By: Hancock, et al. S.B. No. 1264
A BILL TO BE ENTITLED
AN ACT
relating to consumer protections against certain medical and health
care billing by certain out-of-network providers; authorizing a
fee.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. ELIMINATION OF SURPRISE BILLING FOR CERTAIN HEALTH
BENEFIT PLANS
SECTION 1.01. Subtitle G, Title 5, Insurance Code, is
amended by adding Chapter 752 to read as follows:
CHAPTER 752. ENFORCEMENT OF BALANCE BILLING PROHIBITIONS
Sec. 752.0001. INJUNCTION FOR BALANCE BILLING. (a) If the
attorney general believes that an individual or entity has
exhibited a pattern of intentionally violating a law that prohibits
the individual or entity from billing an insured, participant, or
enrollee in an amount greater than an applicable copayment,
coinsurance, or deductible under the insured's, participant's, or
enrollee's managed care plan or that imposes a requirement related
to that prohibition, the attorney general may bring a civil action
in the name of the state to enjoin the individual or entity from the
violation.
(b) If the attorney general prevails in an action brought
under Subsection (a), the attorney general may recover reasonable
attorney's fees, costs, and expenses, including court costs and
witness fees, incurred in bringing the action.
Sec. 752.0002. ENFORCEMENT BY REGULATORY AGENCY. (a) An
appropriate regulatory agency that licenses, certifies, or
otherwise authorizes a physician, health care practitioner, health
care facility, or other health care provider to practice or operate
in this state may take disciplinary action against the physician,
practitioner, facility, or provider if the physician,
practitioner, facility, or provider violates a law that prohibits
the physician, practitioner, facility, or provider from billing an
insured, participant, or enrollee in an amount greater than an
applicable copayment, coinsurance, or deductible under the
insured's, participant's, or enrollee's managed care plan or that
imposes a requirement related to that prohibition.
(b) A regulatory agency described by Subsection (a) may
adopt rules as necessary to implement this section. Section
2001.0045, Government Code, does not apply to rules adopted under
this subsection.
SECTION 1.02. Subchapter A, Chapter 1271, Insurance Code,
is amended by adding Section 1271.008 to read as follows:
Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A
health maintenance organization shall provide written notice in
accordance with this subsection in an explanation of benefits
provided to the enrollee and the physician or provider in
connection with a health care service or supply that is subject to
Section 1271.155, 1271.157, or 1271.158. The notice must include:
(1) a statement of the billing prohibition under
Section 1271.155, 1271.157, or 1271.158, as applicable;
(2) the amount the physician or provider may bill the
enrollee under the enrollee's health benefit plan; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of the
out-of-network claim dispute resolution process under Chapter
1467.
(b) A physician or provider that provides a service or
supply described by Subsection (a) shall provide notice of the
prohibitions described by Subsection (a)(1) in an invoice for the
service or supply provided to an enrollee.
SECTION 1.03. Section 1271.155, Insurance Code, is amended
by amending Subsection (b) and adding Subsection (f) to read as
follows:
(b) A health care plan of a health maintenance organization
must provide the following coverage of emergency care:
(1) a medical screening examination or other
evaluation required by state or federal law necessary to determine
whether an emergency medical condition exists shall be provided to
covered enrollees in a hospital emergency facility or comparable
facility;
(2) necessary emergency care shall be provided to
covered enrollees, including the treatment and stabilization of an
emergency medical condition; [and]
(3) services originated in a hospital emergency
facility, freestanding emergency medical care facility, or
comparable emergency facility following treatment or stabilization
of an emergency medical condition shall be provided to covered
enrollees as approved by the health maintenance organization,
subject to Subsections (c) and (d); and
(4) supplies related to a service described by this
subsection shall be provided to covered enrollees.
(f) For emergency care subject to this section or a supply
related to that care, a non-network physician or provider or a
person asserting a claim as an agent or assignee of the physician or
provider may not bill an enrollee in, and the enrollee does not have
financial responsibility for, an amount greater than an applicable
copayment, coinsurance, or deductible under the enrollee's health
care plan that:
(1) is based on:
(A) the amount initially determined payable by
the health maintenance organization; or
(B) a modified amount as determined under the
health maintenance organization's internal dispute resolution
process; and
(2) is not based on any additional amount determined
to be owed to the physician or provider under Chapter 1467.
SECTION 1.04. Subchapter D, Chapter 1271, Insurance Code,
is amended by adding Sections 1271.157 and 1271.158 to read as
follows:
Sec. 1271.157. NON-NETWORK FACILITY-BASED PROVIDERS.
(a) In this section, "facility-based provider" means a physician
or provider who provides health care services to patients of a
health care facility.
(b) Except as provided by Subsection (d), a health
maintenance organization shall pay for a health care service
performed for or a supply related to that service provided to an
enrollee by a non-network physician or provider who is a
facility-based provider at the usual and customary rate or at an
agreed rate if the provider performed the service at a health care
facility that is a network provider.
(c) Except as provided by Subsection (d), a non-network
facility-based provider or a person asserting a claim as an agent or
assignee of the provider may not bill an enrollee receiving a health
care service or supply described by Subsection (b) in, and the
enrollee does not have financial responsibility for, an amount
greater than an applicable copayment, coinsurance, or deductible
under the enrollee's health care plan that:
(1) is based on:
(A) the amount initially determined payable by
the health maintenance organization; or
(B) a modified amount as determined under the
health maintenance organization's internal dispute resolution
process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) This section does not apply to a nonemergency health
care service that an enrollee elects to receive:
(1) in writing in advance of the service with respect
to each non-network physician or provider providing the service;
and
(2) with notice of the enrollee's potential financial
responsibility from each non-network physician or provider
providing the service.
Sec. 1271.158. NON-NETWORK DIAGNOSTIC IMAGING PROVIDER OR
LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
imaging provider" and "laboratory service provider" have the
meanings assigned by Section 1467.001.
(b) Except as provided by Subsection (d), a health
maintenance organization shall pay for a health care service
performed by or a supply related to that service provided by a
non-network diagnostic imaging provider or laboratory service
provider at the usual and customary rate or at an agreed rate if the
provider performed the service in connection with a health care
service performed by a network physician or provider.
(c) Except as provided by Subsection (d), a non-network
diagnostic imaging provider or laboratory service provider or a
person asserting a claim as an agent or assignee of the provider may
not bill an enrollee receiving a health care service or supply
described by Subsection (b) in, and the enrollee does not have
financial responsibility for, an amount greater than an applicable
copayment, coinsurance, or deductible under the enrollee's health
care plan that:
(1) is based on:
(A) the amount initially determined payable by
the health maintenance organization; or
(B) a modified amount as determined under the
health maintenance organization's internal dispute resolution
process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) This section does not apply to a nonemergency health
care service that an enrollee elects to receive:
(1) in writing in advance of the service with respect
to each non-network provider providing the service; and
(2) with notice of the enrollee's potential financial
responsibility from each non-network physician or provider
providing the service.
SECTION 1.05. Section 1301.0053, Insurance Code, is amended
to read as follows:
Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS:
EMERGENCY CARE. (a) If an out-of-network [a nonpreferred]
provider provides emergency care as defined by Section 1301.155 to
an enrollee in an exclusive provider benefit plan, the issuer of the
plan shall reimburse the out-of-network [nonpreferred] provider at
the usual and customary rate or at a rate agreed to by the issuer and
the out-of-network [nonpreferred] provider for the provision of the
services and any supply related to those services.
(b) For emergency care subject to this section or a supply
related to that care, an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an insured in, and the insured does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the insured's exclusive provider
benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) a modified amount as determined under the
insurer's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 1.06. Subchapter A, Chapter 1301, Insurance Code,
is amended by adding Section 1301.010 to read as follows:
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An
insurer shall provide written notice in accordance with this
subsection in an explanation of benefits provided to the insured
and the physician or health care provider in connection with a
health care service or supply that is subject to Section 1301.0053,
1301.155, 1301.164, or 1301.165. The notice must include:
(1) a statement of the billing prohibition under
Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;
(2) the amount the physician or provider may bill the
insured under the insured's preferred provider benefit plan; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of the
out-of-network claim dispute resolution process under Chapter
1467.
(b) A physician or health care provider that provides a
service or supply described by Subsection (a) shall provide notice
of the prohibitions described by Subsection (a)(1) in an invoice
for the service or supply provided to an insured.
SECTION 1.07. Section 1301.155, Insurance Code, is amended
by amending Subsection (b) and adding Subsection (c) to read as
follows:
(b) If an insured cannot reasonably reach a preferred
provider, an insurer shall provide reimbursement for the following
emergency care services at the usual and customary rate or at an
agreed rate and at the preferred level of benefits until the insured
can reasonably be expected to transfer to a preferred provider:
(1) a medical screening examination or other
evaluation required by state or federal law to be provided in the
emergency facility of a hospital that is necessary to determine
whether a medical emergency condition exists;
(2) necessary emergency care services, including the
treatment and stabilization of an emergency medical condition;
[and]
(3) services originating in a hospital emergency
facility or freestanding emergency medical care facility following
treatment or stabilization of an emergency medical condition; and
(4) supplies related to a service described by this
subsection.
(c) For emergency care subject to this section or a supply
related to that care, an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an insured in, and the insured does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the insured's preferred provider
benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) a modified amount as determined under the
insurer's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 1.08. Subchapter D, Chapter 1301, Insurance Code,
is amended by adding Sections 1301.164 and 1301.165 to read as
follows:
Sec. 1301.164. OUT-OF-NETWORK FACILITY-BASED PROVIDERS.
(a) In this section, "facility-based provider" means a physician
or health care provider who provides health care services to
patients of a health care facility.
(b) Except as provided by Subsection (d), an insurer shall
pay for a health care service performed for or a supply related to
that service provided to an insured by an out-of-network provider
who is a facility-based provider at the usual and customary rate or
at an agreed rate if the provider performed the service at a health
care facility that is a preferred provider.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a facility-based provider or a person asserting a
claim as an agent or assignee of the provider may not bill an
insured receiving a health care service or supply described by
Subsection (b) in, and the insured does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the insured's preferred provider
benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) a modified amount as determined under the
insurer's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) This section does not apply to a nonemergency health
care service that an insured elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the insured's potential financial
responsibility from each out-of-network provider providing the
service.
Sec. 1301.165. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
imaging provider" and "laboratory service provider" have the
meanings assigned by Section 1467.001.
(b) Except as provided by Subsection (d), an insurer shall
pay for a medical care or health care service performed by or a
supply related to that service provided by an out-of-network
provider who is a diagnostic imaging provider or laboratory service
provider at the usual and customary rate or at an agreed rate if the
provider performed the service in connection with a medical care or
health care service performed by a preferred provider.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a diagnostic imaging provider or laboratory service
provider or a person asserting a claim as an agent or assignee of
the provider may not bill an insured receiving a medical care or
health care service or supply described by Subsection (b) in, and
the insured does not have financial responsibility for, an amount
greater than an applicable copayment, coinsurance, or deductible
under the insured's preferred provider benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) the modified amount as determined under the
insurer's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) This section does not apply to a nonemergency health
care service that an insured elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the insured's potential financial
responsibility from each out-of-network provider providing the
service.
SECTION 1.09. Section 1551.003, Insurance Code, is amended
by adding Subdivision (15) to read as follows:
(15) "Usual and customary rate" means the relevant
allowable amount as described by the applicable master benefit plan
document or policy.
SECTION 1.10. Subchapter A, Chapter 1551, Insurance Code,
is amended by adding Section 1551.015 to read as follows:
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE.
(a) The administrator of a managed care plan provided under the
group benefits program shall provide written notice in accordance
with this subsection in an explanation of benefits provided to the
participant and the physician or health care provider in connection
with a health care service or supply that is subject to Section
1551.228, 1551.229, or 1551.230. The notice must include:
(1) a statement of the billing prohibition under
Section 1551.228, 1551.229, or 1551.230, as applicable;
(2) the amount the physician or provider may bill the
participant under the participant's managed care plan; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of the
out-of-network claim dispute resolution process under Chapter
1467.
(b) A physician or health care provider that provides a
service or supply described by Subsection (a) shall provide notice
of the prohibitions described by Subsection (a)(1) in an invoice
for the service or supply provided to a participant.
SECTION 1.11. Subchapter E, Chapter 1551, Insurance Code,
is amended by adding Sections 1551.228, 1551.229, and 1551.230 to
read as follows:
Sec. 1551.228. EMERGENCY CARE COVERAGE. (a) In this
section, "emergency care" has the meaning assigned by Section
1301.155.
(b) A managed care plan provided under the group benefits
program must provide out-of-network emergency care coverage for
participants in accordance with this section.
(c) The coverage must require the administrator of the plan
to pay for emergency care performed by or a supply related to that
care provided by an out-of-network provider at the usual and
customary rate or at an agreed rate.
(d) For emergency care subject to this section or a supply
related to that care, an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill a participant in, and the participant does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the participant's managed care
plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
Sec. 1551.229. OUT-OF-NETWORK FACILITY-BASED PROVIDER
COVERAGE. (a) In this section, "facility-based provider" means a
physician or health care provider who provides health care services
to patients of a health care facility.
(b) A managed care plan provided under the group benefits
program must provide out-of-network facility-based provider
coverage for participants in accordance with this section.
(c) Except as provided by Subsection (e), the coverage must
require the administrator of the plan to pay for a health care
service performed for or a supply related to that service provided
to a participant by an out-of-network provider who is a
facility-based provider at the usual and customary rate or at an
agreed rate if the provider performed the service at a health care
facility that is a participating provider.
(d) Except as provided by Subsection (e), an out-of-network
provider who is a facility-based provider or a person asserting a
claim as an agent or assignee of the provider may not bill a
participant receiving a health care service or supply described by
Subsection (c) in, and the participant does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the participant's managed care
plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(e) This section does not apply to a nonemergency health
care service that a participant elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the participant's potential
financial responsibility from each out-of-network provider
providing the service.
Sec. 1551.230. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
imaging provider" and "laboratory service provider" have the
meanings assigned by Section 1467.001.
(b) A managed care plan provided under the group benefits
program must provide out-of-network diagnostic imaging provider
and laboratory service provider coverage for participants in
accordance with this section.
(c) Except as provided by Subsection (e), the coverage must
require the administrator of the plan to pay for a health care
service performed for or a supply related to that service provided
to a participant by an out-of-network provider who is a diagnostic
imaging provider or laboratory service provider at the usual and
customary rate or at an agreed rate if the provider performed the
service in connection with a health care service performed by a
participating provider.
(d) Except as provided by Subsection (e), an out-of-network
provider who is a diagnostic imaging provider or laboratory service
provider or a person asserting a claim as an agent or assignee of
the provider may not bill a participant receiving a health care
service or supply described by Subsection (c) in, and the
participant does not have financial responsibility for, an amount
greater than an applicable copayment, coinsurance, or deductible
under the participant's managed care plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) the modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(e) This section does not apply to a nonemergency health
care service that a participant elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the participant's potential
financial responsibility from each out-of-network provider
providing the service.
SECTION 1.12. Section 1575.002, Insurance Code, is amended
by adding Subdivision (8) to read as follows:
(8) "Usual and customary rate" means the relevant
allowable amount as described by the applicable master benefit plan
document or policy.
SECTION 1.13. Subchapter A, Chapter 1575, Insurance Code,
is amended by adding Section 1575.009 to read as follows:
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE.
(a) The administrator of a managed care plan provided under the
group program shall provide written notice in accordance with this
subsection in an explanation of benefits provided to the enrollee
and the physician or health care provider in connection with a
health care service or supply that is subject to Section 1575.171,
1575.172, or 1575.173. The notice must include:
(1) a statement of the billing prohibition under
Section 1575.171, 1575.172, or 1575.173, as applicable;
(2) the amount the physician or provider may bill the
enrollee under the enrollee's managed care plan; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of the
out-of-network claim dispute resolution process under Chapter
1467.
(b) A physician or health care provider that provides a
service or supply described by Subsection (a) shall provide notice
of the prohibitions described by Subsection (a)(1) in an invoice
for the service or supply provided to an enrollee.
SECTION 1.14. Subchapter D, Chapter 1575, Insurance Code,
is amended by adding Sections 1575.171, 1575.172, and 1575.173 to
read as follows:
Sec. 1575.171. EMERGENCY CARE COVERAGE. (a) In this
section, "emergency care" has the meaning assigned by Section
1301.155.
(b) A managed care plan provided under the group program
must provide out-of-network emergency care coverage in accordance
with this section.
(c) The coverage must require the administrator of the plan
to pay for emergency care performed by or a supply related to that
care provided by an out-of-network provider at the usual and
customary rate or at an agreed rate.
(d) For emergency care subject to this section or a supply
related to that care, an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an enrollee in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the enrollee's managed care plan
that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
Sec. 1575.172. OUT-OF-NETWORK FACILITY-BASED PROVIDER
COVERAGE. (a) In this section, "facility-based provider" means a
physician or health care provider who provides health care services
to patients of a health care facility.
(b) A managed care plan provided under the group program
must provide out-of-network facility-based provider coverage for
enrollees in accordance with this section.
(c) Except as provided by Subsection (e), the coverage must
require the administrator of the plan to pay for a health care
service performed for or a supply related to that service provided
to an enrollee by an out-of-network provider who is a
facility-based provider at the usual and customary rate or at an
agreed rate if the provider performed the service at a health care
facility that is a participating provider.
(d) Except as provided by Subsection (e), an out-of-network
provider who is a facility-based provider or a person asserting a
claim as an agent or assignee of the provider may not bill an
enrollee receiving a health care service or supply described by
Subsection (c) in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the enrollee's managed care plan
that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(e) This section does not apply to a nonemergency health
care service that an enrollee elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the enrollee's potential financial
responsibility from each out-of-network provider providing the
service.
Sec. 1575.173. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
imaging provider" and "laboratory service provider" have the
meanings assigned by Section 1467.001.
(b) A managed care plan provided under the group program
must provide out-of-network diagnostic imaging provider and
laboratory service provider coverage for enrollees in accordance
with this section.
(c) Except as provided by Subsection (e), the coverage must
require the administrator of the plan to pay for a health care
service performed for or a supply related to that service provided
to an enrollee by an out-of-network provider who is a diagnostic
imaging provider or laboratory service provider at the usual and
customary rate or at an agreed rate if the provider performed the
service in connection with a health care service performed by a
participating provider.
(d) Except as provided by Subsection (e), an out-of-network
provider who is a diagnostic imaging provider or laboratory service
provider or a person asserting a claim as an agent or assignee of
the provider may not bill an enrollee receiving a health care
service or supply described by Subsection (c) in, and the enrollee
does not have financial responsibility for, an amount greater than
an applicable copayment, coinsurance, or deductible under the
enrollee's managed care plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) the modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(e) This section does not apply to a nonemergency health
care service that an enrollee elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the enrollee's potential financial
responsibility from each out-of-network provider providing the
service.
SECTION 1.15. Subchapter A, Chapter 1579, Insurance Code,
is amended by adding Section 1579.009 to read as follows:
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE.
(a) The administrator of a managed care plan provided under this
chapter shall provide written notice in accordance with this
subsection in an explanation of benefits provided to the enrollee
and the physician or health care provider in connection with a
health care service or supply that is subject to Section 1579.109,
1579.110, or 1579.111. The notice must include:
(1) a statement of the billing prohibition under
Section 1579.109, 1579.110, or 1579.111, as applicable;
(2) the amount the physician or provider may bill the
enrollee under the enrollee's managed care plan; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of the
out-of-network claim dispute resolution process under Chapter
1467.
(b) A physician or health care provider that provides a
service or supply described by Subsection (a) shall provide notice
of the prohibitions described by Subsection (a)(1) in an invoice
for the service or supply provided to an enrollee.
SECTION 1.16. Subchapter C, Chapter 1579, Insurance Code,
is amended by adding Sections 1579.109, 1579.110, and 1579.111 to
read as follows:
Sec. 1579.109. EMERGENCY CARE COVERAGE. (a) In this
section, "emergency care" has the meaning assigned by Section
1301.155.
(b) A managed care plan provided under this chapter must
provide out-of-network emergency care coverage in accordance with
this section.
(c) The coverage must require the administrator of the plan
to pay for emergency care performed by or a supply related to that
care provided by an out-of-network provider at the usual and
customary rate or at an agreed rate.
(d) For emergency care subject to this section or a supply
related to that care, an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an enrollee in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the enrollee's managed care plan
that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
Sec. 1579.110. OUT-OF-NETWORK FACILITY-BASED PROVIDER
COVERAGE. (a) In this section, "facility-based provider" means a
physician or health care provider who provides health care services
to patients of a health care facility.
(b) A managed care plan provided under this chapter must
provide out-of-network facility-based provider coverage to
enrollees in accordance with this section.
(c) Except as provided by Subsection (e), the coverage must
require the administrator of the plan to pay for a health care
service performed for or a supply related to that service provided
to an enrollee by an out-of-network provider who is a
facility-based provider at the usual and customary rate or at an
agreed rate if the provider performed the service at a health care
facility that is a participating provider.
(d) Except as provided by Subsection (e), an out-of-network
provider who is a facility-based provider or a person asserting a
claim as an agent or assignee of the provider may not bill an
enrollee receiving a health care service or supply described by
Subsection (c) in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, or deductible under the enrollee's managed care plan
that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) does not include any additional amount determined
to be owed to the provider under Chapter 1467.
(e) This section does not apply to a nonemergency health
care service that an enrollee elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the enrollee's potential financial
responsibility from each out-of-network provider providing the
service.
Sec. 1579.111. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
imaging provider" and "laboratory service provider" have the
meanings assigned by Section 1467.001.
(b) A managed care plan provided under this chapter must
provide out-of-network diagnostic imaging provider and laboratory
service provider coverage for enrollees in accordance with this
section.
(c) Except as provided by Subsection (e), the coverage must
require the administrator of the plan to pay for a health care
service performed for or a supply related to that service provided
to an enrollee by an out-of-network provider who is a diagnostic
imaging provider or laboratory service provider at the usual and
customary rate or at an agreed rate if the provider performed the
service in connection with a health care service performed by a
participating provider.
(d) Except as provided by Subsection (e), an out-of-network
provider who is a diagnostic imaging provider or laboratory service
provider or a person asserting a claim through the provider may not
bill an enrollee receiving a health care service or supply
described by Subsection (c) in, and the enrollee does not have
financial responsibility for, an amount greater than an applicable
copayment, coinsurance, or deductible under the enrollee's managed
care plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) a modified amount as determined under the
administrator's internal dispute resolution process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(e) This section does not apply to a nonemergency health
care service that an enrollee elects to receive:
(1) in writing in advance of the service with respect
to each out-of-network provider providing the service; and
(2) with notice of the enrollee's potential financial
responsibility from each out-of-network provider providing the
service.
ARTICLE 2. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
SECTION 2.01. Section 1467.001, Insurance Code, is amended
by adding Subdivisions (1-a), (2-c), (2-d), (4-b), and (6-a) and
amending Subdivisions (2-a), (2-b), (3), (5), and (7) to read as
follows:
(1-a) "Arbitration" means a process in which an
impartial arbiter issues a binding determination in a dispute
between a health benefit plan issuer and an out-of-network provider
or the provider's representative to settle a health benefit claim.
(2-a) "Diagnostic imaging provider" means a health
care provider who performs a diagnostic imaging service on a
patient for a fee or interprets imaging produced by a diagnostic
imaging service.
(2-b) "Diagnostic imaging service" means magnetic
resonance imaging, computed tomography, positron emission
tomography, or any hybrid technology that combines any of those
imaging modalities.
(2-c) "Emergency care" has the meaning assigned by
Section 1301.155.
(2-d) [(2-b)] "Emergency care provider" means a
physician, health care practitioner, facility, or other health care
provider who provides and bills an enrollee, administrator, or
health benefit plan for emergency care.
(3) "Enrollee" means an individual who is eligible to
receive benefits through a [preferred provider benefit plan or a]
health benefit plan subject to this chapter [under Chapter 1551,
1575, or 1579].
(4-b) "Laboratory service provider" means an
accredited facility in which a specimen taken from a human body is
interpreted and pathological diagnoses are made or a person who
makes an interpretation of or diagnosis based on a specimen or
information provided by a laboratory based on a specimen.
(5) "Mediation" means a process in which an impartial
mediator facilitates and promotes agreement between the [insurer
offering a preferred provider benefit plan or the] administrator
and an out-of-network [a facility-based] provider [or emergency
care provider] or the provider's representative to settle a health
benefit claim of an enrollee.
(6-a) "Out-of-network provider" means a diagnostic
imaging provider, emergency care provider, facility-based
provider, or laboratory service provider that is not a
participating provider for a health benefit plan.
(7) "Party" means a health benefit plan issuer [an
insurer] offering a health [a preferred provider] benefit plan, an
administrator, or an out-of-network [a facility-based provider or
emergency care] provider or the provider's representative who
participates in a mediation or arbitration conducted under this
chapter. [The enrollee is also considered a party to the
mediation.]
SECTION 2.02. Sections 1467.002, 1467.003, and 1467.005,
Insurance Code, are amended to read as follows:
Sec. 1467.002. APPLICABILITY OF CHAPTER. (a) This
chapter, other than Subchapter B-1, applies to:
(1) a preferred provider benefit plan, including an
exclusive provider benefit plan, offered by an insurer under
Chapter 1301; and
(2) a health benefit plan offered by [an administrator
of a health benefit plan, other than] a health maintenance
organization operating under Chapter 843 [plan, under Chapter 1551,
1575, or 1579].
(b) This chapter, other than Subchapter B, applies to an
administrator of a health benefit plan, other than a health
maintenance organization plan, under Chapter 1551, 1575, or 1579.
Sec. 1467.003. RULES. (a) The commissioner, the Texas
Medical Board, any other appropriate regulatory agency, and the
chief administrative law judge shall adopt rules as necessary to
implement their respective powers and duties under this chapter.
(b) Section 2001.0045, Government Code, does not apply to a
rule adopted under this chapter.
Sec. 1467.005. REFORM. This chapter may not be construed to
prohibit:
(1) a health [an insurer offering a preferred
provider] benefit plan issuer or administrator from, at any time,
offering a reformed claim settlement; or
(2) an out-of-network [a facility-based provider or
emergency care] provider from, at any time, offering a reformed
charge for health care or medical services or supplies.
SECTION 2.03. Subchapter A, Chapter 1467, Insurance Code,
is amended by adding Section 1467.006 to read as follows:
Sec. 1467.006. BENCHMARKING DATABASE. (a) The
commissioner shall select an organization to maintain a
benchmarking database that contains information necessary to
calculate, with respect to a health care or medical service or
supply, for each geographical area in this state:
(1) the 80th percentile of billed amounts of all
physicians or health care providers; and
(2) the 50th percentile of rates paid to participating
providers.
(b) The commissioner may not select under Subsection (a) an
organization that is financially affiliated with a health benefit
plan issuer.
SECTION 2.04. The heading to Subchapter B, Chapter 1467,
Insurance Code, is amended to read as follows:
SUBCHAPTER B. MANDATORY BINDING ARBITRATION [MEDIATION]
SECTION 2.05. Subchapter B, Chapter 1467, Insurance Code,
is amended by adding Sections 1467.050 and 1467.0505 to read as
follows:
Sec. 1467.050. ESTABLISHMENT AND ADMINISTRATION OF
ARBITRATION PROGRAM. (a) The commissioner shall establish and
administer an arbitration program to resolve disputes over
out-of-network provider amounts in accordance with this
subchapter.
(b) The commissioner:
(1) shall adopt rules, forms, and procedures necessary
for the implementation and administration of the arbitration
program, including the establishment of a portal on the
department's Internet website through which a request for
arbitration under Section 1467.051 may be submitted; and
(2) shall maintain a list of qualified arbitrators for
the program.
Sec. 1467.0505. ISSUE TO BE ADDRESSED; BASIS FOR
DETERMINATION. (a) The only issue that an arbitrator may
determine under this subchapter is the reasonable amount for the
health care or medical services or supplies provided to the
enrollee by an out-of-network provider.
(b) The determination must, at a minimum, take into account:
(1) whether there is a gross disparity between the fee
billed by the out-of-network provider and:
(A) fees paid to the out-of-network provider for
the same services or supplies rendered by the provider to other
enrollees for which the provider is an out-of-network provider; and
(B) fees paid by the health benefit plan issuer
to reimburse similarly qualified out-of-network providers for the
same services or supplies in the same region;
(2) the level of training, education, and experience
of the out-of-network provider;
(3) the out-of-network provider's usual billed amount
for comparable services or supplies with regard to other enrollees
for which the provider is an out-of-network provider;
(4) the circumstances and complexity of the enrollee's
particular case, including the time and place of the provision of
the service or supply;
(5) individual enrollee characteristics;
(6) the 80th percentile of all billed amounts for the
service or supply performed by a health care provider in the same or
similar specialty and provided in the same geographical area as
reported in a benchmarking database described by Section 1467.006;
and
(7) the 50th percentile of rates for the service or
supply paid to participating providers in the same or similar
specialty and provided in the same geographical area as reported in
a benchmarking database described by Section 1467.006.
SECTION 2.06. The heading to Section 1467.051, Insurance
Code, is amended to read as follows:
Sec. 1467.051. AVAILABILITY OF MANDATORY ARBITRATION
[MEDIATION; EXCEPTION].
SECTION 2.07. Section 1467.051, Insurance Code, is amended
by amending Subsections (a) and (b) and adding Subsections (e),
(f), and (g) to read as follows:
(a) An out-of-network provider or health benefit plan
issuer [An enrollee] may request arbitration [mediation] of a
settlement of an out-of-network health benefit claim through a
portal on the department's Internet website if:
(1) there is an [the] amount billed by the provider and
unpaid by the issuer [for which the enrollee is responsible to a
facility-based provider or emergency care provider,] after
copayments, deductibles, and coinsurance for which an enrollee may
not be billed [, including the amount unpaid by the administrator or
insurer, is greater than $500]; and
(2) the health benefit claim is for:
(A) emergency care; [or]
(B) a health care or medical service or supply
provided by a facility-based provider in a facility that is a
participating [preferred] provider;
(C) an out-of-network laboratory service; or
(D) an out-of-network diagnostic imaging service
[that has a contract with the administrator].
(b) If a person [Except as provided by Subsections (c) and
(d), if an enrollee] requests arbitration [mediation] under this
subchapter, the out-of-network [facility-based] provider [or
emergency care provider,] or the provider's representative, and the
health benefit plan issuer [insurer or the administrator, as
appropriate,] shall participate in the arbitration [mediation].
(e) The person who requests the arbitration shall provide
written notice on the date the arbitration is requested in the form
and manner prescribed by commissioner rule to:
(1) the department; and
(2) each other party.
(f) In an effort to settle the claim before arbitration, all
parties must participate in an informal settlement teleconference
not later than the 30th day after the date on which the arbitration
is requested. A health benefit plan issuer shall make a reasonable
effort to arrange the teleconference.
(g) The parties may agree to submit multiple claims to
arbitration in one proceeding.
SECTION 2.08. Subchapter B, Chapter 1467, Insurance Code,
is amended by adding Section 1467.0515 to read as follows:
Sec. 1467.0515. EFFECT OF ARBITRATION AND APPLICABILITY OF
OTHER LAW. (a) Notwithstanding Section 1467.004, an
out-of-network provider or health benefit plan issuer may not file
suit for an out-of-network claim subject to this chapter until the
conclusion of the arbitration on the issue of the amount to be paid
in the out-of-network claim dispute.
(b) An arbitration conducted under this subchapter is not
subject to Title 7, Civil Practice and Remedies Code.
SECTION 2.09. Subchapter B, Chapter 1467, Insurance Code,
is amended by adding Sections 1467.0535, 1467.0545, 1467.0555, and
1467.0565 to read as follows:
Sec. 1467.0535. SELECTION AND APPROVAL OF ARBITRATOR.
(a) If the parties do not select an arbitrator by mutual agreement
on or before the 30th day after the date the arbitration is
requested, the party requesting the arbitration shall notify the
commissioner, and the commissioner shall select an arbitrator from
the commissioner's list of approved arbitrators.
(b) In approving an individual as an arbitrator, the
commissioner shall ensure that the individual does not have a
conflict of interest that would adversely impact the individual's
independence and impartiality in rendering a decision in an
arbitration. A conflict of interest includes current or recent
ownership or employment of the individual or a close family member
in a health benefit plan issuer or out-of-network provider that may
be involved in the arbitration.
(c) The commissioner shall immediately terminate the
approval of an arbitrator who no longer meets the requirements
under this subchapter and rules adopted under this subchapter to
serve as an arbitrator.
Sec. 1467.0545. PROCEDURES. (a) The arbitrator shall set
a date for submission of all information to be considered by the
arbitrator.
(b) A party may not engage in discovery in connection with
the arbitration.
(c) On agreement of all parties, any deadline under this
subchapter may be extended.
(d) Unless otherwise agreed to by the parties, an
arbitrator:
(1) may not consider medical records that were not
presented to the health benefit plan issuer during an appeals
process offered by the issuer or administrator to resolve an
out-of-network claim;
(2) may not review a claim arising from an adverse
determination by a utilization review agent under Chapter 4201 that
may be reviewed by an independent review organization; and
(3) may not determine whether a health benefit plan
covers a particular health care or medical service or supply.
(e) The parties shall evenly split and pay the arbitrator's
fees and expenses.
Sec. 1467.0555. DECISION. (a) Not later than the 75th day
after the date the arbitration is requested, an arbitrator shall
provide the parties with a written decision in which the
arbitrator:
(1) determines whether the billed amount or the
initial payment made by the health benefit plan issuer is the
closest to the reasonable amount for the services or supplies
determined in accordance with Section 1467.0505(b), provided that:
(A) the provider may revise the billed amount to
correct a billing error before the completion of an appeal process
offered by the issuer or administrator to resolve an out-of-network
claim; and
(B) the health benefit plan issuer may increase
the initial payment under the appeal process offered by the issuer
or administrator to resolve an out-of-network claim; and
(2) selects the amount described by Subdivision (1) as
the binding award amount.
(b) An arbitrator may not modify the binding award amount
selected under Subsection (a).
Sec. 1467.0565. EFFECT OF DECISION. (a) An arbitrator's
decision under Section 1467.0555 is binding.
(b) Not later than the 90th day after the date of an
arbitrator's decision under Section 1467.0555, a party not
satisfied with the decision may file an action to determine the
payment due to an out-of-network provider.
(c) In an action filed under Subsection (b), the court shall
determine whether the arbitrator's decision is proper based on a
substantial evidence standard of review.
(d) A health benefit plan issuer shall pay to an
out-of-network provider any additional amount necessary to satisfy
a binding award or a court's determination in an action filed under
Subsection (b), as applicable.
SECTION 2.10. Chapter 1467, Insurance Code, is amended by
adding Subchapter B-1 to read as follows:
SUBCHAPTER B-1. MANDATORY MEDIATION
Sec. 1467.081. AVAILABILITY OF MANDATORY MEDIATION.
(a) An out-of-network provider or administrator may request
mediation of a settlement of an out-of-network health benefit claim
arising from a health benefit plan to which this subchapter applies
if:
(1) there is an amount billed by the provider and
unpaid by the administrator after copayments, deductibles, and
coinsurance for which an enrollee may not be billed; and
(2) the health benefit claim is for:
(A) emergency care;
(B) a health care or medical service or supply
provided by a facility-based provider in a facility that is a
participating provider;
(C) an out-of-network laboratory service; or
(D) an out-of-network diagnostic imaging
service.
(b) If a person requests mediation under this subchapter,
the out-of-network provider, or the provider's representative, and
the administrator shall participate in the mediation.
Sec. 1467.082. MEDIATOR QUALIFICATIONS. (a) Except as
provided by Subsection (b), to qualify for an appointment as a
mediator under this subchapter a person must have completed at
least 40 classroom hours of training in dispute resolution
techniques in a course conducted by an alternative dispute
resolution organization or other dispute resolution organization
approved by the chief administrative law judge.
(b) A person not qualified under Subsection (a) may be
appointed as a mediator on agreement of the parties.
(c) A person may not act as mediator for a claim settlement
dispute if the person has been employed by, consulted for, or
otherwise had a business relationship with an administrator of a
health benefit plan that is subject to this subchapter or a
physician, health care practitioner, or other health care provider
during the three years immediately preceding the request for
mediation.
Sec. 1467.083. APPOINTMENT OF MEDIATOR; FEES. (a) A
mediation shall be conducted by one mediator.
(b) The chief administrative law judge shall appoint the
mediator through a random assignment from a list of qualified
mediators maintained by the State Office of Administrative
Hearings.
(c) Notwithstanding Subsection (b), a person other than a
mediator appointed by the chief administrative law judge may
conduct the mediation on agreement of all of the parties and notice
to the chief administrative law judge.
(d) The mediator's fees shall be split evenly and paid by
the administrator and the out-of-network provider.
Sec. 1467.084. REQUEST AND PRELIMINARY PROCEDURES FOR
MANDATORY MEDIATION. (a) An out-of-network provider or
administrator may request mandatory mediation under this
subchapter.
(b) A request for mandatory mediation must be provided to
the department on a form prescribed by the commissioner and must
include:
(1) the name of the person requesting mediation;
(2) a brief description of the claim to be mediated;
(3) contact information, including a telephone
number, for the requesting person and the person's counsel, if the
person retains counsel;
(4) the name of the out-of-network provider and name
of the administrator; and
(5) any other information the commissioner may require
by rule.
(c) On receipt of a request for mediation, the department
shall notify the out-of-network provider or the administrator of
the request.
(d) In an effort to settle the claim before mediation, all
parties must participate in an informal settlement teleconference
not later than the 30th day after the date on which a person submits
a request for mediation under this subchapter.
(e) A dispute to be mediated under this subchapter that does
not settle as a result of a teleconference conducted under
Subsection (d) must be conducted in the county in which the health
care or medical services were rendered.
Sec. 1467.085. CONDUCT OF MEDIATION; CONFIDENTIALITY.
(a) A mediator may not impose the mediator's judgment on a party
about an issue that is a subject of the mediation.
(b) A mediation session is under the control of the
mediator.
(c) Except as provided by this chapter, the mediator must
hold in strict confidence all information provided to the mediator
by a party and all communications of the mediator with a party.
(d) A party must have an opportunity during the mediation to
speak and state the party's position.
(e) Except on the agreement of the participating parties, a
mediation may not last more than four hours.
(f) A mediation shall be held not later than the 180th day
after the date of the request for mediation.
(g) A health care or medical service or supply provided by
an out-of-network provider may not be summarily disallowed. This
subsection does not require an administrator to pay for an
uncovered service or supply.
(h) A mediator may not testify in a proceeding, other than a
proceeding to enforce this chapter, related to the mediation
agreement.
Sec. 1467.086. MATTERS CONSIDERED IN MEDIATION; AGREED
RESOLUTION. (a) In a mediation under this subchapter, the parties
shall evaluate whether:
(1) the amount charged by the out-of-network provider
for the health care or medical service or supply is excessive; and
(2) the amount paid by the administrator represents
the usual and customary rate for the health care or medical service
or supply or is unreasonably low.
(b) The out-of-network provider may present information
regarding the amount charged for the health care or medical service
or supply. The administrator may present information regarding the
amount paid by the administrator.
(c) Nothing in this chapter prohibits mediation of more than
one claim between the parties during a mediation.
(d) The goal of the mediation is to reach an agreement
between the out-of-network provider and the administrator as to the
amount paid by the administrator to the provider and the amount
charged by the provider.
Sec. 1467.087. NO AGREED RESOLUTION. (a) The mediator of
an unsuccessful mediation under this subchapter shall report the
outcome of the mediation to the department, the Texas Medical Board
or other appropriate regulatory agency, and the chief
administrative law judge.
(b) The chief administrative law judge shall enter an order
of referral of a matter reported under Subsection (a) to a special
judge under Chapter 151, Civil Practice and Remedies Code, that:
(1) names the special judge on whom the parties agreed
or appoints the special judge if the parties did not agree on a
judge;
(2) states the issues to be referred and the time and
place on which the parties agree for the trial;
(3) requires each party to pay the party's
proportionate share of the special judge's fee; and
(4) certifies that the parties have waived the right
to trial by jury.
(c) A trial by the special judge selected or appointed as
described by Subsection (b) must proceed under Chapter 151, Civil
Practice and Remedies Code, except that the special judge's verdict
is not relevant or material to any other billing dispute and has no
precedential value.
(d) Notwithstanding any other provision of this section,
Section 151.012, Civil Practice and Remedies Code, does not apply
to a mediation under this subchapter.
Sec. 1467.088. CONTINUATION OF MEDIATION. After a referral
is made under Section 1467.087, the out-of-network provider and the
administrator may elect to continue the mediation to further
determine their responsibilities.
Sec. 1467.089. MEDIATION AGREEMENT. The mediator shall
prepare a confidential mediation agreement and order that states
any agreement reached by the parties under Section 1467.088.
Sec. 1467.090. REPORT OF MEDIATOR. The mediator shall
report to the commissioner and the Texas Medical Board or other
appropriate regulatory agency:
(1) the names of the parties to the mediation; and
(2) whether the parties reached an agreement or the
mediator made a referral under Section 1467.087.
SECTION 2.11. Subchapter C, Chapter 1467, Insurance Code,
is amended to read as follows:
SUBCHAPTER C. BAD FAITH PARTICIPATION [MEDIATION]
Sec. 1467.101. BAD FAITH. (a) The following conduct
constitutes bad faith participation [mediation] for purposes of
this chapter:
(1) failing to participate in the informal settlement
teleconference under Section 1467.051(f), arbitration under
Subchapter B, or mediation under Subchapter B-1;
(2) failing to provide information the arbitrator or
mediator believes is necessary to facilitate a decision or [an]
agreement; [or]
(3) failing to designate a representative
participating in the arbitration or mediation with full authority
to enter into any [mediated] agreement; or
(4) failing to appear for the arbitration or
mediation.
(b) Failure to reach an agreement under Subchapter B-1 is
not conclusive proof of bad faith participation [mediation].
Sec. 1467.102. PENALTIES. (a) Bad faith participation or
otherwise failing to comply with Subchapter B [mediation, by a
party other than the enrollee,] is grounds for imposition of an
administrative penalty by the regulatory agency that issued a
license or certificate of authority to the party who committed the
violation.
(b) Except for good cause shown, on a report of a mediator
and appropriate proof of bad faith participation under Subchapter
B-1 [mediation], the regulatory agency that issued the license or
certificate of authority shall impose an administrative penalty.
SECTION 2.12. Sections 1467.151(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) The commissioner and the Texas Medical Board or other
regulatory agency, as appropriate, shall adopt rules regulating the
investigation and review of a complaint filed that relates to the
settlement of an out-of-network health benefit claim that is
subject to this chapter. The rules adopted under this section must:
(1) distinguish among complaints for out-of-network
coverage or payment and give priority to investigating allegations
of delayed health care or medical care;
(2) develop a form for filing a complaint [and
establish an outreach effort to inform enrollees of the
availability of the claims dispute resolution process under this
chapter]; and
(3) ensure that a complaint is not dismissed without
appropriate consideration[;
[(4) ensure that enrollees are informed of the
availability of mandatory mediation; and
[(5) require the administrator to include a notice of
the claims dispute resolution process available under this chapter
with the explanation of benefits sent to an enrollee].
(b) The department and the Texas Medical Board or other
appropriate regulatory agency shall maintain information[:
[(1)] on each complaint filed that concerns a claim,
arbitration, or mediation subject to this chapter[; and
[(2) related to a claim that is the basis of an
enrollee complaint], including:
(1) [(A)] the type of services or supplies that gave
rise to the dispute;
(2) [(B)] the type and specialty, if any, of the
out-of-network [facility-based] provider [or emergency care
provider] who provided the out-of-network service or supply;
(3) [(C)] the county and metropolitan area in which
the health care or medical service or supply was provided;
(4) [(D)] whether the health care or medical service
or supply was for emergency care; and
(5) [(E)] any other information about:
(A) [(i)] the health benefit plan issuer
[insurer] or administrator that the commissioner by rule requires;
or
(B) [(ii)] the out-of-network [facility-based]
provider [or emergency care provider] that the Texas Medical Board
or other appropriate regulatory agency by rule requires.
(c) The information collected and maintained [by the
department and the Texas Medical Board and other appropriate
regulatory agencies] under Subsection (b) [(b)(2)] is public
information as defined by Section 552.002, Government Code, and may
not include personally identifiable information or health care or
medical information.
ARTICLE 3. CONFORMING AMENDMENTS
SECTION 3.01. Section 1456.001(6), Insurance Code, is
amended to read as follows:
(6) "Provider network" means a health benefit plan
under which health care services are provided to enrollees through
contracts with health care providers and that requires those
enrollees to use health care providers participating in the plan
and procedures covered by the plan. [The term includes a network
operated by:
[(A) a health maintenance organization;
[(B) a preferred provider benefit plan issuer; or
[(C) another entity that issues a health benefit
plan, including an insurance company.]
SECTION 3.02. Sections 1456.002(a) and (c), Insurance Code,
are amended to read as follows:
(a) This chapter applies to any health benefit plan that:
(1) provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884;
(E) [a health maintenance organization operating
under Chapter 843;
[(F)] a multiple employer welfare arrangement
that holds a certificate of authority under Chapter 846;
(F) [(G)] an approved nonprofit health
corporation that holds a certificate of authority under Chapter
844; or
(G) [(H)] an entity not authorized under this
code or another insurance law of this state that contracts directly
for health care services on a risk-sharing basis, including a
capitation basis; or
(2) provides health and accident coverage through a
risk pool created under Chapter 172, Local Government Code,
notwithstanding Section 172.014, Local Government Code, or any
other law.
(c) This chapter does not apply to:
(1) Medicaid managed care programs operated under
Chapter 533, Government Code;
(2) Medicaid programs operated under Chapter 32, Human
Resources Code; [or]
(3) the state child health plan operated under Chapter
62 or 63, Health and Safety Code; or
(4) a health benefit plan subject to Section 1271.157,
1301.164, 1551.229, 1575.172, or 1579.110.
SECTION 3.03. The following provisions of the Insurance
Code are repealed:
(1) Section 1456.004(c);
(2) Sections 1467.051(c) and (d);
(3) Section 1467.0511;
(4) Section 1467.052;
(5) Section 1467.053;
(6) Section 1467.054;
(7) Section 1467.055;
(8) Section 1467.056;
(9) Section 1467.057;
(10) Section 1467.058;
(11) Section 1467.059;
(12) Section 1467.060; and
(13) Section 1467.151(d).
ARTICLE 4. STUDY
SECTION 4.01. Subchapter A, Chapter 38, Insurance Code, is
amended by adding Section 38.004 to read as follows:
Sec. 38.004. BALANCE BILLING PROHIBITION REPORT. (a) The
department shall, each biennium, conduct a study on the impacts of
S.B. No. 1264, Acts of the 86th Legislature, Regular Session, 2019,
on Texas consumers and health coverage in this state, including:
(1) trends in billed amounts for health care or
medical services or supplies, especially emergency services,
laboratory services, diagnostic imaging services, and
facility-based services;
(2) comparison of the total amount spent on
out-of-network emergency services, laboratory services, diagnostic
imaging services, and facility-based services by calendar year and
provider type or physician specialty;
(3) trends and changes in network participation by
providers of emergency services, laboratory services, diagnostic
imaging services, and facility-based services by provider type or
physician specialty, including whether any terminations were
initiated by a health benefit plan issuer, administrator, or
provider;
(4) the number of complaints, completed
investigations, and disciplinary sanctions for billing by
providers of emergency services, laboratory services, diagnostic
imaging services, or facility-based services of insureds,
enrollees, or plan participants for amounts greater than the
insured's, enrollee's, or participant's responsibility under an
applicable managed care plan, including an applicable copayment,
coinsurance, or deductible;
(5) trends in amounts paid to out-of-network
providers;
(6) trends in the usual and customary rate for health
care or medical services or supplies, especially emergency
services, laboratory services, diagnostic imaging services, and
facility-based services; and
(7) the effectiveness of the claim dispute resolution
process under Chapter 1467.
(b) In conducting the study described by Subsection (a), the
department shall collect settlement data and verdicts or
arbitration awards from parties to arbitration under Chapter 1467.
(c) The department:
(1) shall collect data quarterly from a health benefit
plan issuer or administrator subject to Chapter 1467 to conduct the
study required by this section; and
(2) may utilize any reliable external resource or
entity to acquire information reasonably necessary to prepare the
report required by Subsection (d).
(d) Not later than December 1 of each even-numbered year,
the department shall prepare and submit a written report on the
results of the study under this section, including the department's
findings, to the legislature.
ARTICLE 5. TRANSITION AND EFFECTIVE DATE
SECTION 5.01. The changes in law made by this Act apply only
to a health care or medical service or supply provided on or after
January 1, 2020. A health care or medical service or supply
provided before January 1, 2020, is governed by the law in effect
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
SECTION 5.02. The Texas Department of Insurance, the
Employees Retirement System of Texas, the Teacher Retirement System
of Texas, and any other state agency subject to this Act are
required to implement a provision of this Act only if the
legislature appropriates money specifically for that purpose. If
the legislature does not appropriate money specifically for that
purpose, those agencies may, but are not required to, implement a
provision of this Act using other appropriations available for that
purpose.
SECTION 5.03. This Act takes effect September 1, 2019.