85R2657 BEE-F
By: Campbell S.B. No. 1485
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, "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.
(b) A preferred provider benefit plan must provide that the
insured will not be balance billed because the insurer pays an
out-of-network provider based on an allowed charge for a covered
service that is less than the average charge for the service by
out-of-network providers in the geozip area in which the service
was provided minus any portion of the charge that is the insured's
responsibility under the preferred provider benefit plan.
(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 average charge for the service by out-of-network providers in
the geozip area in which the service was provided 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.