Texas 2019 - 86th Regular

Texas House Bill HB1718 Compare Versions

Only one version of the bill is available at this time.

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1	1	By: Muñoz, Jr. H.B. No. 1718
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to participation in the health care market by managed care
7	7	plan enrollees.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
10	10	by adding Chapter 1275 to read as follows:
11	11	CHAPTER 1275. HEALTH CARE MARKET PARTICIPATION
12	12	SUBCHAPTER A. GENERAL PROVISIONS
13	13	Sec. 1275.0001. DEFINITIONS. In this chapter:
14	14	(1) "Allowed amount" means the amount paid by a health
15	15	benefit plan issuer to a participating provider for a covered
16	16	service under a contract between the issuer and provider.
17	17	(2) "Enrollee" means an individual who is eligible to
18	18	receive benefits for health care services through a health benefit
19	19	plan.
20	20	(3) "Health benefit plan" means:
21	21	(A) an individual, group, blanket, or franchise
22	22	insurance policy, a certificate issued under an individual or group
23	23	policy, or a group hospital service contract that provides benefits
24	24	for health care services; or
25	25	(B) a group subscriber contract or group or
26	26	individual evidence of coverage issued by a health maintenance
27	27	organization that provides benefits for health care services.
28	28	(4) "Health benefit plan issuer" means a health
29	29	maintenance organization operating under Chapter 843, a preferred
30	30	provider organization operating under Chapter 1301, an approved
31	31	nonprofit health corporation that holds a certificate of authority
32	32	under Chapter 844, and any other entity that issues a health benefit
33	33	plan, including:
34	34	(A) an insurance company;
35	35	(B) a group hospital service corporation
36	36	operating under Chapter 842;
37	37	(C) a fraternal benefit society operating under
38	38	Chapter 885; or
39	39	(D) a stipulated premium company operating under
40	40	Chapter 884.
41	41	(5) "Health care provider" means a physician,
42	42	hospital, pharmacy, pharmacist, laboratory, or other person or
43	43	organization that furnishes health care services and that is
44	44	licensed or otherwise authorized to practice in this state.
45	45	(6) "Health care service" means a service for the
46	46	diagnosis, prevention, treatment, cure, or relief of a health
47	47	condition, illness, injury, or disease.
48	48	(7) "Managed care plan" means a health benefit plan
49	49	under which health care services are provided to enrollees through
50	50	contracts with health care providers and that requires enrollees to
51	51	use participating providers or that provides a different level of
52	52	coverage for enrollees who use participating providers.
53	53	(8) "Out-of-network provider," with respect to a
54	54	managed care plan, means a health care provider who is not a
55	55	participating provider of the plan.
56	56	(9) "Participating provider" means a health care
57	57	provider who has contracted with a health benefit plan issuer to
58	58	provide health care services to enrollees.
59	59	Sec. 1275.0002. APPLICABILITY OF CHAPTER; EXEMPTION. (a)
60	60	This chapter applies only with respect to nonemergency health care
61	61	services covered under a managed care plan.
62	62	(b) Notwithstanding Subsection (a), Subchapters B and C do
63	63	not apply to a covered health care service described by Subsection
64	64	(a) for which the commissioner approves an application for
65	65	exemption filed by the issuer with the department in the form and
66	66	manner prescribed by the commissioner that includes sufficient
67	67	evidence to demonstrate that the variation in allowed amounts for
68	68	the service among participating providers is less than $50.
69	69	Sec. 1275.0003. RULES. The commissioner may adopt rules to
70	70	implement this chapter.
71	71	SUBCHAPTER B. TRANSPARENCY TOOLS
72	72	Sec. 1275.0051. APPLICABILITY OF SUBCHAPTER. This
73	73	subchapter applies only to:
74	74	(1) a small employer health benefit plan written under
75	75	Chapter 1501;
76	76	(2) an individual insurance policy or insurance
77	77	agreement; or
78	78	(3) an individual evidence of coverage or similar
79	79	coverage document.
80	80	Sec. 1275.0052. AVAILABILITY OF PRICE AND QUALITY
81	81	INFORMATION. (a) A health benefit plan issuer shall provide on its
82	82	publicly available Internet website an interactive mechanism that,
83	83	for a specific health care service, allows an enrollee to:
84	84	(1) request and obtain from the issuer:
85	85	(A) information on the payments made by the
86	86	issuer to participating providers under the enrollee's health
87	87	benefit plan; and
88	88	(B) quality data on participating providers to
89	89	the extent that data is available;
90	90	(2) compare allowed amounts among participating
91	91	providers;
92	92	(3) estimate the enrollee's out-of-pocket costs under
93	93	the enrollee's health benefit plan; and
94	94	(4) view the median or mode amount paid to
95	95	participating providers under the enrollee's health benefit plan
96	96	within a reasonable time not to exceed one year.
97	97	(b) A health benefit plan issuer may contract with a third
98	98	party to provide the interactive mechanism described by Subsection
99	99	(a).
100	100	Sec. 1275.0053. ESTIMATE REQUIREMENTS. To satisfy the
101	101	requirement under Section 1275.0052(a)(3), a health benefit plan
102	102	issuer shall provide a good-faith estimate of the amount the
103	103	enrollee will be responsible to pay for a health care service
104	104	provided by a participating provider based on the information
105	105	available to the issuer at the time the estimate is requested.
106	106	Sec. 1275.0054. NOTICE TO ENROLLEES. A health benefit plan
107	107	issuer shall inform an enrollee requesting an estimate under
108	108	Section 1275.0052(a)(3) that the actual amount of the charges and
109	109	the amount the enrollee is responsible to pay for the service may
110	110	vary based upon unforeseen services that arise from the proposed
111	111	service.
112	112	Sec. 1275.0055. WAIVER. (a) A health benefit plan issuer
113	113	may file with the department a request for a waiver from compliance
114	114	with this subchapter for a health care service for which the issuer
115	115	determines that the issuer is unable to comply with Section
116	116	1275.0052.
117	117	(b) A health benefit plan issuer filing a request under
118	118	Subsection (a) must:
119	119	(1) file the request in the form and manner prescribed
120	120	by the commissioner; and
121	121	(2) include evidence supporting the issuer's
122	122	determination that the issuer cannot comply with Section 1275.0052
123	123	for the health care service.
124	124	(c) The commissioner shall approve a waiver request under
125	125	this section if the commissioner determines that the issuer
126	126	provided sufficient evidence to support the waiver. If the
127	127	commissioner approves a waiver request, the commissioner shall
128	128	publicly release the contents of the request.
129	129	Sec. 1275.0056. EFFECT OF SUBCHAPTER. This subchapter does
130	130	not prohibit a health benefit plan issuer from imposing
131	131	deductibles, copayments, or coinsurance under the health benefit
132	132	plan for an unforeseen health care service:
133	133	(1) arising from the health care service that is the
134	134	basis for the original estimate to the enrollee provided under
135	135	Section 1275.0052; and
136	136	(2) that was not included in the original estimate
137	137	provided under Section 1275.0052.
138	138	SUBCHAPTER C. INCENTIVE PROGRAM
139	139	Sec. 1275.0101. APPLICABILITY OF SUBCHAPTER. (a) This
140	140	subchapter applies only to:
141	141	(1) a small employer health benefit plan written under
142	142	Chapter 1501;
143	143	(2) an individual insurance policy or insurance
144	144	agreement; or
145	145	(3) an individual evidence of coverage or similar
146	146	coverage document.
147	147	(b) This subchapter does not apply to a health benefit plan
148	148	for which an enrollee receives a premium subsidy under the Patient
149	149	Protection and Affordable Care Act (Pub. L. No. 111-148).
150	150	Sec. 1275.0102. ESTABLISHMENT OF INCENTIVE PROGRAM. A
151	151	health benefit plan issuer shall establish an incentive program for
152	152	each health benefit plan subject to this subchapter. The program
153	153	must provide an incentive paid in accordance with this subchapter
154	154	to an enrollee who elects to receive a health care service from a
155	155	participating provider who provides that service at a cost that is
156	156	lower than the median or mode allowed amount for that service.
157	157	Sec. 1275.0103. PROGRAM DESCRIPTION REQUIRED. Before
158	158	offering the program required by this subchapter, a health benefit
159	159	plan issuer shall file a description of the program with the
160	160	department in the form and manner prescribed by the commissioner.
161	161	Sec. 1275.0104. NOTICE TO ENROLLEES. Annually and at
162	162	enrollment or renewal of a health benefit plan, the health benefit
163	163	plan issuer shall provide written notice to enrollees about:
164	164	(1) the availability of the program;
165	165	(2) the program's incentives; and
166	166	(3) methods to obtain the program's incentives.
167	167	Sec. 1275.0105. INCENTIVE PAYMENTS. (a) A health benefit
168	168	plan issuer shall pay an incentive under the program regardless of
169	169	whether the enrollee has exceeded the out-of-pocket limit under the
170	170	enrollee's health benefit plan.
171	171	(b) A health benefit plan issuer may pay a program incentive
172	172	in the form of:
173	173	(1) cash;
174	174	(2) a gift card; or
175	175	(3) a credit or reduction in the health benefit plan's
176	176	premium, deductible, copayment, or coinsurance.
177	177	(c) An incentive payment made in accordance with this
178	178	section is not an administrative expense of a health benefit plan
179	179	issuer for purposes of rate development or rate filing.
180	180	SUBCHAPTER D. PARTICIPATION IN OUT-OF-NETWORK PROVIDER MARKET
181	181	Sec. 1275.0151. ENROLLEE ELECTION OF CERTAIN
182	182	OUT-OF-NETWORK CARE; PROVIDER REIMBURSEMENT. (a) If an enrollee
183	183	elects to receive a covered health care service from an
184	184	out-of-network provider who is based in the United States and the
185	185	provider makes the agreement described by Subsection (b), the
186	186	enrollee's health benefit plan issuer shall:
187	187	(1) allow the enrollee to obtain the service from the
188	188	out-of-network provider; and
189	189	(2) pay the provider an amount not to exceed the median
190	190	or mode contracted amount for the service during a reasonable
191	191	period not to exceed one year.
192	192	(b) An out-of-network provider may elect to receive a
193	193	payment under Subsection (a) if the provider agrees to not charge
194	194	the enrollee an amount that exceeds the enrollee's responsibility
195	195	under the health benefit plan for the same service provided by a
196	196	participating provider.
197	197	Sec. 1275.0152. APPLICATION OF ENROLLEE PAYMENT. (a) An
198	198	enrollee who makes an election under Section 1275.0151(a) may file
199	199	with a health benefit plan issuer a request for the enrollee's
200	200	payment to the out-of-network provider to be treated as a payment to
201	201	a participating provider under the enrollee's health benefit plan
202	202	for purposes of a deductible or out-of-pocket maximum if:
203	203	(1) the out-of-network provider made the election
204	204	described by Section 1275.0151(b) with respect to the service that
205	205	is the basis for the request; and
206	206	(2) the enrollee provides proof of payment to the
207	207	out-of-network provider.
208	208	(b) A health benefit plan issuer shall provide a
209	209	downloadable or interactive online form for submitting a request
210	210	under Subsection (a).
211	211	(c) A health benefit plan issuer shall grant a request that
212	212	complies with Subsection (a) and rules adopted under this chapter.
213	213	Sec. 1275.0153. NOTICE TO ENROLLEES. A health benefit plan
214	214	issuer shall provide written notice to enrollees on the issuer's
215	215	Internet website and in the enrollees' health benefit plan
216	216	materials of the enrollees' rights to make an election under
217	217	Section 1275.0151 and a request under Section 1275.0152 and the
218	218	process for making the election and request.
219	219	SECTION 2. Chapter 1275, Insurance Code, as added by this
220	220	Act, applies only to a health benefit plan delivered, issued for
221	221	delivery, or renewed on or after January 1, 2020. A health benefit
222	222	plan that is delivered, issued for delivery, or renewed before
223	223	January 1, 2020, is governed by the law as it existed immediately
224	224	before the effective date of this Act, and that law is continued in
225	225	effect for that purpose.
226	226	SECTION 3. This Act takes effect September 1, 2019.