| 1 | 1 | | 86R13583 SMT-D |
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| 2 | 2 | | By: Lucio III H.B. No. 4536 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | A BILL TO BE ENTITLED |
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| 6 | 6 | | AN ACT |
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| 7 | 7 | | relating to the determination of a usual and customary amount under |
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| 8 | 8 | | the Insurance Code. |
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| 9 | 9 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 10 | 10 | | SECTION 1. Subtitle A, Title 2, Insurance Code, is amended |
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| 11 | 11 | | by adding Chapter 41 to read as follows: |
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| 12 | 12 | | CHAPTER 41. USUAL AND CUSTOMARY AMOUNTS |
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| 13 | 13 | | Sec. 41.0001. STANDARDIZED PROCEDURE. (a) The |
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| 14 | 14 | | commissioner of insurance by rule shall adopt a standardized |
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| 15 | 15 | | procedure to determine the usual and customary rate or amount for a |
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| 16 | 16 | | particular medical care or health care service or supply, including |
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| 17 | 17 | | a dental care service or supply, for purposes of this code. |
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| 18 | 18 | | (b) The procedure may include the use of a database or |
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| 19 | 19 | | clearing house, a survey procedure, or any other mechanism that |
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| 20 | 20 | | facilitates the determination of whether an amount is usual and |
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| 21 | 21 | | customary. |
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| 22 | 22 | | Sec. 41.0002. SIMILAR STATUTORY PROVISIONS. For a |
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| 23 | 23 | | provision of this code that establishes a payment standard for a |
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| 24 | 24 | | medical care or health care service or supply using statutory |
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| 25 | 25 | | language that is similar to "usual and customary," including |
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| 26 | 26 | | "reasonable and customary" or "usual, customary, and reasonable," |
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| 27 | 27 | | the commissioner by rule shall determine whether the provision is |
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| 28 | 28 | | subject to the standardized procedure adopted under Section |
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| 29 | 29 | | 41.0001. |
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| 30 | 30 | | Sec. 41.0003. USE OF PROCEDURE. (a) The issuer of any |
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| 31 | 31 | | health benefit plan regulated under this code, including a health |
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| 32 | 32 | | maintenance organization or a preferred provider organization, |
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| 33 | 33 | | must use the standardized procedure adopted under this chapter to |
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| 34 | 34 | | determine whether the amount of a rate, charge, claim, or analogous |
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| 35 | 35 | | payment to be paid to a physician, health care practitioner, or |
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| 36 | 36 | | other health care provider, including a dentist, for a medical care |
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| 37 | 37 | | or health care service or supply, including a dental care service or |
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| 38 | 38 | | supply, is the usual and customary amount for the service or supply. |
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| 39 | 39 | | (b) The standardized procedure adopted under this chapter |
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| 40 | 40 | | is applicable to the determination of the usual and customary rate |
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| 41 | 41 | | for a service or supply in a mediation conducted under Chapter 1467. |
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| 42 | 42 | | SECTION 2. Not later than December 31, 2019, the |
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| 43 | 43 | | commissioner of insurance shall adopt rules as necessary to |
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| 44 | 44 | | implement Chapter 41, Insurance Code, as added by this Act. |
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| 45 | 45 | | SECTION 3. The standardized procedure adopted under Chapter |
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| 46 | 46 | | 41, Insurance Code, as added by this Act, does not apply to the |
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| 47 | 47 | | amount of a rate, charge, claim, or analogous payment to be paid for |
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| 48 | 48 | | a medical care or health care service or supply provided before |
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| 49 | 49 | | January 1, 2020. |
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| 50 | 50 | | SECTION 4. This Act takes effect September 1, 2019. |
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