agency by rule requires.
305	305	(c) The information collected and maintained by the
306	306	department and the Texas Medical Board and other appropriate
307	307	regulatory agencies under Subsection (b)(2) is public information
308	308	as defined by Section 552.002, Government Code, and may not include
309	309	personally identifiable information or health care or medical
310	310	information.
311	311	(d) A facility-based provider or emergency care provider
312	312	[physician] who fails to provide a disclosure under Section
313	313	1467.051 or 1467.0511 is not subject to discipline by the Texas
314	314	Medical Board or other appropriate regulatory agency for that
315	315	failure and a cause of action is not created by a failure to
316	316	disclose as required by Section 1467.051 or 1467.0511.
317	317	SECTION 17. Section 1467.101(c), Insurance Code, is
318	318	repealed.
319	319	SECTION 18. The changes in law made by this Act apply only
320	320	to a claim for health care or medical services or supplies provided
321	321	on or after January 1, 2018. A claim for health care or medical
322	322	services or supplies provided before January 1, 2018, is governed
323	323	by the law in effect immediately before the effective date of this
324	324	Act, and that law is continued in effect for that purpose.
325	325	SECTION 19. This Act takes effect September 1, 2017.