| 1 | 1 | | 85R9205 SMT-F |
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| 2 | 2 | | By: Campbell S.B. No. 1615 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | A BILL TO BE ENTITLED |
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| 6 | 6 | | AN ACT |
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| 7 | 7 | | relating to what constitutes balance billing of a health benefit |
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| 8 | 8 | | plan enrollee by a physician or health care provider for purposes of |
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| 9 | 9 | | certain disclosure and medication requirements. |
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| 10 | 10 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 11 | 11 | | SECTION 1. Section 1456.001(1), Insurance Code, is amended |
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| 12 | 12 | | to read as follows: |
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| 13 | 13 | | (1) "Balance billing" means the practice of charging |
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| 14 | 14 | | an enrollee in a health benefit plan that uses a provider network to |
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| 15 | 15 | | recover from the enrollee the balance of a non-network health care |
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| 16 | 16 | | provider's fee for service received by the enrollee from the health |
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| 17 | 17 | | care provider that is not fully reimbursed by the enrollee's health |
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| 18 | 18 | | benefit plan. The term does not include charging for: |
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| 19 | 19 | | (A) any deductible, copayment, or coinsurance |
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| 20 | 20 | | amount for which the enrollee is obligated under the health benefit |
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| 21 | 21 | | plan; or |
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| 22 | 22 | | (B) any amount the health benefit plan is |
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| 23 | 23 | | obligated to reimburse the enrollee or to pay on behalf of the |
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| 24 | 24 | | enrollee for service received by the enrollee from the health care |
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| 25 | 25 | | provider. |
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| 26 | 26 | | SECTION 2. Section 1467.051(a), Insurance Code, is amended |
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| 27 | 27 | | to read as follows: |
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| 28 | 28 | | (a) An enrollee may request mediation of a settlement of an |
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| 29 | 29 | | out-of-network health benefit claim if: |
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| 30 | 30 | | (1) the amount charged to the enrollee through balance |
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| 31 | 31 | | billing as defined by Section 1456.001 [amount for which the |
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| 32 | 32 | | enrollee is responsible to a facility-based physician, after |
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| 33 | 33 | | copayments, deductibles, and coinsurance, including the amount |
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| 34 | 34 | | unpaid by the administrator or insurer,] is greater than $500; and |
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| 35 | 35 | | (2) the health benefit claim is for a medical service |
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| 36 | 36 | | or supply provided by a facility-based physician in a hospital that |
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| 37 | 37 | | is a preferred provider or that has a contract with the |
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| 38 | 38 | | administrator. |
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| 39 | 39 | | SECTION 3. This Act takes effect September 1, 2017. |
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