Texas 2017 - 85th Regular

Texas House Bill HB3348 Compare Versions

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

Old	New	Differences
1	1	85R8526 BEE-F
2	2	By: Paul H.B. No. 3348
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to coverage under a preferred provider benefit plan for
8	8	certain services provided by out-of-network providers; authorizing
9	9	a fee.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Chapter 1301, Insurance Code, is amended by
12	12	adding Subchapter F to read as follows:
13	13	SUBCHAPTER F. COVERAGE FOR CERTAIN OUT-OF-NETWORK SERVICES
14	14	Sec. 1301.251. DEFINITIONS. In this subchapter:
15	15	(1) "Database provider" means a database provider
16	16	certified by the department under Section 1301.254.
17	17	(2) "Designated reimbursement information
18	18	organization" means an organization designated by the commissioner
19	19	under Section 1301.256.
20	20	(3) "Emergency care" has the meaning assigned by
21	21	Section 1301.155.
22	22	(4) "Geozip area" means an area that includes all zip
23	23	codes with the identical first three digits. For purposes of this
24	24	term, the geozip area is the closest geozip area to the location in
25	25	which the health care service was performed if the location does not
26	26	have a zip code.
27	27	(5) "Out-of-network provider," with respect to a
28	28	preferred provider benefit plan, means a physician or health care
29	29	provider that is not a preferred provider of the plan.
30	30	(6) "Purchaser" means an insured under a preferred
31	31	provider benefit plan, regardless of whether the insured pays any
32	32	part of the insured's premium, and a sponsor of the preferred
33	33	provider benefit plan, regardless of whether the sponsor pays any
34	34	part of an insured's premium.
35	35	(7) "Usual and customary charge" means an average
36	36	charge for a service or procedure, classified by geozip area and
37	37	Current Procedural Terminology code that is in the 80th percentile
38	38	of the undiscounted billed charges for that service reported to a
39	39	database provider.
40	40	Sec. 1301.252. AVAILABILITY OF PREFERRED BENEFIT COVERAGE
41	41	LEVELS FOR CERTAIN OUT-OF-NETWORK SERVICES. (a) An insurer shall
42	42	offer coverage to the insured that provides reimbursement at the
43	43	preferred level of benefits for emergency care provided by an
44	44	out-of-network provider at an institutional provider that is a
45	45	preferred provider.
46	46	(b) Coverage described by Subsection (a) must provide that
47	47	the insured is held harmless for any amount charged by an
48	48	out-of-network provider in excess of the amount of copayment,
49	49	deductible, or coinsurance that the insured would have paid if the
50	50	insured received the services from a preferred provider.
51	51	(c) An insurer may charge an additional premium for the
52	52	coverage described by Subsection (a).
53	53	Sec. 1301.253. PAYMENT OF CERTAIN CLAIMS. (a) On receipt
54	54	of a claim for payment by an out-of-network provider for a service
55	55	covered under Section 1301.252, an insurer shall obtain from a
56	56	database provider a certification:
57	57	(1) of the usual and customary charge for the service;
58	58	or
59	59	(2) that there are not sufficient reported charges in
60	60	the database provider's database to establish the usual and
61	61	customary charge for the service.
62	62	(b) If an out-of-network provider submits to an insurer a
63	63	claim for payment described by Subsection (a), the insurer shall
64	64	pay, minus any portion of the charge that is the insured's
65	65	responsibility under the preferred provider benefit plan, the
66	66	lesser of:
67	67	(1) the amount that the provider would have received
68	68	if the provider were a preferred provider; or
69	69	(2) the following amount provided by a database
70	70	provider selected by the insurer, as applicable:
71	71	(A) the usual and customary charge for the
72	72	service; or
73	73	(B) if there are not sufficient reported charges
74	74	in the database provider's database to establish the usual and
75	75	customary charge for the service, 80 percent of the billed charge or
76	76	an amount equal to the 90th percentile of the charges for the
77	77	service reported by the designated reimbursement information
78	78	organization for physicians and health care providers in the same
79	79	geozip area.
80	80	(c) An out-of-network provider shall accept as full payment
81	81	for a claim described by Subsection (a) the total of:
82	82	(1) the portion of the charge that is the insured's
83	83	responsibility under the preferred provider benefit plan; and
84	84	(2) a payment received from the insurer that complies
85	85	with Subsection (b).
86	86	(d) An insurer may not pay a provider less than the amount
87	87	required under this section solely because the insurer has not
88	88	received a portion of the charge that is the insured's
89	89	responsibility.
90	90	Sec. 1301.254. CERTIFICATION AND QUALIFICATIONS OF
91	91	DATABASE PROVIDER AND DATABASE. (a) A database provider that is
92	92	used to determine usual and customary charges for the purposes of
93	93	this subchapter must be certified by the department. The
94	94	department may certify a database provider under this subchapter
95	95	only if the department determines that the database provider and
96	96	the database used by the provider for the purposes of this
97	97	subchapter comply with this section.
98	98	(b) A database provider must be a nonprofit organization
99	99	that:
100	100	(1) maintains a database with content that complies
101	101	with this section;
102	102	(2) maintains an active Internet website accessible to
103	103	the public and to all insurers subscribing to the database; and
104	104	(3) demonstrates an ability to:
105	105	(A) maintain a compilation of charge data that is
106	106	absent any data required to be excluded under Subsection (e)(1);
107	107	and
108	108	(B) distinguish charges that are not related to
109	109	one another and eliminate irrelevant or erroneous charges from
110	110	reported charge information.
111	111	(c) A database provider must compute usual and customary
112	112	charges for services provided by physicians or health care
113	113	providers in accordance with this subchapter.
114	114	(d) The data in the database must contain out-of-network
115	115	charges, classified by Current Procedural Terminology code, for
116	116	physician and health care providers in each geozip area in this
117	117	state.
118	118	(e) The data in the database may not:
119	119	(1) include:
120	120	(A) any data other than out-of-network billed
121	121	charges from physicians and health care providers in this state;
122	122	(B) physician and health care provider charges
123	123	that reflect payments discounted under governmental or
124	124	nongovernmental health benefit plans; or
125	125	(C) information that is more than seven years
126	126	old; or
127	127	(2) exclude charges accompanied by modifiers that
128	128	indicate procedures with complications.
129	129	(f) An entity may not be certified as a database provider
130	130	for the purposes of this subchapter if the entity owns or controls,
131	131	or is owned or controlled by, or is an affiliate of, any entity with
132	132	a pecuniary interest in the application of the database, including
133	133	an insurer, a holding company of an insurer, or a trade association
134	134	in the field of insurance or health benefits.
135	135	(g) The Internet website required by this section must allow
136	136	an individual to determine the usual and customary charge for a
137	137	particular service provided by a physician or health care provider.
138	138	(h) The department shall ensure that:
139	139	(1) the data in the database used to compute usual and
140	140	customary charges of out-of-network providers is updated regularly
141	141	to accurately reflect current physician and health care provider
142	142	retail charges;
143	143	(2) charge information that is more than seven years
144	144	old is removed from the database; and
145	145	(3) at least one entity is certified as a database
146	146	provider.
147	147	(i) The department may charge a fee for certification under
148	148	this section in an amount necessary to implement this section.
149	149	Sec. 1301.255. PROVISION OF USUAL AND CUSTOMARY CHARGE BY
150	150	DATABASE PROVIDER. For each service for which a billed charge is
151	151	submitted by a physician or health care provider to an insurer that
152	152	subscribes to the database, the database provider shall provide the
153	153	insurer with a certification of the usual and customary charge or a
154	154	certification that there are not sufficient reported charges in the
155	155	database provider's database to establish the usual and customary
156	156	charge for the service, as applicable.
157	157	Sec. 1301.256. DESIGNATED REIMBURSEMENT INFORMATION
158	158	ORGANIZATION. (a) The commissioner by rule shall designate an
159	159	organization described by this section to report charges for
160	160	services provided by physicians and health care providers for which
161	161	coverage is provided under Section 1301.252.
162	162	(b) The organization designated under this section must be
163	163	an independent, not-for-profit organization created to:
164	164	(1) establish and maintain a database to help insurers
165	165	determine reimbursement rates for out-of-network charges; and
166	166	(2) provide insureds with a clear, unbiased
167	167	explanation of the reimbursement process.
168	168	Sec. 1301.257. DISCLOSURES REGARDING PAYMENT OF
169	169	OUT-OF-NETWORK PROVIDER. (a) An insurer must provide a
170	170	description of the coverage offered under Section 1301.252 on an
171	171	Internet website maintained by the insurer and in a written
172	172	disclosure provided to a prospective purchaser of the coverage.
173	173	The description must include:
174	174	(1) the definition of "usual and customary charge"
175	175	assigned by Section 1301.251 and a description of how payment to an
176	176	out-of-network provider will, if applicable, be based on the lesser
177	177	of:
178	178	(A) the amount the provider would have received
179	179	if the provider were a preferred provider; or
180	180	(B) the following amount provided by a database
181	181	provider selected by the insurer, as applicable:
182	182	(i) the usual and customary charge for the
183	183	service; or
184	184	(ii) if there are not sufficient reported
185	185	charges in the database provider's database to establish the usual
186	186	and customary charge for the service, 80 percent of the billed
187	187	charge or an amount equal to the 90th percentile of the charges for
188	188	the service reported by the designated reimbursement information
189	189	organization for physicians and health care providers in the same
190	190	geozip area;
191	191	(2) examples of the anticipated portion of the charge
192	192	that will be the insured's responsibility for specific services for
193	193	which out-of-network providers frequently bill in situations for
194	194	which coverage is offered under Section 1301.252;
195	195	(3) a methodology for determining the anticipated
196	196	portion of the charge that will be the insured's responsibility for
197	197	a specific service that is based on the amount, not an
198	198	approximation, that the insurer pays;
199	199	(4) the Internet website addresses of each database
200	200	provider certified under this subchapter at which a purchaser or
201	201	prospective purchaser may access the database or a single website
202	202	address at which an updated set of links to the website addresses of
203	203	those database providers may be accessed; and
204	204	(5) a statement that if the insurer's payment due under
205	205	coverage provided under Section 1301.252 is not sufficient to cover
206	206	the total billed charge, the physician or health care provider
207	207	agrees to accept as payment in full the amount paid by the plan in
208	208	accordance with the coverage provisions plus any portion of the
209	209	charge that is the insured's responsibility under the plan.
210	210	(b) Disclosures under this section must:
211	211	(1) be made in language easily understood by
212	212	purchasers and prospective purchasers of preferred provider
213	213	benefit plans;
214	214	(2) be made in a uniform, clearly organized manner;
215	215	(3) be of sufficient detail and comprehensiveness as
216	216	to provide for full and fair disclosure; and
217	217	(4) be updated as necessary to ensure that the
218	218	disclosures are accurate.
219	219	SECTION 2. Subchapter F, Chapter 1301, Insurance Code, as
220	220	added by this Act, applies only to a preferred provider benefit plan
221	221	that is delivered, issued for delivery, or renewed on or after
222	222	January 1, 2018. A plan delivered, issued for delivery, or renewed
223	223	before January 1, 2018, is governed by the law as it existed
224	224	immediately before the effective date of this Act, and that law is
225	225	continued in effect for that purpose.
226	226	SECTION 3. This Act takes effect September 1, 2017.