| 1 | 1 | | By: Bonnen of Galveston H.B. No. 3814 |
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| 2 | 2 | | |
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| 3 | 3 | | |
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| 4 | 4 | | A BILL TO BE ENTITLED |
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| 5 | 5 | | AN ACT |
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| 6 | 6 | | relating to payment standards for preferred provider benefit plans |
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| 7 | 7 | | to reduce balance billing of insureds for out-of-network health |
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| 8 | 8 | | care services. |
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| 9 | 9 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 10 | 10 | | SECTION 1. Subchapter C-1, Chapter 1301, Insurance Code, is |
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| 11 | 11 | | amended by adding Section 1301.140 to read as follows: |
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| 12 | 12 | | Sec. 1301.140. BALANCE BILLING; PAYMENTS TO OUT-OF-NETWORK |
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| 13 | 13 | | PROVIDERS. (a) In this section: |
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| 14 | 14 | | (1) "Geozip area" means an area that includes all zip |
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| 15 | 15 | | codes with the identical first three digits. For purposes of this |
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| 16 | 16 | | section, a covered service performed at a location that does not |
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| 17 | 17 | | have a zip code is considered to be performed in the geozip area |
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| 18 | 18 | | closest to the location at which the service is performed. |
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| 19 | 19 | | (2) "Usual and customary charge" means 135% of the |
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| 20 | 20 | | average maximum allowed charge for a covered service by a physician |
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| 21 | 21 | | or health care provider with the same type of license in the same |
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| 22 | 22 | | geozip area. |
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| 23 | 23 | | (b) An insurer may not cause balance billing of an insured |
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| 24 | 24 | | by paying an out-of-network provider based on an allowed charge for |
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| 25 | 25 | | a covered service that is less than the usual and customary charge |
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| 26 | 26 | | for the service. |
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| 27 | 27 | | (c) If an out-of-network provider submits to an insurer a |
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| 28 | 28 | | claim for payment for a covered service, the insurer shall pay the |
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| 29 | 29 | | out-of-network provider an amount that is equal to or greater than |
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| 30 | 30 | | the usual and customary charge for the service minus any portion of |
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| 31 | 31 | | the charge that is the insured's responsibility under the preferred |
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| 32 | 32 | | provider benefit plan. |
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| 33 | 33 | | SECTION 2. Section 1301.140, Insurance Code, as added by |
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| 34 | 34 | | this Act, applies only to a preferred provider benefit plan that is |
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| 35 | 35 | | delivered, issued for delivery, or renewed on or after January 1, |
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| 36 | 36 | | 2018. A preferred provider benefit plan that is delivered, issued |
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| 37 | 37 | | for delivery, or renewed before January 1, 2018, is governed by the |
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| 38 | 38 | | law as it existed immediately before the effective date of this Act, |
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| 39 | 39 | | and that law is continued in effect for that purpose. |
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| 40 | 40 | | SECTION 3. This Act takes effect September 1, 2017. |
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