TX
Texas Senate Bill SB1264

Texas 2019 - 86th Regular

Texas Senate Bill SB1264 Compare Versions

OldNewDifferences
1-S.B. No. 1264
1+86R31987 SCL-D
2+ By: Hancock, et al. S.B. No. 1264
3+ (Oliverson, Martinez Fischer, Bonnen of Galveston, Zerwas,
4+ Lucio III)
25
36
7+ A BILL TO BE ENTITLED
48 AN ACT
59 relating to consumer protections against certain medical and health
610 care billing by certain out-of-network providers.
711 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
812 ARTICLE 1. ELIMINATION OF SURPRISE BILLING FOR CERTAIN HEALTH
913 BENEFIT PLANS
10- SECTION 1.01. Subtitle G, Title 5, Insurance Code, is
11- amended by adding Chapter 752 to read as follows:
12- CHAPTER 752. ENFORCEMENT OF BALANCE BILLING PROHIBITIONS
13- Sec. 752.0001. DEFINITION. In this chapter,
14- "administrator" has the meaning assigned by Section 1467.001.
15- Sec. 752.0002. INJUNCTION FOR BALANCE BILLING. (a) If the
16- attorney general receives a referral from the appropriate
17- regulatory agency indicating that an individual or entity,
18- including a health benefit plan issuer or administrator, has
19- exhibited a pattern of intentionally violating a law that prohibits
20- the individual or entity from billing an insured, participant, or
21- enrollee in an amount greater than an applicable copayment,
22- coinsurance, and deductible under the insured's, participant's, or
23- enrollee's managed care plan or that imposes a requirement related
24- to that prohibition, the attorney general may bring a civil action
25- in the name of the state to enjoin the individual or entity from the
26- violation.
27- (b) If the attorney general prevails in an action brought
28- under Subsection (a), the attorney general may recover reasonable
29- attorney's fees, costs, and expenses, including court costs and
30- witness fees, incurred in bringing the action.
31- Sec. 752.0003. ENFORCEMENT BY REGULATORY AGENCY. (a) An
32- appropriate regulatory agency that licenses, certifies, or
33- otherwise authorizes a physician, health care practitioner, health
34- care facility, or other health care provider to practice or operate
35- in this state may take disciplinary action against the physician,
36- practitioner, facility, or provider if the physician,
37- practitioner, facility, or provider violates a law that prohibits
38- the physician, practitioner, facility, or provider from billing an
39- insured, participant, or enrollee in an amount greater than an
40- applicable copayment, coinsurance, and deductible under the
41- insured's, participant's, or enrollee's managed care plan or that
42- imposes a requirement related to that prohibition.
43- (b) The department may take disciplinary action against a
44- health benefit plan issuer or administrator if the issuer or
45- administrator violates a law requiring the issuer or administrator
46- to provide notice of a balance billing prohibition or make a related
47- disclosure.
48- (c) A regulatory agency described by Subsection (a) or the
49- commissioner may adopt rules as necessary to implement this
50- section. Section 2001.0045, Government Code, does not apply to
51- rules adopted under this subsection.
52- SECTION 1.02. Subchapter A, Chapter 1271, Insurance Code,
53- is amended by adding Section 1271.008 to read as follows:
54- Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A
55- health maintenance organization shall provide written notice in
56- accordance with this section in an explanation of benefits provided
57- to the enrollee and the physician or provider in connection with a
58- health care service or supply provided by a non-network physician
59- or provider. The notice must include:
60- (1) a statement of the billing prohibition under
61- Section 1271.155, 1271.157, or 1271.158, as applicable;
62- (2) the total amount the physician or provider may
63- bill the enrollee under the enrollee's health benefit plan and an
64- itemization of copayments, coinsurance, deductibles, and other
65- amounts included in that total; and
66- (3) for an explanation of benefits provided to the
67- physician or provider, information required by commissioner rule
68- advising the physician or provider of the availability of mediation
69- or arbitration, as applicable, under Chapter 1467.
70- (b) A health maintenance organization shall provide the
71- explanation of benefits with the notice required by this section to
72- a physician or health care provider not later than the date the
73- health maintenance organization makes a payment under Section
74- 1271.155, 1271.157, or 1271.158, as applicable.
75- SECTION 1.03. Section 1271.155, Insurance Code, is amended
76- by amending Subsection (b) and adding Subsections (f), (g), and (h)
77- to read as follows:
78- (b) A health care plan of a health maintenance organization
79- must provide the following coverage of emergency care:
80- (1) a medical screening examination or other
81- evaluation required by state or federal law necessary to determine
82- whether an emergency medical condition exists shall be provided to
83- covered enrollees in a hospital emergency facility or comparable
84- facility;
85- (2) necessary emergency care shall be provided to
86- covered enrollees, including the treatment and stabilization of an
87- emergency medical condition; [and]
88- (3) services originated in a hospital emergency
89- facility, freestanding emergency medical care facility, or
90- comparable emergency facility following treatment or stabilization
91- of an emergency medical condition shall be provided to covered
92- enrollees as approved by the health maintenance organization,
93- subject to Subsections (c) and (d); and
94- (4) supplies related to a service described by this
95- subsection shall be provided to covered enrollees.
96- (f) For emergency care subject to this section or a supply
97- related to that care, a health maintenance organization shall make
98- a payment required by Subsection (a) directly to the non-network
99- physician or provider not later than, as applicable:
100- (1) the 30th day after the date the health maintenance
101- organization receives an electronic clean claim as defined by
102- Section 843.336 for those services that includes all information
103- necessary for the health maintenance organization to pay the claim;
104- or
105- (2) the 45th day after the date the health maintenance
106- organization receives a nonelectronic clean claim as defined by
107- Section 843.336 for those services that includes all information
108- necessary for the health maintenance organization to pay the claim.
109- (g) For emergency care subject to this section or a supply
110- related to that care, a non-network physician or provider or a
111- person asserting a claim as an agent or assignee of the physician or
112- provider may not bill an enrollee in, and the enrollee does not have
113- financial responsibility for, an amount greater than an applicable
114- copayment, coinsurance, and deductible under the enrollee's health
115- care plan that:
116- (1) is based on:
117- (A) the amount initially determined payable by
118- the health maintenance organization; or
119- (B) if applicable, a modified amount as
120- determined under the health maintenance organization's internal
121- appeal process; and
122- (2) is not based on any additional amount determined
123- to be owed to the physician or provider under Chapter 1467.
124- (h) This section may not be construed to require the
125- imposition of a penalty under Section 843.342.
126- SECTION 1.04. Subchapter D, Chapter 1271, Insurance Code,
127- is amended by adding Sections 1271.157 and 1271.158 to read as
128- follows:
129- Sec. 1271.157. NON-NETWORK FACILITY-BASED PROVIDERS.
130- (a) In this section, "facility-based provider" means a physician
131- or provider who provides health care services to patients of a
132- health care facility.
133- (b) Except as provided by Subsection (d), a health
134- maintenance organization shall pay for a covered health care
135- service performed for or a covered supply related to that service
136- provided to an enrollee by a non-network physician or provider who
137- is a facility-based provider at the usual and customary rate or at
138- an agreed rate if the provider performed the service at a health
139- care facility that is a network provider. The health maintenance
140- organization shall make a payment required by this subsection
141- directly to the physician or provider not later than, as
142- applicable:
143- (1) the 30th day after the date the health maintenance
144- organization receives an electronic clean claim as defined by
145- Section 843.336 for those services that includes all information
146- necessary for the health maintenance organization to pay the claim;
147- or
148- (2) the 45th day after the date the health maintenance
149- organization receives a nonelectronic clean claim as defined by
150- Section 843.336 for those services that includes all information
151- necessary for the health maintenance organization to pay the claim.
152- (c) Except as provided by Subsection (d), a non-network
153- facility-based provider or a person asserting a claim as an agent or
154- assignee of the provider may not bill an enrollee receiving a health
155- care service or supply described by Subsection (b) in, and the
156- enrollee does not have financial responsibility for, an amount
157- greater than an applicable copayment, coinsurance, and deductible
158- under the enrollee's health care plan that:
159- (1) is based on:
160- (A) the amount initially determined payable by
161- the health maintenance organization; or
162- (B) if applicable, a modified amount as
163- determined under the health maintenance organization's internal
164- appeal process; and
165- (2) is not based on any additional amount determined
166- to be owed to the provider under Chapter 1467.
167- (d) This section does not apply to a nonemergency health
168- care or medical service:
169- (1) that an enrollee elects to receive in writing in
170- advance of the service with respect to each non-network physician
171- or provider providing the service; and
172- (2) for which a non-network physician or provider,
173- before providing the service, provides a complete written
174- disclosure to the enrollee that:
175- (A) explains that the physician or provider does
176- not have a contract with the enrollee's health benefit plan;
177- (B) discloses projected amounts for which the
178- enrollee may be responsible; and
179- (C) discloses the circumstances under which the
180- enrollee would be responsible for those amounts.
181- (e) This section may not be construed to require the
182- imposition of a penalty under Section 843.342.
183- Sec. 1271.158. NON-NETWORK DIAGNOSTIC IMAGING PROVIDER OR
184- LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
185- imaging provider" and "laboratory service provider" have the
186- meanings assigned by Section 1467.001.
187- (b) Except as provided by Subsection (d), a health
188- maintenance organization shall pay for a covered health care
189- service performed by or a covered supply related to that service
190- provided to an enrollee by a non-network diagnostic imaging
191- provider or laboratory service provider at the usual and customary
192- rate or at an agreed rate if the provider performed the service in
193- connection with a health care service performed by a network
194- physician or provider. The health maintenance organization shall
195- make a payment required by this subsection directly to the
196- physician or provider not later than, as applicable:
197- (1) the 30th day after the date the health maintenance
198- organization receives an electronic clean claim as defined by
199- Section 843.336 for those services that includes all information
200- necessary for the health maintenance organization to pay the claim;
201- or
202- (2) the 45th day after the date the health maintenance
203- organization receives a nonelectronic clean claim as defined by
204- Section 843.336 for those services that includes all information
205- necessary for the health maintenance organization to pay the claim.
206- (c) Except as provided by Subsection (d), a non-network
207- diagnostic imaging provider or laboratory service provider or a
208- person asserting a claim as an agent or assignee of the provider may
209- not bill an enrollee receiving a health care service or supply
210- described by Subsection (b) in, and the enrollee does not have
211- financial responsibility for, an amount greater than an applicable
212- copayment, coinsurance, and deductible under the enrollee's health
213- care plan that:
214- (1) is based on:
215- (A) the amount initially determined payable by
216- the health maintenance organization; or
217- (B) if applicable, a modified amount as
218- determined under the health maintenance organization's internal
219- appeal process; and
220- (2) is not based on any additional amount determined
221- to be owed to the provider under Chapter 1467.
222- (d) This section does not apply to a nonemergency health
223- care or medical service:
224- (1) that an enrollee elects to receive in writing in
225- advance of the service with respect to each non-network physician
226- or provider providing the service; and
227- (2) for which a non-network physician or provider,
228- before providing the service, provides a complete written
229- disclosure to the enrollee that:
230- (A) explains that the physician or provider does
231- not have a contract with the enrollee's health benefit plan;
232- (B) discloses projected amounts for which the
233- enrollee may be responsible; and
234- (C) discloses the circumstances under which the
235- enrollee would be responsible for those amounts.
236- (e) This section may not be construed to require the
237- imposition of a penalty under Section 843.342.
238- SECTION 1.05. Section 1301.0045(b), Insurance Code, is
239- amended to read as follows:
240- (b) Except as provided by Sections 1301.0052, 1301.0053,
241- [and] 1301.155, 1301.164, and 1301.165, this chapter may not be
242- construed to require an exclusive provider benefit plan to
243- compensate a nonpreferred provider for services provided to an
244- insured.
245- SECTION 1.06. Section 1301.0053, Insurance Code, is amended
246- to read as follows:
247- Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS:
248- EMERGENCY CARE. (a) If an out-of-network [a nonpreferred]
249- provider provides emergency care as defined by Section 1301.155 to
250- an enrollee in an exclusive provider benefit plan, the issuer of the
251- plan shall reimburse the out-of-network [nonpreferred] provider at
252- the usual and customary rate or at a rate agreed to by the issuer and
253- the out-of-network [nonpreferred] provider for the provision of the
254- services and any supply related to those services. The insurer
255- shall make a payment required by this subsection directly to the
256- provider not later than, as applicable:
257- (1) the 30th day after the date the insurer receives an
258- electronic clean claim as defined by Section 1301.101 for those
259- services that includes all information necessary for the insurer to
260- pay the claim; or
261- (2) the 45th day after the date the insurer receives a
262- nonelectronic clean claim as defined by Section 1301.101 for those
263- services that includes all information necessary for the insurer to
264- pay the claim.
265- (b) For emergency care subject to this section or a supply
266- related to that care, an out-of-network provider or a person
267- asserting a claim as an agent or assignee of the provider may not
268- bill an insured in, and the insured does not have financial
269- responsibility for, an amount greater than an applicable copayment,
270- coinsurance, and deductible under the insured's exclusive provider
271- benefit plan that:
272- (1) is based on:
273- (A) the amount initially determined payable by
274- the insurer; or
275- (B) if applicable, a modified amount as
276- determined under the insurer's internal appeal process; and
277- (2) is not based on any additional amount determined
278- to be owed to the provider under Chapter 1467.
279- (c) This section may not be construed to require the
280- imposition of a penalty under Section 1301.137.
281- SECTION 1.07. Subchapter A, Chapter 1301, Insurance Code,
282- is amended by adding Section 1301.010 to read as follows:
283- Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An
284- insurer shall provide written notice in accordance with this
285- section in an explanation of benefits provided to the insured and
286- the physician or health care provider in connection with a medical
287- care or health care service or supply provided by an out-of-network
288- provider. The notice must include:
289- (1) a statement of the billing prohibition under
290- Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;
291- (2) the total amount the physician or provider may
292- bill the insured under the insured's preferred provider benefit
293- plan and an itemization of copayments, coinsurance, deductibles,
294- and other amounts included in that total; and
295- (3) for an explanation of benefits provided to the
296- physician or provider, information required by commissioner rule
297- advising the physician or provider of the availability of mediation
298- or arbitration, as applicable, under Chapter 1467.
299- (b) An insurer shall provide the explanation of benefits
300- with the notice required by this section to a physician or health
301- care provider not later than the date the insurer makes a payment
302- under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as
303- applicable.
304- SECTION 1.08. Section 1301.155, Insurance Code, is amended
305- by amending Subsection (b) and adding Subsections (c), (d), and (e)
306- to read as follows:
307- (b) If an insured cannot reasonably reach a preferred
308- provider, an insurer shall provide reimbursement for the following
309- emergency care services at the usual and customary rate or at an
310- agreed rate and at the preferred level of benefits until the insured
311- can reasonably be expected to transfer to a preferred provider:
312- (1) a medical screening examination or other
313- evaluation required by state or federal law to be provided in the
314- emergency facility of a hospital that is necessary to determine
315- whether a medical emergency condition exists;
316- (2) necessary emergency care services, including the
317- treatment and stabilization of an emergency medical condition;
318- [and]
319- (3) services originating in a hospital emergency
320- facility or freestanding emergency medical care facility following
321- treatment or stabilization of an emergency medical condition; and
322- (4) supplies related to a service described by this
323- subsection.
324- (c) For emergency care subject to this section or a supply
325- related to that care, an insurer shall make a payment required by
326- this section directly to the out-of-network provider not later
327- than, as applicable:
328- (1) the 30th day after the date the insurer receives an
329- electronic clean claim as defined by Section 1301.101 for those
330- services that includes all information necessary for the insurer to
331- pay the claim; or
332- (2) the 45th day after the date the insurer receives a
333- nonelectronic clean claim as defined by Section 1301.101 for those
334- services that includes all information necessary for the insurer to
335- pay the claim.
336- (d) For emergency care subject to this section or a supply
337- related to that care, an out-of-network provider or a person
338- asserting a claim as an agent or assignee of the provider may not
339- bill an insured in, and the insured does not have financial
340- responsibility for, an amount greater than an applicable copayment,
341- coinsurance, and deductible under the insured's preferred provider
342- benefit plan that:
343- (1) is based on:
344- (A) the amount initially determined payable by
345- the insurer; or
346- (B) if applicable, a modified amount as
347- determined under the insurer's internal appeal process; and
348- (2) is not based on any additional amount determined
349- to be owed to the provider under Chapter 1467.
350- (e) This section may not be construed to require the
351- imposition of a penalty under Section 1301.137.
352- SECTION 1.09. Subchapter D, Chapter 1301, Insurance Code,
353- is amended by adding Sections 1301.164 and 1301.165 to read as
354- follows:
355- Sec. 1301.164. OUT-OF-NETWORK FACILITY-BASED PROVIDERS.
356- (a) In this section, "facility-based provider" means a physician
357- or health care provider who provides medical care or health care
358- services to patients of a health care facility.
359- (b) Except as provided by Subsection (d), an insurer shall
360- pay for a covered medical care or health care service performed for
361- or a covered supply related to that service provided to an insured
362- by an out-of-network provider who is a facility-based provider at
363- the usual and customary rate or at an agreed rate if the provider
364- performed the service at a health care facility that is a preferred
365- provider. The insurer shall make a payment required by this
366- subsection directly to the provider not later than, as applicable:
367- (1) the 30th day after the date the insurer receives an
368- electronic clean claim as defined by Section 1301.101 for those
369- services that includes all information necessary for the insurer to
370- pay the claim; or
371- (2) the 45th day after the date the insurer receives a
372- nonelectronic clean claim as defined by Section 1301.101 for those
373- services that includes all information necessary for the insurer to
374- pay the claim.
375- (c) Except as provided by Subsection (d), an out-of-network
376- provider who is a facility-based provider or a person asserting a
377- claim as an agent or assignee of the provider may not bill an
378- insured receiving a medical care or health care service or supply
379- described by Subsection (b) in, and the insured does not have
380- financial responsibility for, an amount greater than an applicable
381- copayment, coinsurance, and deductible under the insured's
382- preferred provider benefit plan that:
383- (1) is based on:
384- (A) the amount initially determined payable by
385- the insurer; or
386- (B) if applicable, a modified amount as
387- determined under the insurer's internal appeal process; and
388- (2) is not based on any additional amount determined
389- to be owed to the provider under Chapter 1467.
390- (d) This section does not apply to a nonemergency health
391- care or medical service:
392- (1) that an insured elects to receive in writing in
393- advance of the service with respect to each out-of-network provider
394- providing the service; and
395- (2) for which an out-of-network provider, before
396- providing the service, provides a complete written disclosure to
397- the insured that:
398- (A) explains that the provider does not have a
399- contract with the insured's preferred provider benefit plan;
400- (B) discloses projected amounts for which the
401- insured may be responsible; and
402- (C) discloses the circumstances under which the
403- insured would be responsible for those amounts.
404- (e) This section may not be construed to require the
405- imposition of a penalty under Section 1301.137.
406- Sec. 1301.165. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
407- OR LABORATORY SERVICE PROVIDER. (a) In this section, "diagnostic
408- imaging provider" and "laboratory service provider" have the
409- meanings assigned by Section 1467.001.
410- (b) Except as provided by Subsection (d), an insurer shall
411- pay for a covered medical care or health care service performed by
412- or a covered supply related to that service provided to an insured
413- by an out-of-network provider who is a diagnostic imaging provider
414- or laboratory service provider at the usual and customary rate or at
415- an agreed rate if the provider performed the service in connection
416- with a medical care or health care service performed by a preferred
417- provider. The insurer shall make a payment required by this
418- subsection directly to the provider not later than, as applicable:
419- (1) the 30th day after the date the insurer receives an
420- electronic clean claim as defined by Section 1301.101 for those
421- services that includes all information necessary for the insurer to
422- pay the claim; or
423- (2) the 45th day after the date the insurer receives a
424- nonelectronic clean claim as defined by Section 1301.101 for those
425- services that includes all information necessary for the insurer to
426- pay the claim.
427- (c) Except as provided by Subsection (d), an out-of-network
428- provider who is a diagnostic imaging provider or laboratory service
429- provider or a person asserting a claim as an agent or assignee of
430- the provider may not bill an insured receiving a medical care or
431- health care service or supply described by Subsection (b) in, and
432- the insured does not have financial responsibility for, an amount
433- greater than an applicable copayment, coinsurance, and deductible
434- under the insured's preferred provider benefit plan that:
435- (1) is based on:
436- (A) the amount initially determined payable by
437- the insurer; or
438- (B) if applicable, the modified amount as
439- determined under the insurer's internal appeal process; and
440- (2) is not based on any additional amount determined
441- to be owed to the provider under Chapter 1467.
442- (d) This section does not apply to a nonemergency health
443- care or medical service:
444- (1) that an insured elects to receive in writing in
445- advance of the service with respect to each out-of-network provider
446- providing the service; and
447- (2) for which an out-of-network provider, before
448- providing the service, provides a complete written disclosure to
449- the insured that:
450- (A) explains that the provider does not have a
451- contract with the insured's preferred provider benefit plan;
452- (B) discloses projected amounts for which the
453- insured may be responsible; and
454- (C) discloses the circumstances under which the
455- insured would be responsible for those amounts.
456- (e) This section may not be construed to require the
457- imposition of a penalty under Section 1301.137.
458- SECTION 1.10. Section 1551.003, Insurance Code, is amended
459- by adding Subdivision (15) to read as follows:
460- (15) "Usual and customary rate" means the relevant
461- allowable amount as described by the applicable master benefit plan
462- document or policy.
463- SECTION 1.11. Subchapter A, Chapter 1551, Insurance Code,
464- is amended by adding Section 1551.015 to read as follows:
465- Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE.
466- (a) The administrator of a managed care plan provided under the
467- group benefits program shall provide written notice in accordance
468- with this section in an explanation of benefits provided to the
469- participant and the physician or health care provider in connection
470- with a health care or medical service or supply provided by an
471- out-of-network provider. The notice must include:
472- (1) a statement of the billing prohibition under
473- Section 1551.228, 1551.229, or 1551.230, as applicable;
474- (2) the total amount the physician or provider may
475- bill the participant under the participant's managed care plan and
476- an itemization of copayments, coinsurance, deductibles, and other
477- amounts included in that total; and
478- (3) for an explanation of benefits provided to the
479- physician or provider, information required by commissioner rule
480- advising the physician or provider of the availability of mediation
481- or arbitration, as applicable, under Chapter 1467.
482- (b) The administrator shall provide the explanation of
483- benefits with the notice required by this section to a physician or
484- health care provider not later than the date the administrator
485- makes a payment under Section 1551.228, 1551.229, or 1551.230, as
486- applicable.
487- SECTION 1.12. Subchapter E, Chapter 1551, Insurance Code,
488- is amended by adding Sections 1551.228, 1551.229, and 1551.230 to
489- read as follows:
490- Sec. 1551.228. EMERGENCY CARE PAYMENTS. (a) In this
491- section, "emergency care" has the meaning assigned by Section
492- 1301.155.
493- (b) The administrator of a managed care plan provided under
494- the group benefits program shall pay for covered emergency care
495- performed by or a covered supply related to that care provided by an
496- out-of-network provider at the usual and customary rate or at an
497- agreed rate. The administrator shall make a payment required by
498- this subsection directly to the provider not later than, as
499- applicable:
500- (1) the 30th day after the date the administrator
501- receives an electronic claim for those services that includes all
502- information necessary for the administrator to pay the claim; or
503- (2) the 45th day after the date the administrator
504- receives a nonelectronic claim for those services that includes all
505- information necessary for the administrator to pay the claim.
506- (c) For emergency care subject to this section or a supply
507- related to that care, an out-of-network provider or a person
508- asserting a claim as an agent or assignee of the provider may not
509- bill a participant in, and the participant does not have financial
510- responsibility for, an amount greater than an applicable copayment,
511- coinsurance, and deductible under the participant's managed care
512- plan that:
513- (1) is based on:
514- (A) the amount initially determined payable by
515- the administrator; or
516- (B) if applicable, a modified amount as
517- determined under the administrator's internal appeal process; and
518- (2) is not based on any additional amount determined
519- to be owed to the provider under Chapter 1467.
520- Sec. 1551.229. OUT-OF-NETWORK FACILITY-BASED PROVIDER
521- PAYMENTS. (a) In this section, "facility-based provider" means a
522- physician or health care provider who provides health care or
523- medical services to patients of a health care facility.
524- (b) Except as provided by Subsection (d), the administrator
525- of a managed care plan provided under the group benefits program
526- shall pay for a covered health care or medical service performed for
527- or a covered supply related to that service provided to a
528- participant by an out-of-network provider who is a facility-based
529- provider at the usual and customary rate or at an agreed rate if the
530- provider performed the service at a health care facility that is a
531- participating provider. The administrator shall make a payment
532- required by this subsection directly to the provider not later
533- than, as applicable:
534- (1) the 30th day after the date the administrator
535- receives an electronic claim for those services that includes all
536- information necessary for the administrator to pay the claim; or
537- (2) the 45th day after the date the administrator
538- receives a nonelectronic claim for those services that includes all
539- information necessary for the administrator to pay the claim.
540- (c) Except as provided by Subsection (d), an out-of-network
541- provider who is a facility-based provider or a person asserting a
542- claim as an agent or assignee of the provider may not bill a
543- participant receiving a health care or medical service or supply
544- described by Subsection (b) in, and the participant does not have
545- financial responsibility for, an amount greater than an applicable
546- copayment, coinsurance, and deductible under the participant's
547- managed care plan that:
548- (1) is based on:
549- (A) the amount initially determined payable by
550- the administrator; or
551- (B) if applicable, a modified amount as
552- determined under the administrator's internal appeal process; and
553- (2) is not based on any additional amount determined
554- to be owed to the provider under Chapter 1467.
555- (d) This section does not apply to a nonemergency health
556- care or medical service:
557- (1) that a participant elects to receive in writing in
558- advance of the service with respect to each out-of-network provider
559- providing the service; and
560- (2) for which an out-of-network provider, before
561- providing the service, provides a complete written disclosure to
562- the participant that:
563- (A) explains that the provider does not have a
564- contract with the participant's managed care plan;
565- (B) discloses projected amounts for which the
566- participant may be responsible; and
567- (C) discloses the circumstances under which the
568- participant would be responsible for those amounts.
569- Sec. 1551.230. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
570- OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section,
571- "diagnostic imaging provider" and "laboratory service provider"
572- have the meanings assigned by Section 1467.001.
573- (b) Except as provided by Subsection (d), the administrator
574- of a managed care plan provided under the group benefits program
575- shall pay for a covered health care or medical service performed for
576- or a covered supply related to that service provided to a
577- participant by an out-of-network provider who is a diagnostic
578- imaging provider or laboratory service provider at the usual and
14+ SECTION 1.01. Subtitle F, Title 8, Insurance Code, is
15+ amended by adding Chapter 1466 to read as follows:
16+ CHAPTER 1466. OUT-OF-NETWORK COVERAGES AND BALANCE BILLING
17+ PROHIBITIONS
18+ SUBCHAPTER A. GENERAL PROVISIONS
19+ Sec. 1466.0001. APPLICABILITY OF DEFINITIONS. In this
20+ chapter, terms defined by Section 1467.001 have the meanings
21+ assigned by that section.
22+ Sec. 1466.0002. APPLICABILITY OF CHAPTER. This chapter
23+ applies only to:
24+ (1) a health benefit plan offered by a health
25+ maintenance organization operating under Chapter 843;
26+ (2) a preferred provider benefit plan, including an
27+ exclusive provider benefit plan, offered by an insurer under
28+ Chapter 1301; and
29+ (3) a health benefit plan, other than a health
30+ maintenance organization plan, under Chapter 1551, 1575, or 1579.
31+ SUBCHAPTER B. REQUIRED COVERAGES
32+ Sec. 1466.0051. USUAL AND CUSTOMARY RATE FOR CERTAIN
33+ GOVERNMENTAL PLANS. For purposes of this subchapter, the usual and
34+ customary rate for a health benefit plan under Chapter 1551, 1575,
35+ or 1579 is the relevant allowable amount as described by the
36+ applicable master benefit plan document or policy.
37+ Sec. 1466.0052. EMERGENCY CARE COVERAGE. A health benefit
38+ plan that provides coverage for emergency care performed for or a
39+ supply related to that care provided to an enrollee by an
40+ out-of-network provider must provide the coverage at the usual and
41+ customary rate or at an agreed rate.
42+ Sec. 1466.0053. FACILITY-BASED PROVIDER COVERAGE;
43+ EXCEPTION. (a) Except as provided by Subsection (b), a health
44+ benefit plan that provides coverage for a health care or medical
45+ service performed for or a supply related to that service provided
46+ to an enrollee by an out-of-network provider who is a
47+ facility-based provider must provide the coverage at the usual and
57948 customary rate or at an agreed rate if the provider performed the
580- service in connection with a health care or medical service
581- performed by a participating provider. The administrator shall
582- make a payment required by this subsection directly to the provider
583- not later than, as applicable:
584- (1) the 30th day after the date the administrator
585- receives an electronic claim for those services that includes all
586- information necessary for the administrator to pay the claim; or
587- (2) the 45th day after the date the administrator
588- receives a nonelectronic claim for those services that includes all
589- information necessary for the administrator to pay the claim.
590- (c) Except as provided by Subsection (d), an out-of-network
591- provider who is a diagnostic imaging provider or laboratory service
592- provider or a person asserting a claim as an agent or assignee of
593- the provider may not bill a participant receiving a health care or
594- medical service or supply described by Subsection (b) in, and the
595- participant does not have financial responsibility for, an amount
596- greater than an applicable copayment, coinsurance, and deductible
597- under the participant's managed care plan that:
598- (1) is based on:
599- (A) the amount initially determined payable by
600- the administrator; or
601- (B) if applicable, the modified amount as
602- determined under the administrator's internal appeal process; and
603- (2) is not based on any additional amount determined
604- to be owed to the provider under Chapter 1467.
605- (d) This section does not apply to a nonemergency health
606- care or medical service:
607- (1) that a participant elects to receive in writing in
608- advance of the service with respect to each out-of-network provider
609- providing the service; and
610- (2) for which an out-of-network provider, before
611- providing the service, provides a complete written disclosure to
612- the participant that:
613- (A) explains that the provider does not have a
614- contract with the participant's managed care plan;
615- (B) discloses projected amounts for which the
616- participant may be responsible; and
617- (C) discloses the circumstances under which the
618- participant would be responsible for those amounts.
619- SECTION 1.13. Section 1575.002, Insurance Code, is amended
620- by adding Subdivision (8) to read as follows:
621- (8) "Usual and customary rate" means the relevant
622- allowable amount as described by the applicable master benefit plan
623- document or policy.
624- SECTION 1.14. Subchapter A, Chapter 1575, Insurance Code,
625- is amended by adding Section 1575.009 to read as follows:
626- Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE.
627- (a) The administrator of a managed care plan provided under the
628- group program shall provide written notice in accordance with this
629- section in an explanation of benefits provided to the enrollee and
630- the physician or health care provider in connection with a health
631- care or medical service or supply provided by an out-of-network
632- provider. The notice must include:
633- (1) a statement of the billing prohibition under
634- Section 1575.171, 1575.172, or 1575.173, as applicable;
635- (2) the total amount the physician or provider may
636- bill the enrollee under the enrollee's managed care plan and an
637- itemization of copayments, coinsurance, deductibles, and other
638- amounts included in that total; and
639- (3) for an explanation of benefits provided to the
640- physician or provider, information required by commissioner rule
641- advising the physician or provider of the availability of mediation
642- or arbitration, as applicable, under Chapter 1467.
643- (b) The administrator shall provide the explanation of
644- benefits with the notice required by this section to a physician or
645- health care provider not later than the date the administrator
646- makes a payment under Section 1575.171, 1575.172, or 1575.173, as
647- applicable.
648- SECTION 1.15. Subchapter D, Chapter 1575, Insurance Code,
649- is amended by adding Sections 1575.171, 1575.172, and 1575.173 to
650- read as follows:
651- Sec. 1575.171. EMERGENCY CARE PAYMENTS. (a) In this
652- section, "emergency care" has the meaning assigned by Section
653- 1301.155.
654- (b) The administrator of a managed care plan provided under
655- the group program shall pay for covered emergency care performed by
656- or a covered supply related to that care provided by an
657- out-of-network provider at the usual and customary rate or at an
658- agreed rate. The administrator shall make a payment required by
659- this subsection directly to the provider not later than, as
660- applicable:
661- (1) the 30th day after the date the administrator
662- receives an electronic claim for those services that includes all
663- information necessary for the administrator to pay the claim; or
664- (2) the 45th day after the date the administrator
665- receives a nonelectronic claim for those services that includes all
666- information necessary for the administrator to pay the claim.
667- (c) For emergency care subject to this section or a supply
668- related to that care, an out-of-network provider or a person
669- asserting a claim as an agent or assignee of the provider may not
670- bill an enrollee in, and the enrollee does not have financial
671- responsibility for, an amount greater than an applicable copayment,
672- coinsurance, and deductible under the enrollee's managed care plan
673- that:
674- (1) is based on:
675- (A) the amount initially determined payable by
676- the administrator; or
677- (B) if applicable, a modified amount as
678- determined under the administrator's internal appeal process; and
679- (2) is not based on any additional amount determined
680- to be owed to the provider under Chapter 1467.
681- Sec. 1575.172. OUT-OF-NETWORK FACILITY-BASED PROVIDER
682- PAYMENTS. (a) In this section, "facility-based provider" means a
683- physician or health care provider who provides health care or
684- medical services to patients of a health care facility.
685- (b) Except as provided by Subsection (d), the administrator
686- of a managed care plan provided under the group program shall pay
687- for a covered health care or medical service performed for or a
688- covered supply related to that service provided to an enrollee by an
689- out-of-network provider who is a facility-based provider at the
690- usual and customary rate or at an agreed rate if the provider
691- performed the service at a health care facility that is a
692- participating provider. The administrator shall make a payment
693- required by this subsection directly to the provider not later
694- than, as applicable:
695- (1) the 30th day after the date the administrator
696- receives an electronic claim for those services that includes all
697- information necessary for the administrator to pay the claim; or
698- (2) the 45th day after the date the administrator
699- receives a nonelectronic claim for those services that includes all
700- information necessary for the administrator to pay the claim.
701- (c) Except as provided by Subsection (d), an out-of-network
702- provider who is a facility-based provider or a person asserting a
703- claim as an agent or assignee of the provider may not bill an
704- enrollee receiving a health care or medical service or supply
705- described by Subsection (b) in, and the enrollee does not have
706- financial responsibility for, an amount greater than an applicable
707- copayment, coinsurance, and deductible under the enrollee's
708- managed care plan that:
709- (1) is based on:
710- (A) the amount initially determined payable by
711- the administrator; or
712- (B) if applicable, a modified amount as
713- determined under the administrator's internal appeal process; and
714- (2) is not based on any additional amount determined
715- to be owed to the provider under Chapter 1467.
716- (d) This section does not apply to a nonemergency health
49+ service at a health care facility that is a participating provider.
50+ (b) This section does not apply to a nonemergency health
71751 care or medical service:
71852 (1) that an enrollee elects to receive in writing in
71953 advance of the service with respect to each out-of-network provider
72054 providing the service; and
72155 (2) for which an out-of-network provider, before
72256 providing the service, provides a complete written disclosure to
72357 the enrollee that:
72458 (A) explains that the provider does not have a
725- contract with the enrollee's managed care plan;
59+ contract with the enrollee's health benefit plan;
72660 (B) discloses projected amounts for which the
72761 enrollee may be responsible; and
72862 (C) discloses the circumstances under which the
72963 enrollee would be responsible for those amounts.
730- Sec. 1575.173. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
731- OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section,
732- "diagnostic imaging provider" and "laboratory service provider"
733- have the meanings assigned by Section 1467.001.
734- (b) Except as provided by Subsection (d), the administrator
735- of a managed care plan provided under the group program shall pay
736- for a covered health care or medical service performed for or a
737- covered supply related to that service provided to an enrollee by an
738- out-of-network provider who is a diagnostic imaging provider or
739- laboratory service provider at the usual and customary rate or at an
64+ Sec. 1466.0054. DIAGNOSTIC IMAGING PROVIDER OR LABORATORY
65+ SERVICE PROVIDER COVERAGE; EXCEPTION. (a) Except as provided by
66+ Subsection (b), a health benefit plan that provides coverage for a
67+ health care or medical service performed for or a supply related to
68+ that service provided to an enrollee by an out-of-network provider
69+ who is a diagnostic imaging provider or laboratory service provider
70+ must provide the coverage at the usual and customary rate or at an
74071 agreed rate if the provider performed the service in connection
741- with a health care or medical service performed by a participating
742- provider. The administrator shall make a payment required by this
743- subsection directly to the provider not later than, as applicable:
744- (1) the 30th day after the date the administrator
745- receives an electronic claim for those services that includes all
746- information necessary for the administrator to pay the claim; or
747- (2) the 45th day after the date the administrator
748- receives a nonelectronic claim for those services that includes all
749- information necessary for the administrator to pay the claim.
750- (c) Except as provided by Subsection (d), an out-of-network
751- provider who is a diagnostic imaging provider or laboratory service
752- provider or a person asserting a claim as an agent or assignee of
753- the provider may not bill an enrollee receiving a health care or
754- medical service or supply described by Subsection (b) in, and the
755- enrollee does not have financial responsibility for, an amount
756- greater than an applicable copayment, coinsurance, and deductible
757- under the enrollee's managed care plan that:
758- (1) is based on:
759- (A) the amount initially determined payable by
760- the administrator; or
761- (B) if applicable, the modified amount as
762- determined under the administrator's internal appeal process; and
763- (2) is not based on any additional amount determined
764- to be owed to the provider under Chapter 1467.
765- (d) This section does not apply to a nonemergency health
72+ with a health care service performed by a participating provider.
73+ (b) This section does not apply to a nonemergency health
76674 care or medical service:
76775 (1) that an enrollee elects to receive in writing in
76876 advance of the service with respect to each out-of-network provider
76977 providing the service; and
77078 (2) for which an out-of-network provider, before
77179 providing the service, provides a complete written disclosure to
77280 the enrollee that:
77381 (A) explains that the provider does not have a
774- contract with the enrollee's managed care plan;
82+ contract with the enrollee's health benefit plan;
77583 (B) discloses projected amounts for which the
77684 enrollee may be responsible; and
77785 (C) discloses the circumstances under which the
77886 enrollee would be responsible for those amounts.
779- SECTION 1.16. Section 1579.002, Insurance Code, is amended
780- by adding Subdivision (8) to read as follows:
781- (8) "Usual and customary rate" means the relevant
782- allowable amount as described by the applicable master benefit plan
783- document or policy.
784- SECTION 1.17. Subchapter A, Chapter 1579, Insurance Code,
785- is amended by adding Section 1579.009 to read as follows:
786- Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE.
787- (a) The administrator of a managed care plan provided under this
788- chapter shall provide written notice in accordance with this
789- section in an explanation of benefits provided to the enrollee and
790- the physician or health care provider in connection with a health
791- care or medical service or supply provided by an out-of-network
792- provider. The notice must include:
87+ Sec. 1466.0055. ACTION ON CLEAN CLAIMS FOR REQUIRED
88+ COVERAGES. (a) A health maintenance organization shall act on a
89+ clean claim as defined by Section 843.336 related to a health care
90+ or medical service or supply required to be covered under this
91+ subchapter in accordance with Section 843.338 as if the
92+ out-of-network provider is a participating physician or provider.
93+ (b) An insurer shall act on a clean claim as defined by
94+ Section 1301.101 related to a health care or medical service or
95+ supply required to be covered under this subchapter in accordance
96+ with Section 1301.103 as if the out-of-network provider is a
97+ preferred provider.
98+ (c) An administrator shall act on a clean claim as defined
99+ by Section 1301.101 related to a health care or medical service or
100+ supply required to be covered under this subchapter in accordance
101+ with Section 1301.103 as if:
102+ (1) the out-of-network provider is a preferred
103+ provider; and
104+ (2) the administrator is an insurer.
105+ SUBCHAPTER C. BALANCE BILLING PROHIBITIONS
106+ Sec. 1466.0101. BALANCE BILLING PROHIBITION NOTICE. A
107+ health benefit plan issuer or administrator shall provide written
108+ notice in accordance with this section in an explanation of
109+ benefits provided to the enrollee and the out-of-network provider
110+ in connection with a health care service or supply that is subject
111+ to Subchapter B. The notice must include:
793112 (1) a statement of the billing prohibition under
794- Section 1579.109, 1579.110, or 1579.111, as applicable;
795- (2) the total amount the physician or provider may
796- bill the enrollee under the enrollee's managed care plan and an
797- itemization of copayments, coinsurance, deductibles, and other
113+ Section 1466.0102;
114+ (2) the total amount the provider may bill the
115+ enrollee under the enrollee's health benefit plan and an
116+ itemization of copayments, deductibles, coinsurance, or other
798117 amounts included in that total; and
799118 (3) for an explanation of benefits provided to the
800- physician or provider, information required by commissioner rule
801- advising the physician or provider of the availability of mediation
802- or arbitration, as applicable, under Chapter 1467.
803- (b) The administrator shall provide the explanation of
804- benefits with the notice required by this section to a physician or
805- health care provider not later than the date the administrator
806- makes a payment under Section 1579.109, 1579.110, or 1579.111, as
807- applicable.
808- SECTION 1.18. Subchapter C, Chapter 1579, Insurance Code,
809- is amended by adding Sections 1579.109, 1579.110, and 1579.111 to
810- read as follows:
811- Sec. 1579.109. EMERGENCY CARE PAYMENTS. (a) In this
812- section, "emergency care" has the meaning assigned by Section
813- 1301.155.
814- (b) The administrator of a managed care plan provided under
815- this chapter shall pay for covered emergency care performed by or a
816- covered supply related to that care provided by an out-of-network
817- provider at the usual and customary rate or at an agreed rate. The
818- administrator shall make a payment required by this subsection
819- directly to the provider not later than, as applicable:
820- (1) the 30th day after the date the administrator
821- receives an electronic claim for those services that includes all
822- information necessary for the administrator to pay the claim; or
823- (2) the 45th day after the date the administrator
824- receives a nonelectronic claim for those services that includes all
825- information necessary for the administrator to pay the claim.
826- (c) For emergency care subject to this section or a supply
827- related to that care, an out-of-network provider or a person
828- asserting a claim as an agent or assignee of the provider may not
829- bill an enrollee in, and the enrollee does not have financial
119+ provider, information required by commissioner rule advising the
120+ provider of the availability of mediation or arbitration, as
121+ applicable, under Chapter 1467.
122+ Sec. 1466.0102. CERTAIN BALANCE BILLING PROHIBITED. For a
123+ health care service or supply required to be covered under
124+ Subchapter B, an out-of-network provider or a person asserting a
125+ claim as an agent or assignee of the provider may not bill an
126+ enrollee in, and the enrollee does not have financial
830127 responsibility for, an amount greater than an applicable copayment,
831- coinsurance, and deductible under the enrollee's managed care plan
128+ coinsurance, or deductible under the enrollee's health benefit plan
832129 that:
833130 (1) is based on:
834131 (A) the amount initially determined payable by
835- the administrator; or
132+ the health benefit plan issuer or administrator; or
836133 (B) if applicable, a modified amount as
837- determined under the administrator's internal appeal process; and
134+ determined under the issuer's or administrator's internal dispute
135+ resolution process; and
838136 (2) is not based on any additional amount determined
839137 to be owed to the provider under Chapter 1467.
840- Sec. 1579.110. OUT-OF-NETWORK FACILITY-BASED PROVIDER
841- PAYMENTS. (a) In this section, "facility-based provider" means a
842- physician or health care provider who provides health care or
843- medical services to patients of a health care facility.
844- (b) Except as provided by Subsection (d), the administrator
845- of a managed care plan provided under this chapter shall pay for a
846- covered health care or medical service performed for or a covered
847- supply related to that service provided to an enrollee by an
848- out-of-network provider who is a facility-based provider at the
849- usual and customary rate or at an agreed rate if the provider
850- performed the service at a health care facility that is a
851- participating provider. The administrator shall make a payment
852- required by this subsection directly to the provider not later
853- than, as applicable:
854- (1) the 30th day after the date the administrator
855- receives an electronic claim for those services that includes all
856- information necessary for the administrator to pay the claim; or
857- (2) the 45th day after the date the administrator
858- receives a nonelectronic claim for those services that includes all
859- information necessary for the administrator to pay the claim.
860- (c) Except as provided by Subsection (d), an out-of-network
861- provider who is a facility-based provider or a person asserting a
862- claim as an agent or assignee of the provider may not bill an
863- enrollee receiving a health care or medical service or supply
864- described by Subsection (b) in, and the enrollee does not have
865- financial responsibility for, an amount greater than an applicable
866- copayment, coinsurance, and deductible under the enrollee's
867- managed care plan that:
868- (1) is based on:
869- (A) the amount initially determined payable by
870- the administrator; or
871- (B) if applicable, a modified amount as
872- determined under the administrator's internal appeal process; and
873- (2) is not based on any additional amount determined
874- to be owed to the provider under Chapter 1467.
875- (d) This section does not apply to a nonemergency health
876- care or medical service:
877- (1) that an enrollee elects to receive in writing in
878- advance of the service with respect to each out-of-network provider
879- providing the service; and
880- (2) for which an out-of-network provider, before
881- providing the service, provides a complete written disclosure to
882- the enrollee that:
883- (A) explains that the provider does not have a
884- contract with the enrollee's managed care plan;
885- (B) discloses projected amounts for which the
886- enrollee may be responsible; and
887- (C) discloses the circumstances under which the
888- enrollee would be responsible for those amounts.
889- Sec. 1579.111. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
890- OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section,
891- "diagnostic imaging provider" and "laboratory service provider"
892- have the meanings assigned by Section 1467.001.
893- (b) Except as provided by Subsection (d), the administrator
894- of a managed care plan provided under this chapter shall pay for a
895- covered health care or medical service performed for or a covered
896- supply related to that service provided to an enrollee by an
897- out-of-network provider who is a diagnostic imaging provider or
898- laboratory service provider at the usual and customary rate or at an
899- agreed rate if the provider performed the service in connection
900- with a health care or medical service performed by a participating
901- provider. The administrator shall make a payment required by this
902- subsection directly to the provider not later than, as applicable:
903- (1) the 30th day after the date the administrator
904- receives an electronic claim for those services that includes all
905- information necessary for the administrator to pay the claim; or
906- (2) the 45th day after the date the administrator
907- receives a nonelectronic claim for those services that includes all
908- information necessary for the administrator to pay the claim.
909- (c) Except as provided by Subsection (d), an out-of-network
910- provider who is a diagnostic imaging provider or laboratory service
911- provider or a person asserting a claim as an agent or assignee of
912- the provider may not bill an enrollee receiving a health care or
913- medical service or supply described by Subsection (b) in, and the
914- enrollee does not have financial responsibility for, an amount
915- greater than an applicable copayment, coinsurance, and deductible
916- under the enrollee's managed care plan that:
917- (1) is based on:
918- (A) the amount initially determined payable by
919- the administrator; or
920- (B) if applicable, a modified amount as
921- determined under the administrator's internal appeal process; and
922- (2) is not based on any additional amount determined
923- to be owed to the provider under Chapter 1467.
924- (d) This section does not apply to a nonemergency health
925- care or medical service:
926- (1) that an enrollee elects to receive in writing in
927- advance of the service with respect to each out-of-network provider
928- providing the service; and
929- (2) for which an out-of-network provider, before
930- providing the service, provides a complete written disclosure to
931- the enrollee that:
932- (A) explains that the provider does not have a
933- contract with the enrollee's managed care plan;
934- (B) discloses projected amounts for which the
935- enrollee may be responsible; and
936- (C) discloses the circumstances under which the
937- enrollee would be responsible for those amounts.
138+ SUBCHAPTER D. ENFORCEMENT
139+ Sec. 1466.0151. INJUNCTION RELATED TO BALANCE BILLING
140+ VIOLATION. (a) If the attorney general receives a referral from
141+ the appropriate regulatory agency indicating that an individual or
142+ entity, including a health benefit plan issuer or administrator,
143+ has exhibited a pattern of intentionally violating Subchapter C,
144+ the attorney general may bring a civil action in the name of the
145+ state to enjoin the individual or entity from the violation.
146+ (b) If the attorney general prevails in an action brought
147+ under Subsection (a), the attorney general may recover reasonable
148+ attorney's fees, costs, and expenses, including court costs and
149+ witness fees, incurred in bringing the action.
150+ Sec. 1466.0152. ENFORCEMENT BY REGULATORY AGENCY. (a) An
151+ appropriate regulatory agency that licenses, certifies, or
152+ otherwise authorizes a physician, health care practitioner, health
153+ care facility, or other health care provider to practice or operate
154+ in this state shall take disciplinary action against the physician,
155+ practitioner, facility, or provider if the physician,
156+ practitioner, facility, or provider violates Section 1466.0102.
157+ (b) A regulatory agency described by Subsection (a) may
158+ adopt rules as necessary to implement this section. Section
159+ 2001.0045, Government Code, does not apply to rules adopted under
160+ this subsection.
938161 ARTICLE 2. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
939162 SECTION 2.01. Section 1467.001, Insurance Code, is amended
940163 by adding Subdivisions (1-a), (2-c), (2-d), (4-b), and (6-a) and
941164 amending Subdivisions (2-a), (2-b), (3), (5), and (7) to read as
942165 follows:
943166 (1-a) "Arbitration" means a process in which an
944167 impartial arbiter issues a binding determination in a dispute
945168 between a health benefit plan issuer or administrator and an
946169 out-of-network provider or the provider's representative to settle
947170 a health benefit claim.
948171 (2-a) "Diagnostic imaging provider" means a health
949172 care provider who performs a diagnostic imaging service on a
950173 patient for a fee or interprets imaging produced by a diagnostic
951174 imaging service.
952175 (2-b) "Diagnostic imaging service" means magnetic
953176 resonance imaging, computed tomography, positron emission
954177 tomography, or any hybrid technology that combines any of those
955178 imaging modalities.
956179 (2-c) "Emergency care" has the meaning assigned by
957180 Section 1301.155.
958181 (2-d) [(2-b)] "Emergency care provider" means a
959182 physician, health care practitioner, facility, or other health care
960183 provider who provides and bills an enrollee, administrator, or
961184 health benefit plan for emergency care.
962185 (3) "Enrollee" means an individual who is eligible to
963186 receive benefits through a [preferred provider benefit plan or a]
964187 health benefit plan subject to this chapter [under Chapter 1551,
965188 1575, or 1579].
966189 (4-b) "Laboratory service provider" means an
967190 accredited facility in which a specimen taken from a human body is
968- interpreted and pathological diagnoses are made or a physician who
191+ interpreted and pathological diagnoses are made or a person who
969192 makes an interpretation of or diagnosis based on a specimen or
970193 information provided by a laboratory based on a specimen.
971194 (5) "Mediation" means a process in which an impartial
972195 mediator facilitates and promotes agreement between the health
973196 [insurer offering a preferred provider] benefit plan issuer or the
974197 administrator and an out-of-network [a facility-based] provider
975198 [or emergency care provider] or the provider's representative to
976199 settle a health benefit claim of an enrollee.
977200 (6-a) "Out-of-network provider" means a diagnostic
978201 imaging provider, emergency care provider, facility-based
979202 provider, or laboratory service provider that is not a
980203 participating provider for a health benefit plan.
981204 (7) "Party" means a health benefit plan issuer [an
982205 insurer] offering a health [a preferred provider] benefit plan, an
983206 administrator, or an out-of-network [a facility-based provider or
984207 emergency care] provider or the provider's representative who
985208 participates in a mediation or arbitration conducted under this
986209 chapter. [The enrollee is also considered a party to the
987210 mediation.]
988211 SECTION 2.02. Sections 1467.002, 1467.003, and 1467.005,
989212 Insurance Code, are amended to read as follows:
990213 Sec. 1467.002. APPLICABILITY OF CHAPTER. This chapter
991214 applies to:
992215 (1) a health benefit plan offered by a health
993216 maintenance organization operating under Chapter 843;
994217 (2) a preferred provider benefit plan, including an
995218 exclusive provider benefit plan, offered by an insurer under
996219 Chapter 1301; and
997220 (3) [(2)] an administrator of a health benefit plan,
998221 other than a health maintenance organization plan, under Chapter
999222 1551, 1575, or 1579.
1000223 Sec. 1467.003. RULES. (a) The commissioner, the Texas
1001224 Medical Board, and any other appropriate regulatory agency[, and
1002225 the chief administrative law judge] shall adopt rules as necessary
1003226 to implement their respective powers and duties under this chapter.
1004227 (b) Section 2001.0045, Government Code, does not apply to a
1005228 rule adopted under this chapter.
1006229 Sec. 1467.005. REFORM. This chapter may not be construed to
1007230 prohibit:
1008231 (1) a health [an insurer offering a preferred
1009232 provider] benefit plan issuer or administrator from, at any time,
1010233 offering a reformed claim settlement; or
1011234 (2) an out-of-network [a facility-based provider or
1012235 emergency care] provider from, at any time, offering a reformed
1013236 charge for health care or medical services or supplies.
1014237 SECTION 2.03. Subchapter A, Chapter 1467, Insurance Code,
1015238 is amended by adding Section 1467.006 to read as follows:
1016- Sec. 1467.006. BENCHMARKING DATABASE. (a) In this
1017- section, "geozip area" means an area that includes all zip codes
1018- with identical first three digits. For purposes of this section, a
1019- health care or medical service or supply provided at a location that
1020- does not have a zip code is considered to be provided in the geozip
1021- area closest to the location at which the service or supply is
1022- provided.
1023- (b) The commissioner shall select an organization to
1024- maintain a benchmarking database in accordance with this section.
1025- The organization may not:
1026- (1) be affiliated with a health benefit plan issuer or
1027- administrator or a physician, health care practitioner, or other
1028- health care provider; or
1029- (2) have any other conflict of interest.
1030- (c) The benchmarking database must contain information
1031- necessary to calculate, with respect to a health care or medical
1032- service or supply, for each geozip area in this state:
239+ Sec. 1467.006. BENCHMARKING DATABASE. (a) The
240+ commissioner shall select an organization to maintain a
241+ benchmarking database that contains information necessary to
242+ calculate, with respect to a health care or medical service or
243+ supply, for each geographical area in this state:
1033244 (1) the 80th percentile of billed charges of all
1034245 physicians or health care providers who are not facilities; and
1035246 (2) the 50th percentile of rates paid to participating
1036247 providers who are not facilities.
1037- (d) The commissioner may adopt rules governing the
1038- submission of information for the benchmarking database described
1039- by Subsection (c).
248+ (b) The commissioner may not select under Subsection (a) an
249+ organization that is financially affiliated with a health benefit
250+ plan issuer.
1040251 SECTION 2.04. The heading to Subchapter B, Chapter 1467,
1041252 Insurance Code, is amended to read as follows:
1042253 SUBCHAPTER B. MANDATORY MEDIATION FOR OUT-OF-NETWORK FACILITIES
1043254 SECTION 2.05. Subchapter B, Chapter 1467, Insurance Code,
1044255 is amended by adding Sections 1467.050 and 1467.0505 to read as
1045256 follows:
1046- Sec. 1467.050. APPLICABILITY OF SUBCHAPTER. (a) This
257+ Sec. 1467.050. APPLICABILITY OF SUBCHAPTER. This
1047258 subchapter applies only with respect to a health benefit claim
1048259 submitted by an out-of-network provider that is a facility.
1049- (b) This subchapter does not apply to a health benefit claim
1050- for the professional or technical component of a physician service.
1051260 Sec. 1467.0505. ESTABLISHMENT AND ADMINISTRATION OF
1052261 MEDIATION PROGRAM. (a) The commissioner shall establish and
1053262 administer a mediation program to resolve disputes over
1054263 out-of-network provider charges in accordance with this
1055264 subchapter.
1056265 (b) The commissioner:
1057266 (1) shall adopt rules, forms, and procedures necessary
1058267 for the implementation and administration of the mediation program,
1059268 including the establishment of a portal on the department's
1060269 Internet website through which a request for mediation under
1061270 Section 1467.051 may be submitted; and
1062271 (2) shall maintain a list of qualified mediators for
1063272 the program.
1064273 SECTION 2.06. The heading to Section 1467.051, Insurance
1065274 Code, is amended to read as follows:
1066275 Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION[;
1067276 EXCEPTION].
1068277 SECTION 2.07. Sections 1467.051(a) and (b), Insurance Code,
1069278 are amended to read as follows:
1070- (a) An out-of-network provider or a health benefit plan
1071- issuer or administrator [An enrollee] may request mediation of a
279+ (a) An out-of-network provider, health benefit plan issuer,
280+ or administrator [An enrollee] may request mediation of a
1072281 settlement of an out-of-network health benefit claim through a
1073282 portal on the department's Internet website if:
1074283 (1) there is an [the] amount billed by the provider and
1075284 unpaid by the issuer or administrator [for which the enrollee is
1076285 responsible to a facility-based provider or emergency care
1077286 provider,] after copayments, deductibles, and coinsurance for
1078287 which an enrollee may not be billed [, including the amount unpaid
1079288 by the administrator or insurer, is greater than $500]; and
1080289 (2) the health benefit claim is for:
1081290 (A) emergency care; [or]
1082291 (B) an out-of-network laboratory service; or
1083292 (C) an out-of-network diagnostic imaging service
1084293 [a health care or medical service or supply provided by a
1085294 facility-based provider in a facility that is a preferred provider
1086295 or that has a contract with the administrator].
1087296 (b) If a person [Except as provided by Subsections (c) and
1088297 (d), if an enrollee] requests mediation under this subchapter, the
1089298 out-of-network [facility-based] provider [or emergency care
1090299 provider,] or the provider's representative, and the health benefit
1091300 plan issuer [insurer] or the administrator, as appropriate, shall
1092301 participate in the mediation.
1093302 SECTION 2.08. Section 1467.052, Insurance Code, is amended
1094303 by amending Subsections (a) and (c) and adding Subsection (d) to
1095304 read as follows:
1096305 (a) Except as provided by Subsection (b), to qualify for an
1097306 appointment as a mediator under this subchapter [chapter] a person
1098307 must have completed at least 40 classroom hours of training in
1099308 dispute resolution techniques in a course conducted by an
1100309 alternative dispute resolution organization or other dispute
1101310 resolution organization approved by the commissioner [chief
1102311 administrative law judge].
1103312 (c) A person may not act as mediator for a claim settlement
1104313 dispute if the person has been employed by, consulted for, or
1105314 otherwise had a business relationship with a health [an insurer
1106315 offering the preferred provider] benefit plan issuer or
1107- administrator or a physician, health care practitioner, or other
1108- health care provider during the three years immediately preceding
1109- the request for mediation.
316+ administrator or a facility [physician, health care practitioner,
317+ or other health care provider] during the three years immediately
318+ preceding the request for mediation.
1110319 (d) The commissioner shall immediately terminate the
1111320 approval of a mediator who no longer meets the requirements under
1112321 this subchapter and rules adopted under this subchapter to serve as
1113322 a mediator.
1114323 SECTION 2.09. Section 1467.053, Insurance Code, is amended
1115324 by adding Subsection (b-1) and amending Subsection (d) to read as
1116325 follows:
1117326 (b-1) If the parties do not select a mediator by mutual
1118327 agreement on or before the 30th day after the date the mediation is
1119328 requested, the party requesting the mediation shall notify the
1120329 commissioner, and the commissioner shall select a mediator from the
1121330 commissioner's list of approved mediators.
1122331 (d) The mediator's fees shall be split evenly and paid by
1123332 the health benefit plan issuer [insurer] or administrator and the
1124333 out-of-network [facility-based provider or emergency care]
1125334 provider.
1126335 SECTION 2.10. Section 1467.054, Insurance Code, is amended
1127336 by amending Subsections (a) and (d) and adding Subsection (b-1) to
1128337 read as follows:
1129- (a) An out-of-network provider or a health benefit plan
1130- issuer or administrator [enrollee] may request mandatory mediation
1131- under this subchapter [chapter].
338+ (a) An out-of-network provider, health benefit plan issuer,
339+ or administrator [enrollee] may request mandatory mediation under
340+ this subchapter [chapter].
1132341 (b-1) The person who requests the mediation shall provide
1133342 written notice on the date the mediation is requested in the form
1134343 and manner provided by commissioner rule to:
1135344 (1) the department; and
1136345 (2) each other party.
1137346 (d) In an effort to settle the claim before mediation, all
1138347 parties must participate in an informal settlement teleconference
1139348 not later than the 30th day after the date on which a person [the
1140349 enrollee] submits a request for mediation under this subchapter
1141350 [section].
1142- SECTION 2.11. Section 1467.055, Insurance Code, is amended
1143- by adding Subsections (c-1) and (k) and amending Subsections (g)
1144- and (i) to read as follows:
1145- (c-1) Information submitted by the parties to the mediator
1146- is confidential and not subject to disclosure under Chapter 552,
1147- Government Code.
351+ SECTION 2.11. Sections 1467.055(g) and (i), Insurance Code,
352+ are amended to read as follows:
1148353 (g) A [Except at the request of an enrollee, a] mediation
1149354 shall be held not later than the 180th day after the date of the
1150355 request for mediation.
1151356 (i) A health care or medical service or supply provided by
1152357 an out-of-network [a facility-based] provider [or emergency care
1153- provider] may not be summarily disallowed. This subsection does
1154- not require a health benefit plan issuer [an insurer] or
1155- administrator to pay for an uncovered service or supply.
1156- (k) On agreement of all parties, any deadline under this
1157- subchapter may be extended.
358+ provider] may not be summarily disallowed. This subsection does not
359+ require a health benefit plan issuer [an insurer] or administrator
360+ to pay for an uncovered service or supply.
1158361 SECTION 2.12. Sections 1467.056(a), (b), and (d), Insurance
1159362 Code, are amended to read as follows:
1160363 (a) In a mediation under this subchapter [chapter], the
1161364 parties shall[:
1162365 [(1)] evaluate whether:
1163366 (1) [(A)] the amount charged by the out-of-network
1164367 [facility-based] provider [or emergency care provider] for the
1165368 health care or medical service or supply is excessive; and
1166369 (2) [(B)] the amount paid by the health benefit plan
1167370 issuer [insurer] or administrator represents the usual and
1168371 customary rate for the health care or medical service or supply or
1169372 is unreasonably low[; and
1170373 [(2) as a result of the amounts described by
1171374 Subdivision (1), determine the amount, after copayments,
1172375 deductibles, and coinsurance are applied, for which an enrollee is
1173376 responsible to the facility-based provider or emergency care
1174377 provider].
1175378 (b) The out-of-network [facility-based] provider [or
1176379 emergency care provider] may present information regarding the
1177- amount charged for the health care or medical service or supply.
1178- The health benefit plan issuer [insurer] or administrator may
1179- present information regarding the amount paid by the issuer
1180- [insurer] or administrator.
380+ amount charged for the health care or medical service or supply. The
381+ health benefit plan issuer [insurer] or administrator may present
382+ information regarding the amount paid by the issuer [insurer] or
383+ administrator.
1181384 (d) The goal of the mediation is to reach an agreement
1182385 between [among the enrollee,] the out-of-network [facility-based]
1183386 provider [or emergency care provider,] and the health benefit plan
1184387 issuer [insurer] or administrator, as applicable, as to the amount
1185388 paid by the issuer [insurer] or administrator to the out-of-network
1186389 [facility-based] provider and [or emergency care provider,] the
1187390 amount charged by the out-of-network [facility-based] provider [or
1188391 emergency care provider, and the amount paid to the facility-based
1189392 provider or emergency care provider by the enrollee].
1190393 SECTION 2.13. Subchapter B, Chapter 1467, Insurance Code,
1191394 is amended by adding Section 1467.0575 to read as follows:
1192- Sec. 1467.0575. RIGHT TO FILE ACTION. Not later than the
1193- 45th day after the date that the mediator's report is provided to
1194- the department under Section 1467.060, either party to a mediation
1195- for which there was no agreement may file a civil action to
1196- determine the amount due to an out-of-network provider. A party may
1197- not bring a civil action before the conclusion of the mediation
1198- process under this subchapter.
395+ Sec. 1467.0575. RIGHT TO RECEIVE PAYMENT; RIGHT TO FILE
396+ ACTION. (a) An out-of-network provider has a right to a reasonable
397+ payment from an enrollee's health benefit plan for covered services
398+ and supplies provided to the enrollee that are subject to this
399+ subchapter and for which the provider has not been fully
400+ reimbursed.
401+ (b) Not later than the 45th day after the date that the
402+ mediator's report is provided to the department under Section
403+ 1467.060, either party to a mediation for which there was no
404+ agreement may file a civil action to determine the amount due to an
405+ out-of-network provider. A party may not bring a civil action
406+ before the conclusion of the mediation process under this
407+ subchapter.
1199408 SECTION 2.14. Section 1467.060, Insurance Code, is amended
1200409 to read as follows:
1201410 Sec. 1467.060. REPORT OF MEDIATOR. Not later than the 45th
1202411 day after the date the mediation concludes, the [The] mediator
1203412 shall report to the commissioner and the Texas Medical Board or
1204413 other appropriate regulatory agency:
1205414 (1) the names of the parties to the mediation; and
1206415 (2) whether the parties reached an agreement [or the
1207416 mediator made a referral under Section 1467.057].
1208417 SECTION 2.15. Chapter 1467, Insurance Code, is amended by
1209418 adding Subchapter B-1 to read as follows:
1210419 SUBCHAPTER B-1. MANDATORY BINDING ARBITRATION FOR OTHER PROVIDERS
1211420 Sec. 1467.081. APPLICABILITY OF SUBCHAPTER. This
1212421 subchapter applies only with respect to a health benefit claim
1213422 submitted by an out-of-network provider who is not a facility.
1214423 Sec. 1467.082. ESTABLISHMENT AND ADMINISTRATION OF
1215424 ARBITRATION PROGRAM. (a) The commissioner shall establish and
1216425 administer an arbitration program to resolve disputes over
1217426 out-of-network provider charges in accordance with this
1218427 subchapter.
1219428 (b) The commissioner:
1220429 (1) shall adopt rules, forms, and procedures necessary
1221430 for the implementation and administration of the arbitration
1222431 program, including the establishment of a portal on the
1223432 department's Internet website through which a request for
1224433 arbitration under Section 1467.084 may be submitted; and
1225434 (2) shall maintain a list of qualified arbitrators for
1226435 the program.
1227436 Sec. 1467.083. ISSUE TO BE ADDRESSED; BASIS FOR
1228437 DETERMINATION. (a) The only issue that an arbitrator may
1229438 determine under this subchapter is the reasonable amount for the
1230439 health care or medical services or supplies provided to the
1231440 enrollee by an out-of-network provider.
1232441 (b) The determination must take into account:
1233442 (1) whether there is a gross disparity between the fee
1234443 billed by the out-of-network provider and:
1235444 (A) fees paid to the out-of-network provider for
1236445 the same services or supplies rendered by the provider to other
1237446 enrollees for which the provider is an out-of-network provider; and
1238447 (B) fees paid by the health benefit plan issuer
1239448 to reimburse similarly qualified out-of-network providers for the
1240449 same services or supplies in the same region;
1241450 (2) the level of training, education, and experience
1242451 of the out-of-network provider;
1243452 (3) the out-of-network provider's usual billed charge
1244453 for comparable services or supplies with regard to other enrollees
1245454 for which the provider is an out-of-network provider;
1246455 (4) the circumstances and complexity of the enrollee's
1247456 particular case, including the time and place of the provision of
1248457 the service or supply;
1249458 (5) individual enrollee characteristics;
1250459 (6) the 80th percentile of all billed charges for the
1251460 service or supply performed by a health care provider in the same or
1252- similar specialty and provided in the same geozip area as reported
1253- in a benchmarking database described by Section 1467.006;
461+ similar specialty and provided in the same geographical area as
462+ reported in a benchmarking database described by Section 1467.006;
1254463 (7) the 50th percentile of rates for the service or
1255464 supply paid to participating providers in the same or similar
1256- specialty and provided in the same geozip area as reported in a
1257- benchmarking database described by Section 1467.006;
1258- (8) the history of network contracting between the
1259- parties;
465+ specialty and provided in the same geographical area as reported in
466+ a benchmarking database described by Section 1467.006;
467+ (8) historical rates paid to participating providers;
468+ and
1260469 (9) historical data for the percentiles described by
1261- Subdivisions (6) and (7); and
1262- (10) an offer made during the informal settlement
1263- teleconference required under Section 1467.084(d).
1264- Sec. 1467.084. AVAILABILITY OF MANDATORY ARBITRATION.
1265- (a) Not later than the 90th day after the date an out-of-network
470+ Subdivisions (6) and (7).
471+ Sec. 1467.084. AVAILABILITY OF MANDATORY ARBITRATION. (a)
472+ Not later than the 90th day after the date an out-of-network
1266473 provider receives the initial payment for a health care or medical
1267474 service or supply, the out-of-network provider or the health
1268475 benefit plan issuer or administrator may request arbitration of a
1269476 settlement of an out-of-network health benefit claim through a
1270477 portal on the department's Internet website if:
1271478 (1) there is a charge billed by the provider and unpaid
1272- by the issuer or administrator after copayments, coinsurance, and
1273- deductibles for which an enrollee may not be billed; and
479+ by the issuer or administrator after copayments, deductibles, and
480+ coinsurance for which an enrollee may not be billed; and
1274481 (2) the health benefit claim is for:
1275482 (A) emergency care;
1276483 (B) a health care or medical service or supply
1277484 provided by a facility-based provider in a facility that is a
1278485 participating provider;
1279486 (C) an out-of-network laboratory service; or
1280487 (D) an out-of-network diagnostic imaging
1281488 service.
1282489 (b) If a person requests arbitration under this subchapter,
1283490 the out-of-network provider or the provider's representative, and
1284491 the health benefit plan issuer or the administrator, as
1285492 appropriate, shall participate in the arbitration.
1286493 (c) The person who requests the arbitration shall provide
1287494 written notice on the date the arbitration is requested in the form
1288495 and manner prescribed by commissioner rule to:
1289496 (1) the department; and
1290497 (2) each other party.
1291498 (d) In an effort to settle the claim before arbitration, all
1292499 parties must participate in an informal settlement teleconference
1293500 not later than the 30th day after the date on which the arbitration
1294501 is requested. A health benefit plan issuer or administrator, as
1295502 applicable, shall make a reasonable effort to arrange the
1296503 teleconference.
1297504 (e) The commissioner shall adopt rules providing
1298- requirements for submitting multiple claims to arbitration in one
1299- proceeding. The rules must provide that:
1300- (1) the total amount in controversy for multiple
1301- claims in one proceeding may not exceed $5,000; and
1302- (2) the multiple claims in one proceeding must be
505+ requirements for submitting arbitration in one proceeding. The
506+ rules must provide that:
507+ (1) a claim for a billed charge of $1,500 or more may
508+ not be combined with another claim;
509+ (2) the total amount in controversy for multiple
510+ claims in one arbitration may not exceed $5,000; and
511+ (3) the multiple claims in one arbitration must be
1303512 limited to the same out-of-network provider.
1304513 Sec. 1467.085. EFFECT OF ARBITRATION AND APPLICABILITY OF
1305514 OTHER LAW. (a) Notwithstanding Section 1467.004, an
1306- out-of-network provider or health benefit plan issuer or
515+ out-of-network provider, health benefit plan issuer, or
1307516 administrator may not file suit for an out-of-network claim subject
1308517 to this chapter until the conclusion of the arbitration on the issue
1309518 of the amount to be paid in the out-of-network claim dispute.
1310519 (b) An arbitration conducted under this subchapter is not
1311520 subject to Title 7, Civil Practice and Remedies Code.
1312521 Sec. 1467.086. SELECTION AND APPROVAL OF ARBITRATOR.
1313522 (a) If the parties do not select an arbitrator by mutual agreement
1314523 on or before the 30th day after the date the arbitration is
1315524 requested, the party requesting the arbitration shall notify the
1316525 commissioner, and the commissioner shall select an arbitrator from
1317526 the commissioner's list of approved arbitrators.
1318527 (b) In selecting an arbitrator under this section, the
1319528 commissioner shall give preference to an arbitrator who is
1320529 knowledgeable and experienced in applicable principles of contract
1321530 and insurance law and the health care industry generally.
1322531 (c) In approving an individual as an arbitrator, the
1323532 commissioner shall ensure that the individual does not have a
1324533 conflict of interest that would adversely impact the individual's
1325534 independence and impartiality in rendering a decision in an
1326535 arbitration. A conflict of interest includes current or recent
1327536 ownership or employment of the individual or a close family member
1328- in any health benefit plan issuer or administrator or physician,
1329- health care practitioner, or other health care provider.
537+ in a health benefit plan issuer or out-of-network provider that may
538+ be involved in the arbitration.
1330539 (d) The commissioner shall immediately terminate the
1331540 approval of an arbitrator who no longer meets the requirements
1332541 under this subchapter and rules adopted under this subchapter to
1333542 serve as an arbitrator.
1334543 Sec. 1467.087. PROCEDURES. (a) The arbitrator shall set a
1335544 date for submission of all information to be considered by the
1336545 arbitrator.
1337546 (b) A party may not engage in discovery in connection with
1338547 the arbitration.
1339548 (c) On agreement of all parties, any deadline under this
1340549 subchapter may be extended.
1341550 (d) Unless otherwise agreed to by the parties, an arbitrator
1342551 may not determine whether a health benefit plan covers a particular
1343552 health care or medical service or supply.
1344553 (e) The parties shall evenly split and pay the arbitrator's
1345554 fees and expenses.
1346- (f) Information submitted by the parties to the arbitrator
1347- is confidential and not subject to disclosure under Chapter 552,
1348- Government Code.
1349- Sec. 1467.088. DECISION. (a) Not later than the 51st day
555+ Sec. 1467.088. DECISION. (a) Not later than the 75th day
1350556 after the date the arbitration is requested, an arbitrator shall
1351557 provide the parties with a written decision in which the
1352558 arbitrator:
1353559 (1) determines whether the billed charge or the
1354- payment made by the health benefit plan issuer or administrator, as
1355- those amounts were last modified during the issuer's or
1356- administrator's internal appeal process, if the provider elects to
1357- participate, or the informal settlement teleconference required by
1358- Section 1467.084(d), as applicable, is the closest to the
1359- reasonable amount for the services or supplies determined in
1360- accordance with Section 1467.083(b); and
1361- (2) selects the amount determined to be closest under
1362- Subdivision (1) as the binding award amount.
560+ initial payment made by the health benefit plan issuer or
561+ administrator is the closest to the reasonable amount for the
562+ services or supplies determined in accordance with Section
563+ 1467.083(b), provided that if the out-of-network provider elects to
564+ participate in the issuer's or administrator's internal appeal
565+ process before arbitration:
566+ (A) the provider may revise the billed charge to
567+ correct a billing error before the completion of the appeal
568+ process; and
569+ (B) the health benefit plan issuer or
570+ administrator may increase the initial payment under the appeal
571+ process; and
572+ (2) selects the billed charge or initial payment
573+ described by Subdivision (1) as the binding award amount.
1363574 (b) An arbitrator may not modify the binding award amount
1364575 selected under Subsection (a).
1365576 (c) An arbitrator shall provide written notice in the form
1366577 and manner prescribed by commissioner rule of the reasonable amount
1367578 for the services or supplies and the binding award amount. If the
1368579 parties settle before a decision, the parties shall provide written
1369580 notice in the form and manner prescribed by commissioner rule of the
1370581 amount of the settlement. The department shall maintain a record of
1371582 notices provided under this subsection.
1372583 Sec. 1467.089. EFFECT OF DECISION. (a) An arbitrator's
1373584 decision under Section 1467.088 is binding.
1374585 (b) Not later than the 45th day after the date of an
1375586 arbitrator's decision under Section 1467.088, a party not satisfied
1376587 with the decision may file an action to determine the payment due to
1377588 an out-of-network provider.
1378589 (c) In an action filed under Subsection (b), the court shall
1379590 determine whether the arbitrator's decision is proper based on a
1380591 substantial evidence standard of review.
1381- (d) Not later than the 30th day after the date of an
1382- arbitrator's decision under Section 1467.088, a health benefit plan
1383- issuer or administrator shall pay to an out-of-network provider any
1384- additional amount necessary to satisfy the binding award.
592+ (d) Not later than the 10th day after the date of an
593+ arbitrator's decision under Section 1467.088 or a court's
594+ determination in an action filed under Subsection (b), a health
595+ benefit plan issuer or administrator shall pay to an out-of-network
596+ provider any additional amount necessary to satisfy the binding
597+ award or the court's determination, as applicable.
1385598 SECTION 2.16. Subchapter C, Chapter 1467, Insurance Code,
1386599 is amended to read as follows:
1387600 SUBCHAPTER C. BAD FAITH PARTICIPATION [MEDIATION]
1388601 Sec. 1467.101. BAD FAITH. (a) The following conduct
1389602 constitutes bad faith participation [mediation] for purposes of
1390603 this chapter:
1391604 (1) failing to participate in the informal settlement
1392605 teleconference under Section 1467.084(d) or an arbitration or
1393606 mediation under this chapter;
1394607 (2) failing to provide information the arbitrator or
1395608 mediator believes is necessary to facilitate a decision or [an]
1396609 agreement; or
1397610 (3) failing to designate a representative
1398611 participating in the arbitration or mediation with full authority
1399612 to enter into any [mediated] agreement.
1400613 (b) Failure to reach an agreement under Subchapter B is not
1401614 conclusive proof of bad faith participation [mediation].
1402615 Sec. 1467.102. PENALTIES. (a) Bad faith participation or
1403616 otherwise failing to comply with Subchapter B-1 [mediation, by a
1404617 party other than the enrollee,] is grounds for imposition of an
1405618 administrative penalty by the regulatory agency that issued a
1406619 license or certificate of authority to the party who committed the
1407620 violation.
1408621 (b) Except for good cause shown, on a report of a mediator
1409622 and appropriate proof of bad faith participation under Subchapter B
1410623 [mediation], the regulatory agency that issued the license or
1411624 certificate of authority shall impose an administrative penalty.
1412625 SECTION 2.17. Sections 1467.151(a), (b), and (c), Insurance
1413626 Code, are amended to read as follows:
1414627 (a) The commissioner and the Texas Medical Board or other
1415628 regulatory agency, as appropriate, shall adopt rules regulating the
1416629 investigation and review of a complaint filed that relates to the
1417630 settlement of an out-of-network health benefit claim that is
1418631 subject to this chapter. The rules adopted under this section must:
1419632 (1) distinguish among complaints for out-of-network
1420633 coverage or payment and give priority to investigating allegations
1421634 of delayed health care or medical care;
1422635 (2) develop a form for filing a complaint [and
1423636 establish an outreach effort to inform enrollees of the
1424637 availability of the claims dispute resolution process under this
1425638 chapter]; and
1426639 (3) ensure that a complaint is not dismissed without
1427640 appropriate consideration[;
1428641 [(4) ensure that enrollees are informed of the
1429642 availability of mandatory mediation; and
1430643 [(5) require the administrator to include a notice of
1431644 the claims dispute resolution process available under this chapter
1432645 with the explanation of benefits sent to an enrollee].
1433646 (b) The department and the Texas Medical Board or other
1434647 appropriate regulatory agency shall maintain information[:
1435648 [(1)] on each complaint filed that concerns a claim,
1436649 arbitration, or mediation subject to this chapter[; and
1437650 [(2) related to a claim that is the basis of an
1438651 enrollee complaint], including:
1439652 (1) [(A)] the type of services or supplies that gave
1440653 rise to the dispute;
1441654 (2) [(B)] the type and specialty, if any, of the
1442655 out-of-network [facility-based] provider [or emergency care
1443656 provider] who provided the out-of-network service or supply;
1444657 (3) [(C)] the county and metropolitan area in which
1445658 the health care or medical service or supply was provided;
1446659 (4) [(D)] whether the health care or medical service
1447660 or supply was for emergency care; and
1448661 (5) [(E)] any other information about:
1449662 (A) [(i)] the health benefit plan issuer
1450663 [insurer] or administrator that the commissioner by rule requires;
1451664 or
1452665 (B) [(ii)] the out-of-network [facility-based]
1453666 provider [or emergency care provider] that the Texas Medical Board
1454667 or other appropriate regulatory agency by rule requires.
1455668 (c) The information collected and maintained [by the
1456669 department and the Texas Medical Board and other appropriate
1457670 regulatory agencies] under Subsection (b) [(b)(2)] is public
1458671 information as defined by Section 552.002, Government Code, and may
1459672 not include personally identifiable information or health care or
1460673 medical information.
1461674 ARTICLE 3. CONFORMING AMENDMENTS
1462- SECTION 3.01. Section 1456.003(a), Insurance Code, is
675+ SECTION 3.01. Section 1456.001(6), Insurance Code, is
1463676 amended to read as follows:
1464- (a) Each health benefit plan that provides health care
1465- through a provider network shall provide notice to its enrollees
1466- that:
1467- (1) a facility-based physician or other health care
1468- practitioner may not be included in the health benefit plan's
1469- provider network; and
1470- (2) a health care practitioner described by
1471- Subdivision (1) may balance bill the enrollee for amounts not paid
1472- by the health benefit plan unless the health care or medical service
1473- or supply provided to the enrollee is subject to a law prohibiting
1474- balance billing.
1475- SECTION 3.02. Section 1456.006, Insurance Code, is amended
1476- to read as follows:
1477- Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. The
1478- commissioner by rule may prescribe specific requirements for the
1479- disclosure required under Section 1456.003. The form of the
1480- disclosure must be substantially as follows:
1481- NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN
1482- PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE
1483- PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER
1484- PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE
1485- FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE
1486- NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR PAYMENT OF
1487- ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT
1488- PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN UNLESS BALANCE BILLING
1489- FOR THOSE SERVICES IS PROHIBITED."
677+ (6) "Provider network" means a health benefit plan
678+ under which health care services are provided to enrollees through
679+ contracts with health care providers and that requires those
680+ enrollees to use health care providers participating in the plan
681+ and procedures covered by the plan. [The term includes a network
682+ operated by:
683+ [(A) a health maintenance organization;
684+ [(B) a preferred provider benefit plan issuer; or
685+ [(C) another entity that issues a health benefit
686+ plan, including an insurance company.]
687+ SECTION 3.02. Sections 1456.002(a) and (c), Insurance Code,
688+ are amended to read as follows:
689+ (a) This chapter applies to any health benefit plan that:
690+ (1) provides benefits for medical or surgical expenses
691+ incurred as a result of a health condition, accident, or sickness,
692+ including an individual, group, blanket, or franchise insurance
693+ policy or insurance agreement, a group hospital service contract,
694+ or an individual or group evidence of coverage that is offered by:
695+ (A) an insurance company;
696+ (B) a group hospital service corporation
697+ operating under Chapter 842;
698+ (C) a fraternal benefit society operating under
699+ Chapter 885;
700+ (D) a stipulated premium company operating under
701+ Chapter 884;
702+ (E) [a health maintenance organization operating
703+ under Chapter 843;
704+ [(F)] a multiple employer welfare arrangement
705+ that holds a certificate of authority under Chapter 846;
706+ (F) [(G)] an approved nonprofit health
707+ corporation that holds a certificate of authority under Chapter
708+ 844; or
709+ (G) [(H)] an entity not authorized under this
710+ code or another insurance law of this state that contracts directly
711+ for health care services on a risk-sharing basis, including a
712+ capitation basis; or
713+ (2) provides health and accident coverage through a
714+ risk pool created under Chapter 172, Local Government Code,
715+ notwithstanding Section 172.014, Local Government Code, or any
716+ other law.
717+ (c) This chapter does not apply to:
718+ (1) Medicaid managed care programs operated under
719+ Chapter 533, Government Code;
720+ (2) Medicaid programs operated under Chapter 32, Human
721+ Resources Code; [or]
722+ (3) the state child health plan operated under Chapter
723+ 62 or 63, Health and Safety Code; or
724+ (4) a health benefit plan subject to Section
725+ 1466.0053.
1490726 SECTION 3.03. The following provisions of the Insurance
1491727 Code are repealed:
1492728 (1) Section 1456.004(c);
1493729 (2) Section 1467.001(2);
1494730 (3) Sections 1467.051(c) and (d);
1495731 (4) Section 1467.0511;
1496732 (5) Sections 1467.053(b) and (c);
1497733 (6) Sections 1467.054(b), (c), (f), and (g);
1498734 (7) Sections 1467.055(d) and (h);
1499735 (8) Section 1467.057;
1500736 (9) Section 1467.058;
1501737 (10) Section 1467.059; and
1502738 (11) Section 1467.151(d).
1503739 ARTICLE 4. STUDY
1504740 SECTION 4.01. Subchapter A, Chapter 38, Insurance Code, is
1505741 amended by adding Section 38.004 to read as follows:
1506742 Sec. 38.004. BALANCE BILLING PROHIBITION REPORT. (a) The
1507743 department shall, each biennium, conduct a study on the impacts of
1508744 S.B. No. 1264, Acts of the 86th Legislature, Regular Session, 2019,
1509745 on Texas consumers and health coverage in this state, including:
1510746 (1) trends in billed amounts for health care or
1511747 medical services or supplies, especially emergency services,
1512748 laboratory services, diagnostic imaging services, and
1513749 facility-based services;
1514750 (2) comparison of the total amount spent on
1515751 out-of-network emergency services, laboratory services, diagnostic
1516752 imaging services, and facility-based services by calendar year and
1517753 provider type or physician specialty;
1518754 (3) trends and changes in network participation by
1519755 providers of emergency services, laboratory services, diagnostic
1520756 imaging services, and facility-based services by provider type or
1521757 physician specialty, including whether any terminations were
1522758 initiated by a health benefit plan issuer, administrator, or
1523759 provider;
1524760 (4) trends and changes in the amounts paid to
1525761 participating providers;
1526762 (5) the number of complaints, completed
1527763 investigations, and disciplinary sanctions for billing by
1528764 providers of emergency services, laboratory services, diagnostic
1529765 imaging services, or facility-based services of enrollees for
1530766 amounts greater than the enrollee's responsibility under an
1531- applicable health benefit plan, including applicable copayments,
1532- coinsurance, and deductibles;
767+ applicable health benefit plan, including an applicable copayment,
768+ coinsurance, or deductible;
1533769 (6) trends in amounts paid to out-of-network
1534770 providers;
1535771 (7) trends in the usual and customary rate for health
1536772 care or medical services or supplies, especially emergency
1537773 services, laboratory services, diagnostic imaging services, and
1538774 facility-based services; and
1539775 (8) the effectiveness of the claim dispute resolution
1540776 process under Chapter 1467.
1541777 (b) In conducting the study described by Subsection (a), the
1542778 department shall collect settlement data and verdicts or
1543779 arbitration awards, as applicable, from parties to mediation or
1544780 arbitration under Chapter 1467.
1545- (c) The department may not publish a particular rate paid to
1546- a participating provider in the study described by Subsection (a),
1547- identifying information of a physician or health care provider, or
1548- non-aggregated study results. Information described by this
1549- subsection is confidential and not subject to disclosure under
1550- Chapter 552, Government Code.
1551- (d) The department:
781+ (c) The department:
1552782 (1) shall collect data quarterly from a health benefit
1553783 plan issuer or administrator subject to Chapter 1467 to conduct the
1554784 study required by this section; and
1555785 (2) may utilize any reliable external resource or
1556786 entity to acquire information reasonably necessary to prepare the
1557- report required by Subsection (e).
1558- (e) Not later than December 1 of each even-numbered year,
787+ report required by Subsection (d).
788+ (d) Not later than December 1 of each even-numbered year,
1559789 the department shall prepare and submit a written report on the
1560790 results of the study under this section, including the department's
1561791 findings, to the legislature.
1562792 ARTICLE 5. TRANSITION AND EFFECTIVE DATE
1563793 SECTION 5.01. The changes in law made by this Act apply only
1564794 to a health care or medical service or supply provided on or after
1565795 January 1, 2020. A health care or medical service or supply
1566796 provided before January 1, 2020, is governed by the law in effect
1567797 immediately before the effective date of this Act, and that law is
1568798 continued in effect for that purpose.
1569- SECTION 5.02. This Act takes effect September 1, 2019.
1570- ______________________________ ______________________________
1571- President of the Senate Speaker of the House
1572- I hereby certify that S.B. No. 1264 passed the Senate on
1573- April 16, 2019, by the following vote: Yeas 29, Nays 2; and that
1574- the Senate concurred in House amendments on May 24, 2019, by the
1575- following vote: Yeas 31, Nays 0.
1576- ______________________________
1577- Secretary of the Senate
1578- I hereby certify that S.B. No. 1264 passed the House, with
1579- amendments, on May 21, 2019, by the following vote: Yeas 146,
1580- Nays 0, one present not voting.
1581- ______________________________
1582- Chief Clerk of the House
1583- Approved:
1584- ______________________________
1585- Date
1586- ______________________________
1587- Governor
799+ SECTION 5.02. The Texas Department of Insurance, the
800+ Employees Retirement System of Texas, the Teacher Retirement System
801+ of Texas, and any other state agency subject to this Act are
802+ required to implement a provision of this Act only if the
803+ legislature appropriates money specifically for that purpose. If
804+ the legislature does not appropriate money specifically for that
805+ purpose, those agencies may, but are not required to, implement a
806+ provision of this Act using other appropriations available for that
807+ purpose.
808+ SECTION 5.03. This Act takes effect September 1, 2019.