85R3983 LED-F
By: Burrows H.B. No. 307
A BILL TO BE ENTITLED
AN ACT
relating to disclosure of certain health care costs and shared
savings between certain health benefit plans and enrollees.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Title 2, Health and Safety Code, is amended by
adding Subtitle J to read as follows:
SUBTITLE J. HEALTH CARE PRICE DISCLOSURES
CHAPTER 185. HEALTH CARE PRICE DISCLOSURES
Sec. 185.001. DEFINITIONS. In this chapter:
(1) "Facility" means a hospital, outpatient clinic,
birthing center, ambulatory surgical center, or other licensed
facility providing health care services. The term does not include
an emergency clinic, a freestanding emergency medical care
facility, or other facility providing only emergency care.
(2) "Patient" includes a prospective patient and a
personal representative of the patient.
(3) "Practitioner" means an individual who is licensed
to provide and provides medical or other health care services.
Sec. 185.002. PRICE DISCLOSURE OR ESTIMATE. (a) Before
providing a nonemergency health care service offered to the patient
by the facility or practitioner, a facility or practitioner shall
provide a price disclosure described by Subsection (b) or an
estimate described by Subsection (c), as applicable, unless
declined by the patient.
(b) Except as provided by Subsection (c), a facility or
practitioner required to provide a price disclosure under
Subsection (a) shall disclose to the patient the amount, including
facility fees, that:
(1) the patient's health benefit plan will reimburse
the facility or practitioner for the service, if the facility or
practitioner is a participating provider under the patient's health
benefit plan; or
(2) the facility or practitioner will charge for the
service, if the facility or practitioner is not a participating
provider under the patient's health benefit plan.
(c) If a facility or practitioner is unable to quote a
specific amount under Subsection (b) because of the facility's or
practitioner's inability to predict the specific service the
patient will need, the facility or practitioner shall provide an
estimate of the amount, including facility fees, that:
(1) the patient's health benefit plan will reimburse
the facility or practitioner for the predicted service, if the
facility or practitioner is a participating provider under the
patient's health benefit plan; or
(2) the facility or practitioner will charge for the
predicted service, if the facility or practitioner is not a
participating provider under the patient's health benefit plan.
(d) A facility or practitioner that provides an estimate
described by Subsection (c) shall:
(1) disclose the incomplete nature of the estimate;
and
(2) inform the patient that the facility or
practitioner may be able to provide an updated estimate after the
facility or practitioner obtains additional information.
(e) Notwithstanding any other law, a facility or
practitioner that does not provide the price disclosure or estimate
required by this section before providing a health care service for
which the price disclosure or estimate is required may not bill the
patient or the patient's health benefit plan for the service.
Sec. 185.003. EFFECT OF OTHER LAW. A facility that provides
an estimate under Section 324.101(d) is not relieved of the
obligation to provide a price disclosure or estimate under Section
185.002.
Sec. 185.004. PATIENT INFORMATION. On request, a facility
or practitioner shall provide a patient with sufficient information
about a proposed nonemergency health care service to enable the
patient to determine the amount for which the patient will be
personally liable by using the patient's health benefit plan's
toll-free telephone number or Internet website. The facility or
practitioner shall provide the information to the patient based on
the information that is available to the facility or practitioner
at the time of the request. The facility or practitioner may assist
the patient in using the telephone number or website.
SECTION 2. Section 324.101, Health and Safety Code, is
amended by adding Subsection (d-1) and amending Subsection (e) to
read as follows:
(d-1) A facility that provides a price disclosure or
estimate under Section 185.002 is not relieved of the obligation to
provide an estimate under Subsection (d).
(e) A facility shall provide to the consumer at the
consumer's request an itemized statement in plain language of the
billed services if the consumer requests the statement not later
than the first anniversary of the date the person is discharged from
the facility. The facility shall provide the statement to the
consumer not later than the 10th business day after the date on
which the statement is requested.
SECTION 3. The heading to Chapter 1456, Insurance Code, is
amended to read as follows:
CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS AND COSTS OF HEALTH
CARE SERVICES; SHARED SAVINGS
SECTION 4. Section 1456.003, Insurance Code, is amended by
amending Subsection (a) and adding Subsection (a-1) to read as
follows:
(a) Each health benefit plan that provides health care
through a provider network shall provide notice to its enrollees
that:
(1) a facility-based physician or other health care
practitioner may not be included in the health benefit plan's
provider network; and
(2) subject to Chapter 185, Health and Safety Code, a
health care practitioner described by Subdivision (1) may balance
bill the enrollee for amounts not paid by the health benefit plan.
(a-1) A health benefit plan shall provide notice to its
enrollees that an enrollee may be eligible for a cost-sharing
payment to the enrollee if the enrollee elects to receive a health
care service that costs less than the average amount quoted for that
service by the health benefit plan's telephone number or website
established for that purpose.
SECTION 5. Sections 1456.006 and 1456.007, Insurance Code,
are amended to read as follows:
Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. The
commissioner by rule may prescribe specific requirements for the
disclosure required under Section 1456.003. The form of the
disclosure under Section 1456.003(a) must be substantially as
follows:
NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN
PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE
PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER
PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE
FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE
NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF
ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT
PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN."
Sec. 1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.
(a) A health benefit plan that must comply with this chapter under
Section 1456.002 shall, on the request of an enrollee, provide a
binding [an] estimate of payments that will be made for any health
care service or supply and shall also specify any deductibles,
copayments, coinsurance, or other amounts for which the enrollee is
responsible, based on the information available to the health
benefit plan at the time the estimate was requested. The estimate
must be provided not later than the 10th business day after the date
on which the estimate was requested. A health benefit plan must
advise the enrollee that:
(1) the actual payment and charges for the services or
supplies may [will] vary based upon the enrollee's actual medical
condition and other factors associated with performance of medical
services, including any factors unknown to or unforeseeable by the
health benefit plan or provider at the time the estimate was
requested; and
(2) subject to Subsection (b) and Chapter 185, Health
and Safety Code, the enrollee may be personally liable for the
payment of services or supplies based upon the enrollee's health
benefit plan coverage.
(b) Except as provided by Subsection (c), a health benefit
plan may not require an enrollee to pay more than the amount
estimated under Subsection (a) for a health care service or supply
that was actually provided.
(c) A health benefit plan may require an enrollee to pay any
deductibles, copayments, coinsurance, or other amounts disclosed
in the enrollee's policy, certificate of coverage, or evidence of
coverage for an unforeseen health care service or supply that
arises out of the provision of the proposed health care service or
supply.
SECTION 6. Chapter 1456, Insurance Code, is amended by
adding Sections 1456.008, 1456.009, and 1456.010 to read as
follows:
Sec. 1456.008. PRICE DISCLOSURE TELEPHONE NUMBER AND
WEBSITE. (a) A health benefit plan shall establish and operate a
toll-free telephone number and publicly accessible Internet
website for an enrollee to:
(1) request and obtain the average amount paid under
the health benefit plan to a provider in the health benefit plan
provider network for a particular health care service or supply in
the preceding 12 months in the enrollee's geographic rating area;
and
(2) request an estimate described by Section 1456.007.
(b) A health benefit plan shall maintain a written record of
the average amount quoted to an enrollee under Subsection (a)(1).
Sec. 1456.009. SHARED SAVINGS. (a) Except as provided by
Subsection (b), if an enrollee elects and receives a health care
service or supply the total cost of which is less than the average
amount quoted under Section 1456.008, a health benefit plan shall
pay to the enrollee the lesser of:
(1) 50 percent of the difference between the average
amount and the actual cost, minus any applicable deductible,
copayment, or coinsurance; or
(2) $7,500.
(b) A health benefit plan is not required to pay an enrollee
under Subsection (a) if the plan's saved cost is $50 or less.
(c) A health benefit plan shall pay an enrollee not later
than the 30th day after the day on which the enrollee submits a
claim for shared savings under this section.
(d) If an enrollee elects and receives a health care service
or supply from a provider outside the health benefit plan provider
network the total cost of which is less than the average amount
quoted under Section 1456.008, a health benefit plan may hold the
enrollee responsible only for any deductible, copayment, or
coinsurance that would be due if the service were provided by a
provider in the health benefit plan provider network.
Sec. 1456.010. SHARED SAVINGS REPORTING. Not later than
February 1 of each year, a health benefit plan shall submit to the
commissioner a report for the preceding calendar year stating:
(1) the total number of requests for a binding
estimate received for the plan under Section 1456.007;
(2) the total number of health care services or
supplies for which an enrollee is eligible for a payment under
Section 1456.009 and the average cost of each service or supply by
category;
(3) the difference between the average cost of health
care services or supplies for which an enrollee is eligible for a
payment under Section 1456.009 and the average amount for the same
service or supply quoted under Section 1456.008;
(4) the total payments made under Section 1456.009 to
enrollees; and
(5) the total number and percentage of the health
benefit plan's enrollees who received a payment under Section
1456.009.
SECTION 7. (a) Chapter 185, Health and Safety Code, as
added by this Act, and Section 324.101(e), Health and Safety Code,
as amended by this Act, apply only to a service provided by a
facility or practitioner on or after January 1, 2018. A service
provided before January 1, 2018, 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 1456, Insurance Code, as amended by this Act,
applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2018. A health benefit
plan delivered, issued for delivery, or renewed before January 1,
2018, 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.
SECTION 8. This Act takes effect September 1, 2017.