85R12718 LED-F
By: Cook H.B. No. 4178
A BILL TO BE ENTITLED
AN ACT
relating to disclosure of certain health care costs and shared
savings between certain health benefit plans and state employees.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1551, Insurance Code, is amended by
adding Subchapters K and L to read as follows:
SUBCHAPTER K. HEALTH CARE PRICE DISCLOSURES
Sec. 1551.501. DEFINITIONS. In this subchapter:
(1) "Administrator" means an administering firm for a
health benefit plan provided as basic coverage under this chapter.
(2) "Enrollee" means a participant enrolled in a
health benefit plan provided as basic coverage under this chapter.
(3) "Facility" means a hospital, outpatient clinic,
birthing center, ambulatory surgical center, or other licensed
facility providing health care services. The term does not include
an emergency clinic, a freestanding emergency medical care
facility, or other facility providing only emergency care.
(4) "Practitioner" means an individual who is licensed
to provide and provides medical or other health care services.
Sec. 1551.502. PROVIDER PRICE DISCLOSURE OR ESTIMATE. (a)
On the request of an enrollee and before providing a nonemergency
health care service offered to the enrollee by the facility or
practitioner, a facility or practitioner shall provide a price
disclosure described by Subsection (b) or an estimate described by
Subsection (c), as applicable, not later than the second business
day after the date on which the enrollee requests the disclosure or
estimate.
(b) Except as provided by Subsection (c), a facility or
practitioner required to provide a price disclosure under
Subsection (a) shall disclose to the enrollee the amount, including
facility fees, that:
(1) the enrollee's health benefit plan will reimburse
the facility or practitioner for the service, if the facility or
practitioner is participating in the enrollee's health benefit plan
provider network; or
(2) the facility or practitioner will charge for the
service, if the facility or practitioner is not participating in
the enrollee's health benefit plan provider network.
(c) If a facility or practitioner is unable to quote a
specific amount under Subsection (b) because of the facility's or
practitioner's inability to predict the specific service the
enrollee will need, the facility or practitioner shall provide an
estimate of the amount required to be disclosed, including facility
fees.
(d) A facility or practitioner that provides an estimate
described by Subsection (c) shall:
(1) disclose the incomplete nature of the estimate;
and
(2) inform the enrollee that the facility or
practitioner may be able to provide an updated estimate after the
facility or practitioner obtains additional information.
Sec. 1551.503. EFFECT OF OTHER LAW. A facility that
provides an estimate under Section 324.101(d) is not relieved of
the obligation to provide a price disclosure or estimate under
Section 1551.502.
Sec. 1551.504. HEALTH CARE SERVICE INFORMATION. On
request, a facility or practitioner participating in the enrollee's
health benefit plan provider network shall provide an enrollee with
sufficient information about a proposed nonemergency health care
service to enable the enrollee to obtain a cost estimate to
determine the amount for which the enrollee will be personally
liable by using the enrollee's health benefit plan's toll-free
telephone number or Internet website or a third-party service. The
facility or practitioner shall provide the information to the
enrollee based on the information that is available to the facility
or practitioner at the time of the request. The facility or
practitioner may assist the enrollee in using the telephone number,
website, or third-party service.
Sec. 1551.505. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.
(a) The administrator for an enrollee's health benefit plan shall,
on the request of the enrollee, provide a good faith estimate of
payments that will be made for any medically necessary, covered
health care service from a network provider and shall also specify
any deductibles, copayments, coinsurance, or other amounts for
which the enrollee is responsible, based on the information
available to the administrator at the time the estimate was
requested. The estimate must be provided not later than the second
business day after the date on which the estimate was requested.
The administrator must advise the enrollee that the actual payment
and charges for the services may vary based upon the enrollee's
actual medical condition and other factors associated with
performance of medical services, including any factors unknown to
or unforeseeable by the administrator or provider at the time the
estimate was requested.
(b) An administrator may require an enrollee to pay any
deductibles, copayments, coinsurance, or other amounts disclosed
in the enrollee's coverage documents for an unforeseen health care
service that arises out of the provision of the proposed health care
service.
SUBCHAPTER L. SHARED SAVINGS INCENTIVE PROGRAM
Sec. 1551.551. DEFINITIONS. In this subchapter:
(1) "Administrator" means an administering firm for a
health benefit plan provided as basic coverage under this chapter.
(2) "Enrollee" means a participant enrolled in a
health benefit plan provided as basic coverage under this chapter.
(3) "Program" means the shared savings incentive
program established under this subchapter.
(4) "Shoppable health care service" means a health
care service covered by an enrollee's health benefit plan for which
the plan provides an incentive under the program. The term
includes:
(A) physical and occupational therapy services;
(B) obstetrical and gynecological services;
(C) radiology and imaging services;
(D) laboratory services;
(E) infusion therapy;
(F) inpatient and outpatient surgical
procedures;
(G) outpatient nonsurgical diagnostic tests or
procedures; and
(H) any other health care service designated as a
shoppable health care service by the commissioner for purposes of
this subchapter.
Sec. 1551.552. APPLICABILITY. This subchapter applies to a
health benefit plan provided as basic coverage under this chapter.
Sec. 1551.553. RULES. The commissioner may adopt rules to
implement this subchapter.
Sec. 1551.554. SHARED SAVINGS INCENTIVE PROGRAM. An
administrator shall develop and implement a shared savings
incentive program through which a health benefit plan provides an
incentive in accordance with this subchapter to an enrollee for
electing to receive a shoppable health care service at a lower cost
than the average cost for that service paid by the health benefit
plan.
Sec. 1551.555. DEPARTMENT REVIEW OF PROGRAM. Before
offering the program, an administrator shall file a description of
the program with the department in the form and manner prescribed by
the commissioner. The department shall review the description to
determine whether the program complies with this subchapter and
rules adopted under this subchapter. A description of a shared
savings incentive program and any supporting documentation filed
under this section are confidential until the department has
reviewed and approved a program.
Sec. 1551.556. NOTICE TO PARTICIPANTS. Annually and at
enrollment or renewal of a health benefit plan, the board of
trustees or administrator shall provide written notice to
participants and enrollees about the availability of the program.
Sec. 1551.557. PRICE DISCLOSURE TELEPHONE NUMBER AND
WEBSITE. (a) An administrator shall establish and operate a
toll-free telephone number and an interactive mechanism on the
publicly accessible Internet website for the health benefit plan
that an enrollee may use to:
(1) request and obtain from the administrator or a
designated third party the average amount paid under the health
benefit plan to providers in the health benefit plan provider
network for a particular health care service; and
(2) compare the cost of a shoppable health care
service among network providers.
(b) An administrator may contract with a third party to
operate the telephone number or interactive mechanism described by
Subsection (a).
Sec. 1551.558. AVERAGE COST DETERMINATION. (a) Except as
provided by Subsection (b), for purposes of this subchapter an
administrator shall determine the average amount paid under a
health benefit plan to providers in the health benefit plan
provider network for a particular health care service using amounts
paid within a reasonable period of not more than one year.
(b) The commissioner may approve an alternative method for
determining the average cost amount described by Subsection (a).
Sec. 1551.559. INCENTIVE PAYMENTS. (a) An administrator
must calculate an incentive under this section as a percentage of
the difference in price, as a flat dollar amount, or by some other
reasonable method approved by the commissioner. The administrator
must provide the incentive as a cash payment to the enrollee.
(b) Except as provided by Subsection (c), if an enrollee
elects to receive a shoppable health care service the total cost of
which is less than the average cost amount determined for the
service under Section 1551.558, the administrator shall pay to the
enrollee an incentive payment that is at least 50 percent of the
health benefit plan's saved cost.
(c) An administrator is not required to pay an enrollee
under Subsection (b) if the health benefit plan's saved cost is $50
or less.
(d) If an enrollee elects to receive a shoppable health care
service from a provider outside the enrollee's health benefit plan
provider network the total cost of which is less than the average
cost amount determined for the service under Section 1551.558, the
administrator, in addition to paying any incentive payment due
under Subsection (b):
(1) may hold the enrollee responsible only for any
deductible, copayment, or coinsurance that would be due if the
service were provided by a provider in the health benefit plan
provider network; and
(2) shall apply the amount paid for the service toward
the enrollee's cost-sharing maximums, as if the service were
provided by a provider in the health benefit plan provider network.
(e) An incentive payment made in accordance with this
section is not an administrative expense of the administrator for
purposes of rate development or rate filing.
Sec. 1551.560. SHARED SAVINGS REPORTING. (a) Not later
than February 1 of each year, an administrator shall submit to the
commissioner and the board of trustees a report for the preceding
calendar year stating:
(1) the total number of incentive payments made under
Section 1551.559;
(2) the total amount of those incentive payments;
(3) the average amount of those incentive payments by
category of health care service;
(4) the total number and percentage of the health
benefit plan's enrollees who received an incentive payment;
(5) the number of shoppable health care services by
category for which incentive payments were made and the average
cost amount for those services; and
(6) the total savings achieved by the health benefit
plan for each category of health care service for which an incentive
payment was made.
(b) Not later than April 1 of each year, the department
shall submit a report aggregating the information submitted by each
health benefit plan administrator under this section to the
governor, the lieutenant governor, the speaker of the house of
representatives, and each legislative committee with jurisdiction
over health insurance matters.
SECTION 2. Section 324.101, Health and Safety Code, is
amended by adding Subsection (d-1) to read as follows:
(d-1) A facility that provides a price disclosure or
estimate under Section 1551.502, Insurance Code, is not relieved of
the obligation to provide an estimate under Subsection (d).
SECTION 3. (a) Subchapter K, Chapter 1551, Insurance Code,
as added by this Act, applies only to a service provided by a
facility or practitioner during a plan year beginning on or after
January 1, 2018. A service provided during a plan year beginning
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.
(b) Subchapter L, Chapter 1551, Insurance Code, as added by
this Act, applies only to a health benefit plan for a plan year
beginning on or after January 1, 2018. A health benefit plan for a
plan year beginning 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 4. This Act takes effect September 1, 2017.