Texas 2017 - 85th Regular

Texas Senate Bill SB507 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	85R21367 SMT-F
2		-	By: Hancock, et al. S.B. No. 507
3		-	(Frullo, Collier)
4		-	Substitute the following for S.B. No. 507: No.
	1	+	S.B. No. 507
5	2
6	3
7		-	A BILL TO BE ENTITLED
8	4		AN ACT
9	5		relating to mediation of the settlement of certain out-of-network
10	6		health benefit claims involving balance billing.
11	7		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	8		SECTION 1. Section 1467.001, Insurance Code, is amended by
13	9		amending Subdivisions (1), (3), (4), (5), and (7) and adding
14	10		Subdivisions (2-a), (2-b), (3-a), and (4-a) to read as follows:
15	11		(1) "Administrator" means:
16	12		(A) an administering firm for a health benefit
17	13		plan providing coverage under Chapter 1551, 1575, or 1579; and
18	14		(B) if applicable, the claims administrator for
19	15		the health benefit plan.
20	16		(2-a) "Emergency care" has the meaning assigned by
21	17		Section 1301.155.
22	18		(2-b) "Emergency care provider" means a physician,
23	19		health care practitioner, facility, or other health care provider
24	20		who provides and bills an enrollee, administrator, or health
25	21		benefit plan for emergency care.
26	22		(3) "Enrollee" means an individual who is eligible to
27	23		receive benefits through a preferred provider benefit plan or a
28	24		health benefit plan under Chapter 1551, 1575, or 1579.
29	25		(3-a) "Facility" has the meaning assigned by Section
30	26		324.001, Health and Safety Code.
31	27		(4) "Facility-based provider [physician]" means a
32	28		physician, health care practitioner, or other health care provider
33	29		[radiologist, an anesthesiologist, a pathologist, an emergency
34	30		department physician, a neonatologist, or an assistant surgeon:
35	31		[(A) to whom the facility has granted clinical
36	32		privileges; and
37	33		[(B)] who provides health care or medical
38	34		services to patients of a [the] facility [under those clinical
39	35		privileges].
40	36		(4-a) "Health care practitioner" means an individual
41	37		who is licensed to provide health care services.
42	38		(5) "Mediation" means a process in which an impartial
43	39		mediator facilitates and promotes agreement between the insurer
44	40		offering a preferred provider benefit plan or the administrator and
45	41		a facility-based provider or emergency care provider [physician] or
46	42		the provider's [physician's] representative to settle a health
47	43		benefit claim of an enrollee.
48	44		(7) "Party" means an insurer offering a preferred
49	45		provider benefit plan, an administrator, or a facility-based
50	46		provider or emergency care provider [physician] or the provider's
51	47		[physician's] representative who participates in a mediation
52	48		conducted under this chapter. The enrollee is also considered a
53	49		party to the mediation.
54	50		SECTION 2. Section 1467.002, Insurance Code, is amended to
55	51		read as follows:
56	52		Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter
57	53		applies to:
58	54		(1) a preferred provider benefit plan offered by an
59	55		insurer under Chapter 1301; and
60	56		(2) an administrator of a health benefit plan, other
61	57		than a health maintenance organization plan, under Chapter 1551,
62	58		1575, or 1579.
63	59		SECTION 3. Section 1467.003, Insurance Code, is amended to
64	60		read as follows:
65	61		Sec. 1467.003. RULES. The commissioner, the Texas Medical
66	62		Board, any other appropriate regulatory agency, and the chief
67	63		administrative law judge shall adopt rules as necessary to
68	64		implement their respective powers and duties under this chapter.
69	65		SECTION 4. Section 1467.005, Insurance Code, is amended to
70	66		read as follows:
71	67		Sec. 1467.005. REFORM. This chapter may not be construed to
72	68		prohibit:
73	69		(1) an insurer offering a preferred provider benefit
74	70		plan or administrator from, at any time, offering a reformed claim
75	71		settlement; or
76	72		(2) a facility-based provider or emergency care
77	73		provider [physician] from, at any time, offering a reformed charge
78	74		for health care or medical services or supplies.
79	75		SECTION 5. Section 1467.051, Insurance Code, is amended to
80	76		read as follows:
81	77		Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION;
82	78		EXCEPTION. (a) An enrollee may request mediation of a settlement
83	79		of an out-of-network health benefit claim if:
84	80		(1) the amount for which the enrollee is responsible
85	81		to a facility-based provider or emergency care provider
86	82		[physician], after copayments, deductibles, and coinsurance,
87	83		including the amount unpaid by the administrator or insurer, is
88	84		greater than $500; and
89	85		(2) the health benefit claim is for:
90	86		(A) emergency care; or
91	87		(B) a health care or medical service or supply
92	88		provided by a facility-based provider [physician] in a facility
93	89		[hospital] that is a preferred provider or that has a contract with
94	90		the administrator.
95	91		(b) Except as provided by Subsections (c) and (d), if an
96	92		enrollee requests mediation under this subchapter, the
97	93		facility-based provider or emergency care provider, [physician] or
98	94		the provider's [physician's] representative, and the insurer or the
99	95		administrator, as appropriate, shall participate in the mediation.
100	96		(c) Except in the case of an emergency and if requested by
101	97		the enrollee, a facility-based provider [physician] shall, before
102	98		providing a health care or medical service or supply, provide a
103	99		complete disclosure to an enrollee that:
104	100		(1) explains that the facility-based provider
105	101		[physician] does not have a contract with the enrollee's health
106	102		benefit plan;
107	103		(2) discloses projected amounts for which the enrollee
108	104		may be responsible; and
109	105		(3) discloses the circumstances under which the
110	106		enrollee would be responsible for those amounts.
111	107		(d) A facility-based provider [physician] who makes a
112	108		disclosure under Subsection (c) and obtains the enrollee's written
113	109		acknowledgment of that disclosure may not be required to mediate a
114	110		billed charge under this subchapter if the amount billed is less
115	111		than or equal to the maximum amount projected in the disclosure.
116	112		SECTION 6. Subchapter B, Chapter 1467, Insurance Code, is
117	113		amended by adding Section 1467.0511 to read as follows:
118	114		Sec. 1467.0511. NOTICE AND INFORMATION PROVIDED TO
119	115		ENROLLEE. (a) A bill sent to an enrollee by a facility-based
120	116		provider or emergency care provider or an explanation of benefits
121	117		sent to an enrollee by an insurer or administrator for an
122	118		out-of-network health benefit claim eligible for mediation under
123	119		this chapter must contain, in not less than 10-point boldface type,
124	120		a conspicuous, plain-language explanation of the mediation process
125	121		available under this chapter, including information on how to
126	122		request mediation and a statement that is substantially similar to
127	123		the following:
128	124		"You may be able to reduce some of your out-of-pocket costs
129	125		for an out-of-network medical or health care claim that is eligible
130	126		for mediation by contacting the Texas Department of Insurance at
131	127		(website) and (phone number)."
132	128		(b) If an enrollee contacts an insurer, administrator,
133	129		facility-based provider, or emergency care provider about a bill
134	130		that may be eligible for mediation under this chapter, the insurer,
135	131		administrator, facility-based provider, or emergency care provider
136	132		is encouraged to:
137	133		(1) inform the enrollee about mediation under this
138	134		chapter; and
139	135		(2) provide the enrollee with the department's
140	136		toll-free telephone number and Internet website address.
141	137		SECTION 7. Section 1467.052(c), Insurance Code, is amended
142	138		to read as follows:
143	139		(c) A person may not act as mediator for a claim settlement
144	140		dispute if the person has been employed by, consulted for, or
145	141		otherwise had a business relationship with an insurer offering the
146	142		preferred provider benefit plan or a physician, health care
147	143		practitioner, or other health care provider during the three years
148	144		immediately preceding the request for mediation.
149	145		SECTION 8. Section 1467.053(d), Insurance Code, is amended
150	146		to read as follows:
151	147		(d) The mediator's fees shall be split evenly and paid by
152	148		the insurer or administrator and the facility-based provider or
153	149		emergency care provider [physician].
154	150		SECTION 9. Sections 1467.054(b), (c), and (e), Insurance
155	151		Code, are amended to read as follows:
156	152		(b) A request for mandatory mediation must be provided to
157	153		the department on a form prescribed by the commissioner and must
158	154		include:
159	155		(1) the name of the enrollee requesting mediation;
160	156		(2) a brief description of the claim to be mediated;
161	157		(3) contact information, including a telephone
162	158		number, for the requesting enrollee and the enrollee's counsel, if
163	159		the enrollee retains counsel;
164	160		(4) the name of the facility-based provider or
165	161		emergency care provider [physician] and name of the insurer or
166	162		administrator; and
167	163		(5) any other information the commissioner may require
168	164		by rule.
169	165		(c) On receipt of a request for mediation, the department
170	166		shall notify the facility-based provider or emergency care provider
171	167		[physician] and insurer or administrator of the request.
172	168		(e) A dispute to be mediated under this chapter that does
173	169		not settle as a result of a teleconference conducted under
174	170		Subsection (d) must be conducted in the county in which the health
175	171		care or medical services were rendered.
176	172		SECTION 10. Sections 1467.055(d), (h), and (i), Insurance
177	173		Code, are amended to read as follows:
178	174		(d) If the enrollee is participating in the mediation in
179	175		person, at the beginning of the mediation the mediator shall inform
180	176		the enrollee that if the enrollee is not satisfied with the mediated
181	177		agreement, the enrollee may file a complaint with:
182	178		(1) the Texas Medical Board or other appropriate
183	179		regulatory agency against the facility-based provider or emergency
184	180		care provider [physician] for improper billing; and
185	181		(2) the department for unfair claim settlement
186	182		practices.
187	183		(h) On receipt of notice from the department that an
188	184		enrollee has made a request for mediation that meets the
189	185		requirements of this chapter, the facility-based provider or
190	186		emergency care provider [physician] may not pursue any collection
191	187		effort against the enrollee who has requested mediation for amounts
192	188		other than copayments, deductibles, and coinsurance before the
193	189		earlier of:
194	190		(1) the date the mediation is completed; or
195	191		(2) the date the request to mediate is withdrawn.
196	192		(i) A health care or medical service or supply provided by a
197	193		facility-based provider or emergency care provider [physician] may
198	194		not be summarily disallowed. This subsection does not require an
199	195		insurer or administrator to pay for an uncovered service or supply.
200	196		SECTION 11. Sections 1467.056(a), (b), and (d), Insurance
201	197		Code, are amended to read as follows:
202	198		(a) In a mediation under this chapter, the parties shall:
203	199		(1) evaluate whether:
204	200		(A) the amount charged by the facility-based
205	201		provider or emergency care provider [physician] for the health care
206	202		or medical service or supply is excessive; and
207	203		(B) the amount paid by the insurer or
208	204		administrator represents the usual and customary rate for the
209	205		health care or medical service or supply or is unreasonably low; and
210	206		(2) as a result of the amounts described by
211	207		Subdivision (1), determine the amount, after copayments,
212	208		deductibles, and coinsurance are applied, for which an enrollee is
213	209		responsible to the facility-based provider or emergency care
214	210		provider [physician].
215	211		(b) The facility-based provider or emergency care provider
216	212		[physician] may present information regarding the amount charged
217	213		for the health care or medical service or supply. The insurer or
218	214		administrator may present information regarding the amount paid by
219	215		the insurer or administrator.
220	216		(d) The goal of the mediation is to reach an agreement among
221	217		the enrollee, the facility-based provider or emergency care
222	218		provider [physician], and the insurer or administrator, as
223	219		applicable, as to the amount paid by the insurer or administrator to
224	220		the facility-based provider or emergency care provider
225	221		[physician], the amount charged by the facility-based provider or
226	222		emergency care provider [physician], and the amount paid to the
227	223		facility-based provider or emergency care provider [physician] by
228	224		the enrollee.
229	225		SECTION 12. Section 1467.057(a), Insurance Code, is amended
230	226		to read as follows:
231	227		(a) The mediator of an unsuccessful mediation under this
232	228		chapter shall report the outcome of the mediation to the
233	229		department, the Texas Medical Board or other appropriate regulatory
234	230		agency, and the chief administrative law judge.
235	231		SECTION 13. Section 1467.058, Insurance Code, is amended to
236	232		read as follows:
237	233		Sec. 1467.058. CONTINUATION OF MEDIATION. After a referral
238	234		is made under Section 1467.057, the facility-based provider or
239	235		emergency care provider [physician] and the insurer or
240	236		administrator may elect to continue the mediation to further
241	237		determine their responsibilities. Continuation of mediation under
242	238		this section does not affect the amount of the billed charge to the
243	239		enrollee.
244	240		SECTION 14. Section 1467.059, Insurance Code, is amended to
245	241		read as follows:
246	242		Sec. 1467.059. MEDIATION AGREEMENT. The mediator shall
247	243		prepare a confidential mediation agreement and order that states:
248	244		(1) the total amount for which the enrollee will be
249	245		responsible to the facility-based provider or emergency care
250	246		provider [physician], after copayments, deductibles, and
251	247		coinsurance; and
252	248		(2) any agreement reached by the parties under Section
253	249		1467.058.
254	250		SECTION 15. Section 1467.060, Insurance Code, is amended to
255	251		read as follows:
256	252		Sec. 1467.060. REPORT OF MEDIATOR. The mediator shall
257	253		report to the commissioner and the Texas Medical Board or other
258	254		appropriate regulatory agency:
259	255		(1) the names of the parties to the mediation; and
260	256		(2) whether the parties reached an agreement or the
261	257		mediator made a referral under Section 1467.057.
262	258		SECTION 16. Section 1467.151, Insurance Code, is amended to
263	259		read as follows:
264	260		Sec. 1467.151. CONSUMER PROTECTION; RULES. (a) The
265	261		commissioner and the Texas Medical Board or other regulatory
266	262		agency, as appropriate, shall adopt rules regulating the
267	263		investigation and review of a complaint filed that relates to the
268	264		settlement of an out-of-network health benefit claim that is
269	265		subject to this chapter. The rules adopted under this section must:
270	266		(1) distinguish among complaints for out-of-network
271	267		coverage or payment and give priority to investigating allegations
272	268		of delayed health care or medical care;
273	269		(2) develop a form for filing a complaint and
274	270		establish an outreach effort to inform enrollees of the
275	271		availability of the claims dispute resolution process under this
276	272		chapter;
277	273		(3) ensure that a complaint is not dismissed without
278	274		appropriate consideration;
279	275		(4) ensure that enrollees are informed of the
280	276		availability of mandatory mediation; and
281	277		(5) require the administrator to include a notice of
282	278		the claims dispute resolution process available under this chapter
283	279		with the explanation of benefits sent to an enrollee.
284	280		(b) The department and the Texas Medical Board or other
285	281		appropriate regulatory agency shall maintain information:
286	282		(1) on each complaint filed that concerns a claim or
287	283		mediation subject to this chapter; and
288	284		(2) related to a claim that is the basis of an enrollee
289	285		complaint, including:
290	286		(A) the type of services that gave rise to the
291	287		dispute;
292	288		(B) the type and specialty, if any, of the
293	289		facility-based provider or emergency care provider [physician] who
294	290		provided the out-of-network service;
295	291		(C) the county and metropolitan area in which the
296	292		health care or medical service or supply was provided;
297	293		(D) whether the health care or medical service or
298	294		supply was for emergency care; and
299	295		(E) any other information about:
300	296		(i) the insurer or administrator that the
301	297		commissioner by rule requires; or
302	298		(ii) the facility-based provider or
303	299		emergency care provider [physician] that the Texas Medical Board or
304	300		other appropriate regulatory agency by rule requires.
305	301		(c) The information collected and maintained by the
306	302		department and the Texas Medical Board and other appropriate
307	303		regulatory agencies under Subsection (b)(2) is public information
308	304		as defined by Section 552.002, Government Code, and may not include
309	305		personally identifiable information or health care or medical
310	306		information.
311	307		(d) A facility-based provider or emergency care provider
312	308		[physician] who fails to provide a disclosure under Section
313	309		1467.051 or 1467.0511 is not subject to discipline by the Texas
314	310		Medical Board or other appropriate regulatory agency for that
315	311		failure and a cause of action is not created by a failure to
316	312		disclose as required by Section 1467.051 or 1467.0511.
317	313		SECTION 17. Section 1467.101(c), Insurance Code, is
318	314		repealed.
319	315		SECTION 18. The changes in law made by this Act apply only
320	316		to a claim for health care or medical services or supplies provided
321	317		on or after January 1, 2018. A claim for health care or medical
322	318		services or supplies provided before January 1, 2018, is governed
323	319		by the law in effect immediately before the effective date of this
324	320		Act, and that law is continued in effect for that purpose.
325	321		SECTION 19. This Act takes effect September 1, 2017.
	322	+	______________________________ ______________________________
	323	+	President of the Senate Speaker of the House
	324	+	I hereby certify that S.B. No. 507 passed the Senate on
	325	+	March 28, 2017, by the following vote: Yeas 29, Nays 2; and that
	326	+	the Senate concurred in House amendment on May 11, 2017, by the
	327	+	following vote: Yeas 29, Nays 2.
	328	+	______________________________
	329	+	Secretary of the Senate
	330	+	I hereby certify that S.B. No. 507 passed the House, with
	331	+	amendment, on May 4, 2017, by the following vote: Yeas 133,
	332	+	Nays 12, two present not voting.
	333	+	______________________________
	334	+	Chief Clerk of the House
	335	+	Approved:
	336	+	______________________________
	337	+	Date
	338	+	______________________________
	339	+	Governor