86R9507 SCL-F
By: Burrows H.B. No. 2525
A BILL TO BE ENTITLED
AN ACT
relating to participation in the health care market by enrollees of
certain governmental managed care plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle H, Title 8, Insurance Code, is amended
by adding Chapter 1580 to read as follows:
CHAPTER 1580. HEALTH CARE MARKET PARTICIPATION FOR CERTAIN
GOVERNMENTAL MANAGED CARE PLANS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1580.0001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible to
receive benefits for health care services through a health benefit
plan.
(2) "Health benefit plan" means a plan to which this
chapter applies under Section 1580.0002.
(3) "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.
(4) "Health care service" means a service for the
diagnosis, prevention, treatment, cure, or relief of a health
condition, illness, injury, or disease.
(5) "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.
(6) "Participating provider" means a health care
provider who has contracted with a health benefit plan issuer or
administrator to provide health care services to enrollees.
Sec. 1580.0002. APPLICABILITY OF CHAPTER. (a) This
chapter applies only with respect to nonemergency health care
services covered under a managed care plan.
(b) Notwithstanding any provision in Chapter 1551, 1575, or
1579 or any other law, this chapter applies only to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575; and
(3) a health coverage plan under Chapter 1579.
(c) Notwithstanding any other law, this chapter applies to
an independent administrator, manager, or third-party
administrator of a health benefit plan described by this section.
Sec. 1580.0003. RULES. The board of trustees of the
Employees Retirement System of Texas or Teacher Retirement System
of Texas, as applicable, may adopt rules to implement this chapter.
SUBCHAPTER B. TRANSPARENCY TOOLS
Sec. 1580.0051. AVAILABILITY OF PRICE AND QUALITY
INFORMATION. (a) A health benefit plan issuer or administrator
shall provide by a toll-free telephone number and on its publicly
available Internet website an interactive mechanism that, for a
specific health care service, allows an enrollee to request and
obtain from the issuer or administrator:
(1) information on the payments made by the issuer or
administrator to participating providers under the enrollee's
health benefit plan sufficient for the enrollee to compare costs
for that service among participating providers, including costs for
that service among participating providers after an enrollee has
exceeded the enrollee's deductible;
(2) quality data on participating providers to the
extent that data is available; and
(3) an estimate of the enrollee's out-of-pocket costs
under the enrollee's health benefit plan.
(b) A health benefit plan issuer or administrator may
contract with a third-party vendor to satisfy the requirements of
this section.
Sec. 1580.0052. NOTICE TO ENROLLEES. A health benefit plan
issuer or administrator shall inform an enrollee requesting an
estimate under Section 1580.0051 that any out-of-pocket amount
provided is only an estimate and that the actual amount of the cost
and the amount the enrollee is responsible to pay for the service
may vary based upon unforeseen issues that arise in connection with
the proposed service.
Sec. 1580.0053. EFFECT OF SUBCHAPTER. This subchapter does
not prohibit a health benefit plan issuer or administrator from
imposing deductibles, copayments, or coinsurance under the health
benefit plan for a health care service that was not included in the
original estimate provided under Section 1580.0051.
SUBCHAPTER C. SHARED SAVINGS INCENTIVE PROGRAM
Sec. 1580.0101. ESTABLISHMENT OF INCENTIVE PROGRAM. A
health benefit plan issuer or administrator shall establish a
shared savings incentive program for all enrollees of the health
benefit plan. 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 a high-quality service at a reasonable cost, as determined
by the Employees Retirement System of Texas or the Teacher
Retirement System of Texas, as applicable.
Sec. 1580.0102. NOTICE TO ENROLLEES. The health benefit
plan issuer or administrator shall annually provide written notice
to enrollees about the program.
Sec. 1580.0103. INCENTIVE PAYMENTS. A health benefit plan
issuer or administrator may pay a program incentive in the form and
manner approved by the Employees Retirement System of Texas or
Teacher Retirement System of Texas, as applicable.
SECTION 2. Chapter 1580, Insurance Code, as added by this
Act, applies only to a health benefit plan for a plan year that
begins after the first open enrollment period that occurs on or
after January 1, 2020.
SECTION 3. This Act takes effect September 1, 2019.