| 1 | 1 | | By: Bonnen of Galveston H.B. No. 3753 |
|---|
| 2 | 2 | | |
|---|
| 3 | 3 | | |
|---|
| 4 | 4 | | A BILL TO BE ENTITLED |
|---|
| 5 | 5 | | AN ACT |
|---|
| 6 | 6 | | relating to payment standards for preferred provider benefit plans |
|---|
| 7 | 7 | | to reduce balance billing of insureds for out-of-network health |
|---|
| 8 | 8 | | care services. |
|---|
| 9 | 9 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|---|
| 10 | 10 | | SECTION 1. Subchapter C-1, Chapter 1301, Insurance Code, is |
|---|
| 11 | 11 | | amended by adding Section 1301.140 to read as follows: |
|---|
| 12 | 12 | | Sec. 1301.140. BALANCE BILLING; PAYMENTS TO OUT-OF-NETWORK |
|---|
| 13 | 13 | | PROVIDERS. (a) In this section: |
|---|
| 14 | 14 | | (1) "Geozip area" means an area that includes all zip |
|---|
| 15 | 15 | | codes with the identical first three digits. For purposes of this |
|---|
| 16 | 16 | | section, a covered service performed at a location that does not |
|---|
| 17 | 17 | | have a zip code is considered to be performed in the geozip area |
|---|
| 18 | 18 | | closest to the location at which the service is performed. |
|---|
| 19 | 19 | | (2) "Usual and customary charge" means the average |
|---|
| 20 | 20 | | allowed charge for a covered service by a physician or health care |
|---|
| 21 | 21 | | provider with the same type of license in the same geozip area. |
|---|
| 22 | 22 | | (b) An insurer may not cause balance billing of an insured |
|---|
| 23 | 23 | | by paying an out-of-network provider based on an allowed charge for |
|---|
| 24 | 24 | | a covered service that is less than the usual and customary charge |
|---|
| 25 | 25 | | for the service. |
|---|
| 26 | 26 | | (c) If an out-of-network provider submits to an insurer a |
|---|
| 27 | 27 | | claim for payment for a covered service, the insurer shall pay the |
|---|
| 28 | 28 | | out-of-network provider an amount that is equal to or greater than |
|---|
| 29 | 29 | | the usual and customary charge for the service minus any portion of |
|---|
| 30 | 30 | | the charge that is the insured's responsibility under the preferred |
|---|
| 31 | 31 | | provider benefit plan. |
|---|
| 32 | 32 | | SECTION 2. Section 1301.140, Insurance Code, as added by |
|---|
| 33 | 33 | | this Act, applies only to a preferred provider benefit plan that is |
|---|
| 34 | 34 | | delivered, issued for delivery, or renewed on or after January 1, |
|---|
| 35 | 35 | | 2018. A preferred provider benefit plan that is delivered, issued |
|---|
| 36 | 36 | | for delivery, or renewed before January 1, 2018, is governed by the |
|---|
| 37 | 37 | | law as it existed immediately before the effective date of this Act, |
|---|
| 38 | 38 | | and that law is continued in effect for that purpose. |
|---|
| 39 | 39 | | SECTION 3. This Act takes effect September 1, 2017. |
|---|