By: Muñoz, Jr. H.B. No. 1718
A BILL TO BE ENTITLED
AN ACT
relating to participation in the health care market by managed care
plan enrollees.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
by adding Chapter 1275 to read as follows:
CHAPTER 1275. HEALTH CARE MARKET PARTICIPATION
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1275.0001. DEFINITIONS. In this chapter:
(1) "Allowed amount" means the amount paid by a health
benefit plan issuer to a participating provider for a covered
service under a contract between the issuer and provider.
(2) "Enrollee" means an individual who is eligible to
receive benefits for health care services through a health benefit
plan.
(3) "Health benefit plan" means:
(A) an individual, group, blanket, or franchise
insurance policy, a certificate issued under an individual or group
policy, or a group hospital service contract that provides benefits
for health care services; or
(B) a group subscriber contract or group or
individual evidence of coverage issued by a health maintenance
organization that provides benefits for health care services.
(4) "Health benefit plan issuer" means a health
maintenance organization operating under Chapter 843, a preferred
provider organization operating under Chapter 1301, an approved
nonprofit health corporation that holds a certificate of authority
under Chapter 844, and any other entity that issues a health benefit
plan, including:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885; or
(D) a stipulated premium company operating under
Chapter 884.
(5) "Health care provider" means a physician,
hospital, pharmacy, pharmacist, laboratory, or other person or
organization that furnishes health care services and that is
licensed or otherwise authorized to practice in this state.
(6) "Health care service" means a service for the
diagnosis, prevention, treatment, cure, or relief of a health
condition, illness, injury, or disease.
(7) "Managed care plan" means a health benefit plan
under which health care services are provided to enrollees through
contracts with health care providers and that requires enrollees to
use participating providers or that provides a different level of
coverage for enrollees who use participating providers.
(8) "Out-of-network provider," with respect to a
managed care plan, means a health care provider who is not a
participating provider of the plan.
(9) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer to
provide health care services to enrollees.
Sec. 1275.0002. APPLICABILITY OF CHAPTER; EXEMPTION. (a)
This chapter applies only with respect to nonemergency health care
services covered under a managed care plan.
(b) Notwithstanding Subsection (a), Subchapters B and C do
not apply to a covered health care service described by Subsection
(a) for which the commissioner approves an application for
exemption filed by the issuer with the department in the form and
manner prescribed by the commissioner that includes sufficient
evidence to demonstrate that the variation in allowed amounts for
the service among participating providers is less than $50.
Sec. 1275.0003. RULES. The commissioner may adopt rules to
implement this chapter.
SUBCHAPTER B. TRANSPARENCY TOOLS
Sec. 1275.0051. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to:
(1) a small employer health benefit plan written under
Chapter 1501;
(2) an individual insurance policy or insurance
agreement; or
(3) an individual evidence of coverage or similar
coverage document.
Sec. 1275.0052. AVAILABILITY OF PRICE AND QUALITY
INFORMATION. (a) A health benefit plan issuer shall provide on its
publicly available Internet website an interactive mechanism that,
for a specific health care service, allows an enrollee to:
(1) request and obtain from the issuer:
(A) information on the payments made by the
issuer to participating providers under the enrollee's health
benefit plan; and
(B) quality data on participating providers to
the extent that data is available;
(2) compare allowed amounts among participating
providers;
(3) estimate the enrollee's out-of-pocket costs under
the enrollee's health benefit plan; and
(4) view the median or mode amount paid to
participating providers under the enrollee's health benefit plan
within a reasonable time not to exceed one year.
(b) A health benefit plan issuer may contract with a third
party to provide the interactive mechanism described by Subsection
(a).
Sec. 1275.0053. ESTIMATE REQUIREMENTS. To satisfy the
requirement under Section 1275.0052(a)(3), a health benefit plan
issuer shall provide a good-faith estimate of the amount the
enrollee will be responsible to pay for a health care service
provided by a participating provider based on the information
available to the issuer at the time the estimate is requested.
Sec. 1275.0054. NOTICE TO ENROLLEES. A health benefit plan
issuer shall inform an enrollee requesting an estimate under
Section 1275.0052(a)(3) that the actual amount of the charges and
the amount the enrollee is responsible to pay for the service may
vary based upon unforeseen services that arise from the proposed
service.
Sec. 1275.0055. WAIVER. (a) A health benefit plan issuer
may file with the department a request for a waiver from compliance
with this subchapter for a health care service for which the issuer
determines that the issuer is unable to comply with Section
1275.0052.
(b) A health benefit plan issuer filing a request under
Subsection (a) must:
(1) file the request in the form and manner prescribed
by the commissioner; and
(2) include evidence supporting the issuer's
determination that the issuer cannot comply with Section 1275.0052
for the health care service.
(c) The commissioner shall approve a waiver request under
this section if the commissioner determines that the issuer
provided sufficient evidence to support the waiver. If the
commissioner approves a waiver request, the commissioner shall
publicly release the contents of the request.
Sec. 1275.0056. EFFECT OF SUBCHAPTER. This subchapter does
not prohibit a health benefit plan issuer from imposing
deductibles, copayments, or coinsurance under the health benefit
plan for an unforeseen health care service:
(1) arising from the health care service that is the
basis for the original estimate to the enrollee provided under
Section 1275.0052; and
(2) that was not included in the original estimate
provided under Section 1275.0052.
SUBCHAPTER C. INCENTIVE PROGRAM
Sec. 1275.0101. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies only to:
(1) a small employer health benefit plan written under
Chapter 1501;
(2) an individual insurance policy or insurance
agreement; or
(3) an individual evidence of coverage or similar
coverage document.
(b) This subchapter does not apply to a health benefit plan
for which an enrollee receives a premium subsidy under the Patient
Protection and Affordable Care Act (Pub. L. No. 111-148).
Sec. 1275.0102. ESTABLISHMENT OF INCENTIVE PROGRAM. A
health benefit plan issuer shall establish an incentive program for
each health benefit plan subject to this subchapter. The program
must provide an incentive paid in accordance with this subchapter
to an enrollee who elects to receive a health care service from a
participating provider who provides that service at a cost that is
lower than the median or mode allowed amount for that service.
Sec. 1275.0103. PROGRAM DESCRIPTION REQUIRED. Before
offering the program required by this subchapter, a health benefit
plan issuer shall file a description of the program with the
department in the form and manner prescribed by the commissioner.
Sec. 1275.0104. NOTICE TO ENROLLEES. Annually and at
enrollment or renewal of a health benefit plan, the health benefit
plan issuer shall provide written notice to enrollees about:
(1) the availability of the program;
(2) the program's incentives; and
(3) methods to obtain the program's incentives.
Sec. 1275.0105. INCENTIVE PAYMENTS. (a) A health benefit
plan issuer shall pay an incentive under the program regardless of
whether the enrollee has exceeded the out-of-pocket limit under the
enrollee's health benefit plan.
(b) A health benefit plan issuer may pay a program incentive
in the form of:
(1) cash;
(2) a gift card; or
(3) a credit or reduction in the health benefit plan's
premium, deductible, copayment, or coinsurance.
(c) An incentive payment made in accordance with this
section is not an administrative expense of a health benefit plan
issuer for purposes of rate development or rate filing.
SUBCHAPTER D. PARTICIPATION IN OUT-OF-NETWORK PROVIDER MARKET
Sec. 1275.0151. ENROLLEE ELECTION OF CERTAIN
OUT-OF-NETWORK CARE; PROVIDER REIMBURSEMENT. (a) If an enrollee
elects to receive a covered health care service from an
out-of-network provider who is based in the United States and the
provider makes the agreement described by Subsection (b), the
enrollee's health benefit plan issuer shall:
(1) allow the enrollee to obtain the service from the
out-of-network provider; and
(2) pay the provider an amount not to exceed the median
or mode contracted amount for the service during a reasonable
period not to exceed one year.
(b) An out-of-network provider may elect to receive a
payment under Subsection (a) if the provider agrees to not charge
the enrollee an amount that exceeds the enrollee's responsibility
under the health benefit plan for the same service provided by a
participating provider.
Sec. 1275.0152. APPLICATION OF ENROLLEE PAYMENT. (a) An
enrollee who makes an election under Section 1275.0151(a) may file
with a health benefit plan issuer a request for the enrollee's
payment to the out-of-network provider to be treated as a payment to
a participating provider under the enrollee's health benefit plan
for purposes of a deductible or out-of-pocket maximum if:
(1) the out-of-network provider made the election
described by Section 1275.0151(b) with respect to the service that
is the basis for the request; and
(2) the enrollee provides proof of payment to the
out-of-network provider.
(b) A health benefit plan issuer shall provide a
downloadable or interactive online form for submitting a request
under Subsection (a).
(c) A health benefit plan issuer shall grant a request that
complies with Subsection (a) and rules adopted under this chapter.
Sec. 1275.0153. NOTICE TO ENROLLEES. A health benefit plan
issuer shall provide written notice to enrollees on the issuer's
Internet website and in the enrollees' health benefit plan
materials of the enrollees' rights to make an election under
Section 1275.0151 and a request under Section 1275.0152 and the
process for making the election and request.
SECTION 2. Chapter 1275, Insurance Code, as added by this
Act, applies only to a health benefit plan delivered, issued for
delivery, or renewed on or after January 1, 2020. A health benefit
plan that is delivered, issued for delivery, or renewed before
January 1, 2020, 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, 2019.