| 1 | 1 | | 85R2665 BEE-F |
|---|
| 2 | 2 | | By: Anderson of Dallas H.B. No. 3755 |
|---|
| 3 | 3 | | |
|---|
| 4 | 4 | | |
|---|
| 5 | 5 | | A BILL TO BE ENTITLED |
|---|
| 6 | 6 | | AN ACT |
|---|
| 7 | 7 | | relating to payment standards for preferred provider benefit plans |
|---|
| 8 | 8 | | to reduce balance billing of insureds for out-of-network health |
|---|
| 9 | 9 | | care services. |
|---|
| 10 | 10 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|---|
| 11 | 11 | | SECTION 1. Subchapter C-1, Chapter 1301, Insurance Code, is |
|---|
| 12 | 12 | | amended by adding Section 1301.140 to read as follows: |
|---|
| 13 | 13 | | Sec. 1301.140. BALANCE BILLING; PAYMENTS TO OUT-OF-NETWORK |
|---|
| 14 | 14 | | PROVIDERS. (a) In this section, "geozip area" means an area that |
|---|
| 15 | 15 | | includes all zip codes with the identical first three digits. For |
|---|
| 16 | 16 | | purposes of this section, a covered service performed at a location |
|---|
| 17 | 17 | | that does not have a zip code is considered to be performed in the |
|---|
| 18 | 18 | | geozip area closest to the location at which the service is |
|---|
| 19 | 19 | | performed. |
|---|
| 20 | 20 | | (b) An insurer may not cause balance billing of an insured |
|---|
| 21 | 21 | | by paying an out-of-network provider based on an allowed charge for |
|---|
| 22 | 22 | | a covered service that is less than the average amount billed for |
|---|
| 23 | 23 | | the service by preferred providers in the geozip area in which the |
|---|
| 24 | 24 | | service was provided. |
|---|
| 25 | 25 | | (c) If an out-of-network provider submits to an insurer a |
|---|
| 26 | 26 | | claim for payment for a covered service, the insurer shall pay the |
|---|
| 27 | 27 | | out-of-network provider an amount that is equal to or greater than |
|---|
| 28 | 28 | | the average amount billed for the service by preferred providers in |
|---|
| 29 | 29 | | the geozip area in which the service was provided minus any portion |
|---|
| 30 | 30 | | of the charge that is the insured's responsibility under the |
|---|
| 31 | 31 | | preferred 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. |
|---|