Texas 2017 - 85th Regular

Texas Senate Bill SB1935 Compare Versions

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1	1	By: Hughes S.B. No. 1935
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to disclosure of certain health care costs and shared
7	7	savings between certain health benefit plans and state employees.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Chapter 1551, Insurance Code, is amended by
10	10	adding Subchapters K and L to read as follows:
11	11	SUBCHAPTER K. HEALTH CARE PRICE DISCLOSURES
12	12	Sec. 1551.501. DEFINITIONS. In this subchapter:
13	13	(1) "Administrator" means an administering firm for a
14	14	health benefit plan provided as basic coverage under this chapter.
15	15	(2) "Enrollee" means a participant enrolled in a
16	16	health benefit plan provided as basic coverage under this chapter.
17	17	(3) "Facility" means a hospital, outpatient clinic,
18	18	birthing center, ambulatory surgical center, or other licensed
19	19	facility providing health care services. The term does not include
20	20	an emergency clinic, a freestanding emergency medical care
21	21	facility, or other facility providing only emergency care.
22	22	(4) "Practitioner" means an individual who is licensed
23	23	to provide and provides medical or other health care services.
24	24	Sec. 1551.502. PROVIDER PRICE DISCLOSURE OR ESTIMATE.
25	25	(a) On the request of an enrollee and before providing a
26	26	nonemergency health care service offered to the enrollee by the
27	27	facility or practitioner, a facility or practitioner shall provide
28	28	a price disclosure described by Subsection (b) or an estimate
29	29	described by Subsection (c), as applicable, not later than the
30	30	second business day after the date on which the enrollee requests
31	31	the disclosure or estimate.
32	32	(b) Except as provided by Subsection (c), a facility or
33	33	practitioner required to provide a price disclosure under
34	34	Subsection (a) shall disclose to the enrollee the amount, including
35	35	facility fees, that:
36	36	(1) the enrollee's health benefit plan will reimburse
37	37	the facility or practitioner for the service, if the facility or
38	38	practitioner is participating in the enrollee's health benefit plan
39	39	provider network; or
40	40	(2) the facility or practitioner will charge for the
41	41	service, if the facility or practitioner is not participating in
42	42	the enrollee's health benefit plan provider network.
43	43	(c) If a facility or practitioner is unable to quote a
44	44	specific amount under Subsection (b) because of the facility's or
45	45	practitioner's inability to predict the specific service the
46	46	enrollee will need, the facility or practitioner shall provide an
47	47	estimate of the amount required to be disclosed, including facility
48	48	fees.
49	49	(d) A facility or practitioner that provides an estimate
50	50	described by Subsection (c) shall:
51	51	(1) disclose the incomplete nature of the estimate;
52	52	and
53	53	(2) inform the enrollee that the facility or
54	54	practitioner may be able to provide an updated estimate after the
55	55	facility or practitioner obtains additional information.
56	56	Sec. 1551.503. EFFECT OF OTHER LAW. A facility that
57	57	provides an estimate under Section 324.101(d) is not relieved of
58	58	the obligation to provide a price disclosure or estimate under
59	59	Section 1551.502.
60	60	Sec. 1551.504. HEALTH CARE SERVICE INFORMATION. On
61	61	request, a facility or practitioner participating in the enrollee's
62	62	health benefit plan provider network shall provide an enrollee with
63	63	sufficient information about a proposed nonemergency health care
64	64	service to enable the enrollee to obtain a cost estimate to
65	65	determine the amount for which the enrollee will be personally
66	66	liable by using the enrollee's health benefit plan's toll-free
67	67	telephone number or Internet website or a third-party service. The
68	68	facility or practitioner shall provide the information to the
69	69	enrollee based on the information that is available to the facility
70	70	or practitioner at the time of the request. The facility or
71	71	practitioner may assist the enrollee in using the telephone number,
72	72	website, or third-party service.
73	73	Sec. 1551.505. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.
74	74	(a) The administrator for an enrollee's health benefit plan shall,
75	75	on the request of the enrollee, provide a good faith estimate of
76	76	payments that will be made for any medically necessary, covered
77	77	health care service from a network provider and shall also specify
78	78	any deductibles, copayments, coinsurance, or other amounts for
79	79	which the enrollee is responsible, based on the information
80	80	available to the administrator at the time the estimate was
81	81	requested. The estimate must be provided not later than the second
82	82	business day after the date on which the estimate was requested.
83	83	The administrator must advise the enrollee that the actual payment
84	84	and charges for the services may vary based upon the enrollee's
85	85	actual medical condition and other factors associated with
86	86	performance of medical services, including any factors unknown to
87	87	or unforeseeable by the administrator or provider at the time the
88	88	estimate was requested.
89	89	(b) An administrator may require an enrollee to pay any
90	90	deductibles, copayments, coinsurance, or other amounts disclosed
91	91	in the enrollee's coverage documents for an unforeseen health care
92	92	service that arises out of the provision of the proposed health care
93	93	service.
94	94	SUBCHAPTER L. SHARED SAVINGS INCENTIVE PROGRAM
95	95	Sec. 1551.551. DEFINITIONS. In this subchapter:
96	96	(1) "Administrator" means an administering firm for a
97	97	health benefit plan provided as basic coverage under this chapter.
98	98	(2) "Enrollee" means a participant enrolled in a
99	99	health benefit plan provided as basic coverage under this chapter.
100	100	(3) "Program" means the shared savings incentive
101	101	program established under this subchapter.
102	102	(4) "Shoppable health care service" means a health
103	103	care service covered by an enrollee's health benefit plan for which
104	104	the plan provides an incentive under the program. The term
105	105	includes:
106	106	(A) physical and occupational therapy services;
107	107	(B) obstetrical and gynecological services;
108	108	(C) radiology and imaging services;
109	109	(D) laboratory services;
110	110	(E) infusion therapy;
111	111	(F) inpatient and outpatient surgical
112	112	procedures;
113	113	(G) outpatient nonsurgical diagnostic tests or
114	114	procedures; and
115	115	(H) any other health care service designated as a
116	116	shoppable health care service by the commissioner for purposes of
117	117	this subchapter.
118	118	Sec. 1551.552. APPLICABILITY. This subchapter applies to a
119	119	health benefit plan provided as basic coverage under this chapter.
120	120	Sec. 1551.553. RULES. The commissioner may adopt rules to
121	121	implement this subchapter.
122	122	Sec. 1551.554. SHARED SAVINGS INCENTIVE PROGRAM. An
123	123	administrator shall develop and implement a shared savings
124	124	incentive program through which a health benefit plan provides an
125	125	incentive in accordance with this subchapter to an enrollee for
126	126	electing to receive a shoppable health care service at a lower cost
127	127	than the average cost for that service paid by the health benefit
128	128	plan.
129	129	Sec. 1551.555. DEPARTMENT REVIEW OF PROGRAM. Before
130	130	offering the program, an administrator shall file a description of
131	131	the program with the department in the form and manner prescribed by
132	132	the commissioner. The department shall review the description to
133	133	determine whether the program complies with this subchapter and
134	134	rules adopted under this subchapter. A description of a shared
135	135	savings incentive program and any supporting documentation filed
136	136	under this section are confidential until the department has
137	137	reviewed and approved a program.
138	138	Sec. 1551.556. NOTICE TO PARTICIPANTS. Annually and at
139	139	enrollment or renewal of a health benefit plan, the board of
140	140	trustees or administrator shall provide written notice to
141	141	participants and enrollees about the availability of the program.
142	142	Sec. 1551.557. PRICE DISCLOSURE TELEPHONE NUMBER AND
143	143	WEBSITE. (a) An administrator shall establish and operate a
144	144	toll-free telephone number and an interactive mechanism on the
145	145	publicly accessible Internet website for the health benefit plan
146	146	that an enrollee may use to:
147	147	(1) request and obtain from the administrator or a
148	148	designated third party the average amount paid under the health
149	149	benefit plan to providers in the health benefit plan provider
150	150	network for a particular health care service; and
151	151	(2) compare the cost of a shoppable health care
152	152	service among network providers.
153	153	(b) An administrator may contract with a third party to
154	154	operate the telephone number or interactive mechanism described by
155	155	Subsection (a).
156	156	Sec. 1551.558. AVERAGE COST DETERMINATION. (a) Except as
157	157	provided by Subsection (b), for purposes of this subchapter an
158	158	administrator shall determine the average amount paid under a
159	159	health benefit plan to providers in the health benefit plan
160	160	provider network for a particular health care service using amounts
161	161	paid within a reasonable period of not more than one year.
162	162	(b) The commissioner may approve an alternative method for
163	163	determining the average cost amount described by Subsection (a).
164	164	Sec. 1551.559. INCENTIVE PAYMENTS. (a) An administrator
165	165	must calculate an incentive under this section as a percentage of
166	166	the difference in price, as a flat dollar amount, or by some other
167	167	reasonable method approved by the commissioner. The administrator
168	168	must provide the incentive as a cash payment to the enrollee.
169	169	(b) Except as provided by Subsection (c), if an enrollee
170	170	elects to receive a shoppable health care service the total cost of
171	171	which is less than the average cost amount determined for the
172	172	service under Section 1551.558, the administrator shall pay to the
173	173	enrollee an incentive payment that is at least 50 percent of the
174	174	health benefit plan's saved cost.
175	175	(c) An administrator is not required to pay an enrollee
176	176	under Subsection (b) if the health benefit plan's saved cost is $50
177	177	or less.
178	178	(d) If an enrollee elects to receive a shoppable health care
179	179	service from a provider outside the enrollee's health benefit plan
180	180	provider network the total cost of which is less than the average
181	181	cost amount determined for the service under Section 1551.558, the
182	182	administrator, in addition to paying any incentive payment due
183	183	under Subsection (b):
184	184	(1) may hold the enrollee responsible only for any
185	185	deductible, copayment, or coinsurance that would be due if the
186	186	service were provided by a provider in the health benefit plan
187	187	provider network; and
188	188	(2) shall apply the amount paid for the service toward
189	189	the enrollee's cost-sharing maximums, as if the service were
190	190	provided by a provider in the health benefit plan provider network.
191	191	(e) An incentive payment made in accordance with this
192	192	section is not an administrative expense of the administrator for
193	193	purposes of rate development or rate filing.
194	194	Sec. 1551.560. SHARED SAVINGS REPORTING. (a) Not later
195	195	than February 1 of each year, an administrator shall submit to the
196	196	commissioner and the board of trustees a report for the preceding
197	197	calendar year stating:
198	198	(1) the total number of incentive payments made under
199	199	Section 1551.559;
200	200	(2) the total amount of those incentive payments;
201	201	(3) the average amount of those incentive payments by
202	202	category of health care service;
203	203	(4) the total number and percentage of the health
204	204	benefit plan's enrollees who received an incentive payment;
205	205	(5) the number of shoppable health care services by
206	206	category for which incentive payments were made and the average
207	207	cost amount for those services; and
208	208	(6) the total savings achieved by the health benefit
209	209	plan for each category of health care service for which an incentive
210	210	payment was made.
211	211	(b) Not later than April 1 of each year, the department
212	212	shall submit a report aggregating the information submitted by each
213	213	health benefit plan administrator under this section to the
214	214	governor, the lieutenant governor, the speaker of the house of
215	215	representatives, and each legislative committee with jurisdiction
216	216	over health insurance matters.
217	217	SECTION 2. Section 324.101, Health and Safety Code, is
218	218	amended by adding Subsection (d-1) to read as follows:
219	219	(d-1) A facility that provides a price disclosure or
220	220	estimate under Section 1551.502, Insurance Code, is not relieved of
221	221	the obligation to provide an estimate under Subsection (d).
222	222	SECTION 3. (a) Subchapter K, Chapter 1551, Insurance Code,
223	223	as added by this Act, applies only to a service provided by a
224	224	facility or practitioner during a plan year beginning on or after
225	225	January 1, 2018. A service provided during a plan year beginning
226	226	before January 1, 2018, is governed by the law as it existed
227	227	immediately before the effective date of this Act, and that law is
228	228	continued in effect for that purpose.
229	229	(b) Subchapter L, Chapter 1551, Insurance Code, as added by
230	230	this Act, applies only to a health benefit plan for a plan year
231	231	beginning on or after January 1, 2018. A health benefit plan for a
232	232	plan year beginning before January 1, 2018, is governed by the law
233	233	as it existed immediately before the effective date of this Act, and
234	234	that law is continued in effect for that purpose.
235	235	SECTION 4. This Act takes effect September 1, 2017.