Texas 2019 - 86th Regular

Texas House Bill HB2967 Compare Versions

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

Old	New	Differences
1	1	86R10376 SCL-F
2	2	By: Oliverson H.B. No. 2967
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to prohibited balance billing and an independent dispute
8	8	resolution program for out-of-network coverage under certain
9	9	managed care plans; authorizing a fee.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
12	12	by adding Chapter 1275 to read as follows:
13	13	CHAPTER 1275. ENROLLEE RESPONSIBILITY FOR COVERED OUT-OF-NETWORK
14	14	SERVICES
15	15	Sec. 1275.0001. DEFINITIONS. In this chapter:
16	16	(1) "Enrollee" means an individual who is eligible for
17	17	coverage under a health benefit plan.
18	18	(2) "Health benefit plan" means an individual, group,
19	19	blanket, or franchise insurance policy or insurance agreement, a
20	20	group hospital service contract, or an individual or group evidence
21	21	of coverage or similar coverage document that provides benefits for
22	22	health care services. The term does not include:
23	23	(A) the state Medicaid program, including the
24	24	Medicaid managed care program operated under Chapter 533,
25	25	Government Code;
26	26	(B) the child health plan program operated under
27	27	Chapter 62, Health and Safety Code;
28	28	(C) Medicare benefits; or
29	29	(D) benefits designated as excepted benefits
30	30	under 42 U.S.C. Section 300gg-91(c).
31	31	(3) "Health benefit plan issuer" means an entity
32	32	authorized to engage in business under this code or another
33	33	insurance law of this state that issues or offers to issue a health
34	34	benefit plan in this state, including:
35	35	(A) an insurance company;
36	36	(B) a group hospital service corporation
37	37	operating under Chapter 842;
38	38	(C) a health maintenance organization operating
39	39	under Chapter 843; and
40	40	(D) a stipulated premium company operating under
41	41	Chapter 884.
42	42	(4) "Health care facility" means a hospital, emergency
43	43	clinic, outpatient clinic, birthing center, ambulatory surgical
44	44	center, or other facility licensed to provide health care services.
45	45	(5) "Health care practitioner" means an individual who
46	46	is licensed to provide and provides health care services.
47	47	(6) "Health care provider" means a health care
48	48	practitioner or health care facility.
49	49	(7) "Managed care plan" means a health benefit plan
50	50	under which health care services are provided to enrollees through
51	51	contracts with health care providers and that requires enrollees to
52	52	use participating providers or that provides a different level of
53	53	coverage for enrollees who use participating providers. The term
54	54	includes a health benefit plan issued by:
55	55	(A) a health maintenance organization;
56	56	(B) a preferred provider benefit plan issuer; or
57	57	(C) any other health benefit plan issuer.
58	58	(8) "Out-of-network provider" means a health care
59	59	provider who is not a participating provider.
60	60	(9) "Participating provider" means a health care
61	61	provider, including a preferred provider, who has contracted with a
62	62	health benefit plan issuer to provide services to enrollees.
63	63	(10) "Usual, customary, and reasonable rate" has the
64	64	meaning assigned by Section 1467.201.
65	65	Sec. 1275.0002. APPLICABILITY OF CHAPTER. This chapter
66	66	applies only with respect to a managed care plan.
67	67	Sec. 1275.0003. CERTAIN PLANS EXCLUDED. This chapter does
68	68	not apply to a service covered by a health benefit plan subject to
69	69	Subchapter B, Chapter 1467.
70	70	Sec. 1275.0004. BALANCE BILLING PROHIBITED. (a) A health
71	71	benefit plan issuer shall pay for a covered service performed for an
72	72	enrollee under the health benefit plan by an out-of-network
73	73	provider at the usual, customary, and reasonable rate or at an
74	74	agreed rate.
75	75	(b) An out-of-network provider may not bill an enrollee in,
76	76	and the enrollee has no financial responsibility for, an amount
77	77	greater than the enrollee's responsibility under the enrollee's
78	78	managed care plan, including an applicable copayment, coinsurance,
79	79	or deductible.
80	80	SECTION 2. Chapter 1467, Insurance Code, is amended by
81	81	adding Subchapter E to read as follows:
82	82	SUBCHAPTER E. INDEPENDENT DISPUTE RESOLUTION PROGRAM
83	83	Sec. 1467.201. DEFINITIONS. In this subchapter:
84	84	(1) "Health benefit plan" means an individual, group,
85	85	blanket, or franchise insurance policy or insurance agreement, a
86	86	group hospital service contract, or an individual or group evidence
87	87	of coverage or similar coverage document that provides benefits for
88	88	health care services. The term does not include:
89	89	(A) the state Medicaid program, including the
90	90	Medicaid managed care program operated under Chapter 533,
91	91	Government Code;
92	92	(B) the child health plan program operated under
93	93	Chapter 62, Health and Safety Code;
94	94	(C) Medicare benefits; or
95	95	(D) benefits designated as excepted benefits
96	96	under 42 U.S.C. Section 300gg-91(c).
97	97	(2) "Health benefit plan issuer" means an entity
98	98	authorized to engage in business under this code or another
99	99	insurance law of this state that issues or offers to issue a health
100	100	benefit plan in this state, including:
101	101	(A) an insurance company;
102	102	(B) a group hospital service corporation
103	103	operating under Chapter 842;
104	104	(C) a health maintenance organization operating
105	105	under Chapter 843; and
106	106	(D) a stipulated premium company operating under
107	107	Chapter 884.
108	108	(3) "Health care facility" means a hospital, emergency
109	109	clinic, outpatient clinic, birthing center, ambulatory surgical
110	110	center, or other facility licensed to provide health care services.
111	111	(4) "Health care provider" means a health care
112	112	practitioner or health care facility.
113	113	(5) "Managed care plan" means a health benefit plan
114	114	under which health care services are provided to enrollees through
115	115	contracts with health care providers and that requires enrollees to
116	116	use participating providers or that provides a different level of
117	117	coverage for enrollees who use participating providers. The term
118	118	includes a health benefit plan issued by:
119	119	(A) a health maintenance organization;
120	120	(B) a preferred provider benefit plan issuer; or
121	121	(C) any other health benefit plan issuer.
122	122	(6) "Out-of-network provider" means a health care
123	123	provider who is not a participating provider.
124	124	(7) "Participating provider" means a health care
125	125	provider who has contracted with a health benefit plan issuer to
126	126	provide services to enrollees.
127	127	(8) "Usual, customary, and reasonable rate" means the
128	128	80th percentile of all charges for a particular health care service
129	129	performed by a health care provider in the same or similar specialty
130	130	and provided in the same geographical area as reported in a
131	131	benchmarking database described by Section 1467.203.
132	132	Sec. 1467.202. APPLICABILITY OF SUBCHAPTER. This
133	133	subchapter applies only with respect to a managed care plan.
134	134	Sec. 1467.203. BENCHMARKING DATABASE. (a) The
135	135	commissioner shall select a nonprofit organization to maintain a
136	136	benchmarking database that contains information necessary to
137	137	calculate the usual, customary, and reasonable rate for each
138	138	geographical area in this state.
139	139	(b) The commissioner may not select under Subsection (a) a
140	140	nonprofit organization that is financially affiliated with a health
141	141	benefit plan issuer.
142	142	Sec. 1467.204. ESTABLISHMENT AND ADMINISTRATION OF
143	143	PROGRAM. (a) The commissioner shall establish and administer an
144	144	independent dispute resolution program to resolve disputes over
145	145	out-of-network provider charges, including balance billing, in
146	146	accordance with this subchapter.
147	147	(b) The commissioner:
148	148	(1) shall adopt rules, forms, and procedures necessary
149	149	for the implementation and administration of the independent
150	150	dispute resolution program;
151	151	(2) may impose a fee on the parties participating in
152	152	the program as necessary to cover the cost of implementation and
153	153	administration of the program; and
154	154	(3) shall maintain a list of qualified reviewers for
155	155	the program.
156	156	Sec. 1467.205. ISSUE TO BE ADDRESSED; BASIS FOR
157	157	DETERMINATION. (a) The only issue that an independent reviewer may
158	158	determine in a hearing under the independent dispute resolution
159	159	program is the reasonable charge for the health care services
160	160	provided to the enrollee by an out-of-network provider.
161	161	(b) The determination must take into account:
162	162	(1) whether there is a gross disparity between the fee
163	163	charged by the out-of-network provider and:
164	164	(A) fees paid to the out-of-network provider for
165	165	the same services rendered by the provider to other enrollees for
166	166	which the provider is an out-of-network provider; and
167	167	(B) fees paid by the health benefit plan issuer
168	168	to reimburse similarly qualified out-of-network providers for the
169	169	same services in the same region;
170	170	(2) the level of training, education, and experience
171	171	of the out-of-network provider;
172	172	(3) the out-of-network provider's usual charge for
173	173	comparable services with regard to other enrollees for which the
174	174	provider is an out-of-network provider;
175	175	(4) the circumstances and complexity of the enrollee's
176	176	particular case, including the time and place of the service;
177	177	(5) individual enrollee characteristics; and
178	178	(6) the usual, customary, and reasonable rate for the
179	179	health care service.
180	180	Sec. 1467.206. INITIATION OF PROCESS. (a) A health benefit
181	181	plan issuer or out-of-network provider may initiate an independent
182	182	dispute resolution process in the form and manner provided by
183	183	commissioner rule to determine the amount of reimbursement for a
184	184	health care service provided by the provider.
185	185	(b) A party may respond to the claims made by the party
186	186	initiating the independent dispute resolution process under
187	187	Subsection (a) not later than the 15th day after the date the
188	188	process is initiated. If the responding party fails to respond,
189	189	that party accepts the claims made by the initiating party.
190	190	Sec. 1467.207. SELECTION AND APPROVAL OF INDEPENDENT
191	191	REVIEWERS. (a) If the parties do not select an independent
192	192	reviewer by mutual agreement on or before the 30th day after the
193	193	date the independent dispute resolution process is initiated, the
194	194	commissioner shall select a reviewer from the commissioner's list
195	195	of qualified reviewers.
196	196	(b) To be eligible to serve as an independent reviewer, an
197	197	individual must be knowledgeable and experienced in applicable
198	198	principles of contract and insurance law and the health care
199	199	industry generally.
200	200	(c) In approving an individual as an independent reviewer,
201	201	the commissioner shall ensure that the individual does not have a
202	202	conflict of interest that would adversely impact the individual's
203	203	independence and impartiality in rendering a decision in an
204	204	independent dispute resolution process. A conflict of interest
205	205	includes current or recent ownership or employment of the
206	206	individual or a close family member in a health benefit plan issuer
207	207	or out-of-network provider that may be involved in the process.
208	208	(d) The commissioner shall immediately terminate the
209	209	approval of an independent reviewer who no longer meets the
210	210	requirements under this subchapter and rules adopted under this
211	211	subchapter to serve as an independent reviewer.
212	212	Sec. 1467.208. PROCEDURES. (a) A party to an independent
213	213	dispute resolution process may request an oral hearing.
214	214	(b) If an oral hearing is not requested, the independent
215	215	reviewer shall set a date for submission of all information to be
216	216	considered by the reviewer.
217	217	(c) A party to an independent dispute resolution process
218	218	shall submit a binding award amount to the independent reviewer.
219	219	(d) An independent reviewer may make procedural rulings
220	220	during an oral hearing.
221	221	(e) A party may not engage in discovery in connection with
222	222	an independent dispute resolution process.
223	223	Sec. 1467.209. DECISION. (a) Not later than the 10th day
224	224	after the date of an oral hearing or the deadline for submission of
225	225	information, as applicable, an independent reviewer shall provide
226	226	the parties with a written decision in which the reviewer
227	227	determines which binding award amount submitted under Section
228	228	1467.208 is the closest to the reasonable charge for the services
229	229	provided in accordance with Section 1467.205(b).
230	230	(b) An independent reviewer may not modify the binding award
231	231	amount selected under Subsection (a).
232	232	(c) The decision described by Subsection (a) is binding and
233	233	final. The prevailing party may seek enforcement of the decision in
234	234	any court of competent jurisdiction.
235	235	Sec. 1467.210. ATTORNEY'S FEES AND COSTS. Unless otherwise
236	236	agreed by the parties to an independent dispute resolution process,
237	237	each party shall:
238	238	(1) bear the party's own attorney's fees and costs; and
239	239	(2) equally split the fees and costs of the
240	240	independent reviewer.
241	241	SECTION 3. Sections 1467.001(3), (5), and (7), Insurance
242	242	Code, are amended to read as follows:
243	243	(3) "Enrollee" means an individual who is eligible to
244	244	receive benefits through [a preferred provider benefit plan or] a
245	245	health benefit plan [under Chapter 1551, 1575, or 1579].
246	246	(5) "Mediation" means a process in which an impartial
247	247	mediator facilitates and promotes agreement between an [the insurer
248	248	offering a preferred provider benefit plan or the] administrator
249	249	and a facility-based provider or emergency care provider or the
250	250	provider's representative to settle a health benefit claim of an
251	251	enrollee.
252	252	(7) "Party" means a health [an insurer offering a
253	253	preferred provider] benefit plan issuer, an administrator, or a
254	254	facility-based provider or emergency care provider or the
255	255	provider's representative who participates in a mediation
256	256	conducted under this chapter. The enrollee is also considered a
257	257	party to the mediation.
258	258	SECTION 4. Section 1467.002, Insurance Code, is amended to
259	259	read as follows:
260	260	Sec. 1467.002. APPLICABILITY OF CHAPTER. Except as
261	261	provided by Subchapter E, this [This] chapter applies only to[:
262	262	[(1) a preferred provider benefit plan offered by an
263	263	insurer under Chapter 1301; and
264	264	[(2)] an administrator of a health benefit plan, other
265	265	than a health maintenance organization plan, under Chapter 1551,
266	266	1575, or 1579.
267	267	SECTION 5. Section 1467.005, Insurance Code, is amended to
268	268	read as follows:
269	269	Sec. 1467.005. REFORM. This chapter may not be construed to
270	270	prohibit:
271	271	(1) an [insurer offering a preferred provider benefit
272	272	plan or] administrator from, at any time, offering a reformed claim
273	273	settlement; or
274	274	(2) a facility-based provider or emergency care
275	275	provider from, at any time, offering a reformed charge for health
276	276	care or medical services or supplies.
277	277	SECTION 6. Sections 1467.051(a) and (b), Insurance Code,
278	278	are amended to read as follows:
279	279	(a) An enrollee may request mediation of a settlement of an
280	280	out-of-network health benefit claim if:
281	281	(1) the amount for which the enrollee is responsible
282	282	to a facility-based provider or emergency care provider, after
283	283	copayments, deductibles, and coinsurance, including the amount
284	284	unpaid by the administrator [or insurer], is greater than $500; and
285	285	(2) the health benefit claim is for:
286	286	(A) emergency care; or
287	287	(B) a health care or medical service or supply
288	288	provided by a facility-based provider in a facility that is a
289	289	preferred provider or that has a contract with the administrator.
290	290	(b) Except as provided by Subsections (c) and (d), if an
291	291	enrollee requests mediation under this subchapter, the
292	292	facility-based provider or emergency care provider, or the
293	293	provider's representative, and [the insurer or] the
294	294	administrator[, as appropriate,] shall participate in the
295	295	mediation.
296	296	SECTION 7. Section 1467.0511, Insurance Code, is amended to
297	297	read as follows:
298	298	Sec. 1467.0511. NOTICE AND INFORMATION PROVIDED TO
299	299	ENROLLEE. (a) A bill sent to an enrollee by a facility-based
300	300	provider or emergency care provider or an explanation of benefits
301	301	sent to an enrollee by an [insurer or] administrator for an
302	302	out-of-network health benefit claim eligible for mediation under
303	303	this chapter must contain, in not less than 10-point boldface type,
304	304	a conspicuous, plain-language explanation of the mediation process
305	305	available under this chapter, including information on how to
306	306	request mediation and a statement that is substantially similar to
307	307	the following:
308	308	"You may be able to reduce some of your out-of-pocket costs
309	309	for an out-of-network medical or health care claim that is eligible
310	310	for mediation by contacting the Texas Department of Insurance at
311	311	(website) and (phone number)."
312	312	(b) If an enrollee contacts an [insurer,] administrator,
313	313	facility-based provider, or emergency care provider about a bill
314	314	that may be eligible for mediation under this chapter, the
315	315	[insurer,] administrator, facility-based provider, or emergency
316	316	care provider is encouraged to:
317	317	(1) inform the enrollee about mediation under this
318	318	chapter; and
319	319	(2) provide the enrollee with the department's
320	320	toll-free telephone number and Internet website address.
321	321	SECTION 8. Section 1467.052(c), Insurance Code, is amended
322	322	to read as follows:
323	323	(c) A person may not act as mediator for a claim settlement
324	324	dispute if the person has been employed by, consulted for, or
325	325	otherwise had a business relationship with [an insurer offering the
326	326	preferred provider benefit plan or] a physician, health care
327	327	practitioner, or other health care provider during the three years
328	328	immediately preceding the request for mediation.
329	329	SECTION 9. Section 1467.053(d), Insurance Code, is amended
330	330	to read as follows:
331	331	(d) The mediator's fees shall be split evenly and paid by
332	332	the [insurer or] administrator and the facility-based provider or
333	333	emergency care provider.
334	334	SECTION 10. Sections 1467.054(b) and (c), Insurance Code,
335	335	are amended to read as follows:
336	336	(b) A request for mandatory mediation must be provided to
337	337	the department on a form prescribed by the commissioner and must
338	338	include:
339	339	(1) the name of the enrollee requesting mediation;
340	340	(2) a brief description of the claim to be mediated;
341	341	(3) contact information, including a telephone
342	342	number, for the requesting enrollee and the enrollee's counsel, if
343	343	the enrollee retains counsel;
344	344	(4) the name of the facility-based provider or
345	345	emergency care provider and name of the [insurer or] administrator;
346	346	and
347	347	(5) any other information the commissioner may require
348	348	by rule.
349	349	(c) On receipt of a request for mediation, the department
350	350	shall notify the facility-based provider or emergency care provider
351	351	and [insurer or] administrator of the request.
352	352	SECTION 11. Section 1467.055(i), Insurance Code, is amended
353	353	to read as follows:
354	354	(i) A health care or medical service or supply provided by a
355	355	facility-based provider or emergency care provider may not be
356	356	summarily disallowed. This subsection does not require an [insurer
357	357	or] administrator to pay for an uncovered service or supply.
358	358	SECTION 12. Sections 1467.056(a), (b), and (d), Insurance
359	359	Code, are amended to read as follows:
360	360	(a) In a mediation under this chapter, the parties shall:
361	361	(1) evaluate whether:
362	362	(A) the amount charged by the facility-based
363	363	provider or emergency care provider for the health care or medical
364	364	service or supply is excessive; and
365	365	(B) the amount paid by the [insurer or]
366	366	administrator represents the usual and customary rate for the
367	367	health care or medical service or supply or is unreasonably low; and
368	368	(2) as a result of the amounts described by
369	369	Subdivision (1), determine the amount, after copayments,
370	370	deductibles, and coinsurance are applied, for which an enrollee is
371	371	responsible to the facility-based provider or emergency care
372	372	provider.
373	373	(b) The facility-based provider or emergency care provider
374	374	may present information regarding the amount charged for the health
375	375	care or medical service or supply. The [insurer or] administrator
376	376	may present information regarding the amount paid by the [insurer
377	377	or] administrator.
378	378	(d) The goal of the mediation is to reach an agreement among
379	379	the enrollee, the facility-based provider or emergency care
380	380	provider, and the [insurer or] administrator[, as applicable,] as
381	381	to the amount paid by the [insurer or] administrator to the
382	382	facility-based provider or emergency care provider, the amount
383	383	charged by the facility-based provider or emergency care provider,
384	384	and the amount paid to the facility-based provider or emergency
385	385	care provider by the enrollee.
386	386	SECTION 13. Section 1467.058, Insurance Code, is amended to
387	387	read as follows:
388	388	Sec. 1467.058. CONTINUATION OF MEDIATION. After a referral
389	389	is made under Section 1467.057, the facility-based provider or
390	390	emergency care provider and the [insurer or] administrator may
391	391	elect to continue the mediation to further determine their
392	392	responsibilities. Continuation of mediation under this section
393	393	does not affect the amount of the billed charge to the enrollee.
394	394	SECTION 14. Section 1467.151(b), Insurance Code, is amended
395	395	to read as follows:
396	396	(b) The department and the Texas Medical Board or other
397	397	appropriate regulatory agency shall maintain information:
398	398	(1) on each complaint filed that concerns a claim or
399	399	mediation subject to this chapter; and
400	400	(2) related to a claim that is the basis of an enrollee
401	401	complaint, including:
402	402	(A) the type of services that gave rise to the
403	403	dispute;
404	404	(B) the type and specialty, if any, of the
405	405	facility-based provider or emergency care provider who provided the
406	406	out-of-network service;
407	407	(C) the county and metropolitan area in which the
408	408	health care or medical service or supply was provided;
409	409	(D) whether the health care or medical service or
410	410	supply was for emergency care; and
411	411	(E) any other information about:
412	412	(i) the [insurer or] administrator that the
413	413	commissioner by rule requires; or
414	414	(ii) the facility-based provider or
415	415	emergency care provider that the Texas Medical Board or other
416	416	appropriate regulatory agency by rule requires.
417	417	SECTION 15. The changes in law made by this Act apply only
418	418	to a health benefit plan delivered, issued for delivery, or renewed
419	419	on or after January 1, 2020. A health benefit plan delivered,
420	420	issued for delivery, or renewed before January 1, 2020, is governed
421	421	by the law as it existed immediately before the effective date of
422	422	this Act, and that law is continued in effect for that purpose.
423	423	SECTION 16. This Act takes effect September 1, 2019.