By: Bonnen of Galveston H.B. No. 3814
A BILL TO BE ENTITLED
AN ACT
relating to payment standards for preferred provider benefit plans
to reduce balance billing of insureds for out-of-network health
care services.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter C-1, Chapter 1301, Insurance Code, is
amended by adding Section 1301.140 to read as follows:
Sec. 1301.140. BALANCE BILLING; PAYMENTS TO OUT-OF-NETWORK
PROVIDERS. (a) In this section:
(1) "Geozip area" means an area that includes all zip
codes with the identical first three digits. For purposes of this
section, a covered service performed at a location that does not
have a zip code is considered to be performed in the geozip area
closest to the location at which the service is performed.
(2) "Usual and customary charge" means 135% of the
average maximum allowed charge for a covered service by a physician
or health care provider with the same type of license in the same
geozip area.
(b) An insurer may not cause balance billing of an insured
by paying an out-of-network provider based on an allowed charge for
a covered service that is less than the usual and customary charge
for the service.
(c) If an out-of-network provider submits to an insurer a
claim for payment for a covered service, the insurer shall pay the
out-of-network provider an amount that is equal to or greater than
the usual and customary charge for the service minus any portion of
the charge that is the insured's responsibility under the preferred
provider benefit plan.
SECTION 2. Section 1301.140, Insurance Code, as added by
this Act, applies only to a preferred provider benefit plan that is
delivered, issued for delivery, or renewed on or after January 1,
2018. A preferred provider benefit plan that is 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 3. This Act takes effect September 1, 2017.