Texas 2017 - 85th Regular

Texas House Bill HB4178 Compare Versions

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

Old	New	Differences
1	1	85R12718 LED-F
2	2	By: Cook H.B. No. 4178
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to disclosure of certain health care costs and shared
8	8	savings between certain health benefit plans and state employees.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Chapter 1551, Insurance Code, is amended by
11	11	adding Subchapters K and L to read as follows:
12	12	SUBCHAPTER K. HEALTH CARE PRICE DISCLOSURES
13	13	Sec. 1551.501. DEFINITIONS. In this subchapter:
14	14	(1) "Administrator" means an administering firm for a
15	15	health benefit plan provided as basic coverage under this chapter.
16	16	(2) "Enrollee" means a participant enrolled in a
17	17	health benefit plan provided as basic coverage under this chapter.
18	18	(3) "Facility" means a hospital, outpatient clinic,
19	19	birthing center, ambulatory surgical center, or other licensed
20	20	facility providing health care services. The term does not include
21	21	an emergency clinic, a freestanding emergency medical care
22	22	facility, or other facility providing only emergency care.
23	23	(4) "Practitioner" means an individual who is licensed
24	24	to provide and provides medical or other health care services.
25	25	Sec. 1551.502. PROVIDER PRICE DISCLOSURE OR ESTIMATE. (a)
26	26	On the request of an enrollee and before providing a nonemergency
27	27	health care service offered to the enrollee by the facility or
28	28	practitioner, a facility or practitioner shall provide a price
29	29	disclosure described by Subsection (b) or an estimate described by
30	30	Subsection (c), as applicable, not later than the second business
31	31	day after the date on which the enrollee requests the disclosure or
32	32	estimate.
33	33	(b) Except as provided by Subsection (c), a facility or
34	34	practitioner required to provide a price disclosure under
35	35	Subsection (a) shall disclose to the enrollee the amount, including
36	36	facility fees, that:
37	37	(1) the enrollee's health benefit plan will reimburse
38	38	the facility or practitioner for the service, if the facility or
39	39	practitioner is participating in the enrollee's health benefit plan
40	40	provider network; or
41	41	(2) the facility or practitioner will charge for the
42	42	service, if the facility or practitioner is not participating in
43	43	the enrollee's health benefit plan provider network.
44	44	(c) If a facility or practitioner is unable to quote a
45	45	specific amount under Subsection (b) because of the facility's or
46	46	practitioner's inability to predict the specific service the
47	47	enrollee will need, the facility or practitioner shall provide an
48	48	estimate of the amount required to be disclosed, including facility
49	49	fees.
50	50	(d) A facility or practitioner that provides an estimate
51	51	described by Subsection (c) shall:
52	52	(1) disclose the incomplete nature of the estimate;
53	53	and
54	54	(2) inform the enrollee that the facility or
55	55	practitioner may be able to provide an updated estimate after the
56	56	facility or practitioner obtains additional information.
57	57	Sec. 1551.503. EFFECT OF OTHER LAW. A facility that
58	58	provides an estimate under Section 324.101(d) is not relieved of
59	59	the obligation to provide a price disclosure or estimate under
60	60	Section 1551.502.
61	61	Sec. 1551.504. HEALTH CARE SERVICE INFORMATION. On
62	62	request, a facility or practitioner participating in the enrollee's
63	63	health benefit plan provider network shall provide an enrollee with
64	64	sufficient information about a proposed nonemergency health care
65	65	service to enable the enrollee to obtain a cost estimate to
66	66	determine the amount for which the enrollee will be personally
67	67	liable by using the enrollee's health benefit plan's toll-free
68	68	telephone number or Internet website or a third-party service. The
69	69	facility or practitioner shall provide the information to the
70	70	enrollee based on the information that is available to the facility
71	71	or practitioner at the time of the request. The facility or
72	72	practitioner may assist the enrollee in using the telephone number,
73	73	website, or third-party service.
74	74	Sec. 1551.505. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.
75	75	(a) The administrator for an enrollee's health benefit plan shall,
76	76	on the request of the enrollee, provide a good faith estimate of
77	77	payments that will be made for any medically necessary, covered
78	78	health care service from a network provider and shall also specify
79	79	any deductibles, copayments, coinsurance, or other amounts for
80	80	which the enrollee is responsible, based on the information
81	81	available to the administrator at the time the estimate was
82	82	requested. The estimate must be provided not later than the second
83	83	business day after the date on which the estimate was requested.
84	84	The administrator must advise the enrollee that the actual payment
85	85	and charges for the services may vary based upon the enrollee's
86	86	actual medical condition and other factors associated with
87	87	performance of medical services, including any factors unknown to
88	88	or unforeseeable by the administrator or provider at the time the
89	89	estimate was requested.
90	90	(b) An administrator may require an enrollee to pay any
91	91	deductibles, copayments, coinsurance, or other amounts disclosed
92	92	in the enrollee's coverage documents for an unforeseen health care
93	93	service that arises out of the provision of the proposed health care
94	94	service.
95	95	SUBCHAPTER L. SHARED SAVINGS INCENTIVE PROGRAM
96	96	Sec. 1551.551. DEFINITIONS. In this subchapter:
97	97	(1) "Administrator" means an administering firm for a
98	98	health benefit plan provided as basic coverage under this chapter.
99	99	(2) "Enrollee" means a participant enrolled in a
100	100	health benefit plan provided as basic coverage under this chapter.
101	101	(3) "Program" means the shared savings incentive
102	102	program established under this subchapter.
103	103	(4) "Shoppable health care service" means a health
104	104	care service covered by an enrollee's health benefit plan for which
105	105	the plan provides an incentive under the program. The term
106	106	includes:
107	107	(A) physical and occupational therapy services;
108	108	(B) obstetrical and gynecological services;
109	109	(C) radiology and imaging services;
110	110	(D) laboratory services;
111	111	(E) infusion therapy;
112	112	(F) inpatient and outpatient surgical
113	113	procedures;
114	114	(G) outpatient nonsurgical diagnostic tests or
115	115	procedures; and
116	116	(H) any other health care service designated as a
117	117	shoppable health care service by the commissioner for purposes of
118	118	this subchapter.
119	119	Sec. 1551.552. APPLICABILITY. This subchapter applies to a
120	120	health benefit plan provided as basic coverage under this chapter.
121	121	Sec. 1551.553. RULES. The commissioner may adopt rules to
122	122	implement this subchapter.
123	123	Sec. 1551.554. SHARED SAVINGS INCENTIVE PROGRAM. An
124	124	administrator shall develop and implement a shared savings
125	125	incentive program through which a health benefit plan provides an
126	126	incentive in accordance with this subchapter to an enrollee for
127	127	electing to receive a shoppable health care service at a lower cost
128	128	than the average cost for that service paid by the health benefit
129	129	plan.
130	130	Sec. 1551.555. DEPARTMENT REVIEW OF PROGRAM. Before
131	131	offering the program, an administrator shall file a description of
132	132	the program with the department in the form and manner prescribed by
133	133	the commissioner. The department shall review the description to
134	134	determine whether the program complies with this subchapter and
135	135	rules adopted under this subchapter. A description of a shared
136	136	savings incentive program and any supporting documentation filed
137	137	under this section are confidential until the department has
138	138	reviewed and approved a program.
139	139	Sec. 1551.556. NOTICE TO PARTICIPANTS. Annually and at
140	140	enrollment or renewal of a health benefit plan, the board of
141	141	trustees or administrator shall provide written notice to
142	142	participants and enrollees about the availability of the program.
143	143	Sec. 1551.557. PRICE DISCLOSURE TELEPHONE NUMBER AND
144	144	WEBSITE. (a) An administrator shall establish and operate a
145	145	toll-free telephone number and an interactive mechanism on the
146	146	publicly accessible Internet website for the health benefit plan
147	147	that an enrollee may use to:
148	148	(1) request and obtain from the administrator or a
149	149	designated third party the average amount paid under the health
150	150	benefit plan to providers in the health benefit plan provider
151	151	network for a particular health care service; and
152	152	(2) compare the cost of a shoppable health care
153	153	service among network providers.
154	154	(b) An administrator may contract with a third party to
155	155	operate the telephone number or interactive mechanism described by
156	156	Subsection (a).
157	157	Sec. 1551.558. AVERAGE COST DETERMINATION. (a) Except as
158	158	provided by Subsection (b), for purposes of this subchapter an
159	159	administrator shall determine the average amount paid under a
160	160	health benefit plan to providers in the health benefit plan
161	161	provider network for a particular health care service using amounts
162	162	paid within a reasonable period of not more than one year.
163	163	(b) The commissioner may approve an alternative method for
164	164	determining the average cost amount described by Subsection (a).
165	165	Sec. 1551.559. INCENTIVE PAYMENTS. (a) An administrator
166	166	must calculate an incentive under this section as a percentage of
167	167	the difference in price, as a flat dollar amount, or by some other
168	168	reasonable method approved by the commissioner. The administrator
169	169	must provide the incentive as a cash payment to the enrollee.
170	170	(b) Except as provided by Subsection (c), if an enrollee
171	171	elects to receive a shoppable health care service the total cost of
172	172	which is less than the average cost amount determined for the
173	173	service under Section 1551.558, the administrator shall pay to the
174	174	enrollee an incentive payment that is at least 50 percent of the
175	175	health benefit plan's saved cost.
176	176	(c) An administrator is not required to pay an enrollee
177	177	under Subsection (b) if the health benefit plan's saved cost is $50
178	178	or less.
179	179	(d) If an enrollee elects to receive a shoppable health care
180	180	service from a provider outside the enrollee's health benefit plan
181	181	provider network the total cost of which is less than the average
182	182	cost amount determined for the service under Section 1551.558, the
183	183	administrator, in addition to paying any incentive payment due
184	184	under Subsection (b):
185	185	(1) may hold the enrollee responsible only for any
186	186	deductible, copayment, or coinsurance that would be due if the
187	187	service were provided by a provider in the health benefit plan
188	188	provider network; and
189	189	(2) shall apply the amount paid for the service toward
190	190	the enrollee's cost-sharing maximums, as if the service were
191	191	provided by a provider in the health benefit plan provider network.
192	192	(e) An incentive payment made in accordance with this
193	193	section is not an administrative expense of the administrator for
194	194	purposes of rate development or rate filing.
195	195	Sec. 1551.560. SHARED SAVINGS REPORTING. (a) Not later
196	196	than February 1 of each year, an administrator shall submit to the
197	197	commissioner and the board of trustees a report for the preceding
198	198	calendar year stating:
199	199	(1) the total number of incentive payments made under
200	200	Section 1551.559;
201	201	(2) the total amount of those incentive payments;
202	202	(3) the average amount of those incentive payments by
203	203	category of health care service;
204	204	(4) the total number and percentage of the health
205	205	benefit plan's enrollees who received an incentive payment;
206	206	(5) the number of shoppable health care services by
207	207	category for which incentive payments were made and the average
208	208	cost amount for those services; and
209	209	(6) the total savings achieved by the health benefit
210	210	plan for each category of health care service for which an incentive
211	211	payment was made.
212	212	(b) Not later than April 1 of each year, the department
213	213	shall submit a report aggregating the information submitted by each
214	214	health benefit plan administrator under this section to the
215	215	governor, the lieutenant governor, the speaker of the house of
216	216	representatives, and each legislative committee with jurisdiction
217	217	over health insurance matters.
218	218	SECTION 2. Section 324.101, Health and Safety Code, is
219	219	amended by adding Subsection (d-1) to read as follows:
220	220	(d-1) A facility that provides a price disclosure or
221	221	estimate under Section 1551.502, Insurance Code, is not relieved of
222	222	the obligation to provide an estimate under Subsection (d).
223	223	SECTION 3. (a) Subchapter K, Chapter 1551, Insurance Code,
224	224	as added by this Act, applies only to a service provided by a
225	225	facility or practitioner during a plan year beginning on or after
226	226	January 1, 2018. A service provided during a plan year beginning
227	227	before January 1, 2018, is governed by the law as it existed
228	228	immediately before the effective date of this Act, and that law is
229	229	continued in effect for that purpose.
230	230	(b) Subchapter L, Chapter 1551, Insurance Code, as added by
231	231	this Act, applies only to a health benefit plan for a plan year
232	232	beginning on or after January 1, 2018. A health benefit plan for a
233	233	plan year beginning before January 1, 2018, is governed by the law
234	234	as it existed immediately before the effective date of this Act, and
235	235	that law is continued in effect for that purpose.
236	236	SECTION 4. This Act takes effect September 1, 2017.