86R13583 SMT-D
By: Lucio III H.B. No. 4536
A BILL TO BE ENTITLED
AN ACT
relating to the determination of a usual and customary amount under
the Insurance Code.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle A, Title 2, Insurance Code, is amended
by adding Chapter 41 to read as follows:
CHAPTER 41. USUAL AND CUSTOMARY AMOUNTS
Sec. 41.0001. STANDARDIZED PROCEDURE. (a) The
commissioner of insurance by rule shall adopt a standardized
procedure to determine the usual and customary rate or amount for a
particular medical care or health care service or supply, including
a dental care service or supply, for purposes of this code.
(b) The procedure may include the use of a database or
clearing house, a survey procedure, or any other mechanism that
facilitates the determination of whether an amount is usual and
customary.
Sec. 41.0002. SIMILAR STATUTORY PROVISIONS. For a
provision of this code that establishes a payment standard for a
medical care or health care service or supply using statutory
language that is similar to "usual and customary," including
"reasonable and customary" or "usual, customary, and reasonable,"
the commissioner by rule shall determine whether the provision is
subject to the standardized procedure adopted under Section
41.0001.
Sec. 41.0003. USE OF PROCEDURE. (a) The issuer of any
health benefit plan regulated under this code, including a health
maintenance organization or a preferred provider organization,
must use the standardized procedure adopted under this chapter to
determine whether the amount of a rate, charge, claim, or analogous
payment to be paid to a physician, health care practitioner, or
other health care provider, including a dentist, for a medical care
or health care service or supply, including a dental care service or
supply, is the usual and customary amount for the service or supply.
(b) The standardized procedure adopted under this chapter
is applicable to the determination of the usual and customary rate
for a service or supply in a mediation conducted under Chapter 1467.
SECTION 2. Not later than December 31, 2019, the
commissioner of insurance shall adopt rules as necessary to
implement Chapter 41, Insurance Code, as added by this Act.
SECTION 3. The standardized procedure adopted under Chapter
41, Insurance Code, as added by this Act, does not apply to the
amount of a rate, charge, claim, or analogous payment to be paid for
a medical care or health care service or supply provided before
January 1, 2020.
SECTION 4. This Act takes effect September 1, 2019.