Texas 2019 - 86th Regular

Texas Senate Bill SB1914 Compare Versions

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

Old	New	Differences
1	1	86R9268 SMT-D
2	2	By: Johnson S.B. No. 1914
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the mediation of the settlement of certain health
8	8	benefit claims involving balance billing by out-of-network
9	9	laboratories.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Section 1467.001, Insurance Code, is amended by
12	12	amending Subdivisions (4), (5), and (7) and adding Subdivisions
13	13	(4-b) and (4-c) to read as follows:
14	14	(4) "Facility-based provider" means a physician,
15	15	health care practitioner, or other health care provider who
16	16	provides health care [or medical] services to patients of a
17	17	facility.
18	18	(4-b) "Health care services" has the meaning assigned
19	19	by Section 562.002.
20	20	(4-c) "Laboratory" means an accredited facility in
21	21	which a specimen taken from a human body is interpreted and
22	22	pathological diagnoses are made.
23	23	(5) "Mediation" means a process in which an impartial
24	24	mediator facilitates and promotes agreement between the insurer
25	25	offering a preferred provider benefit plan or the administrator and
26	26	a laboratory, facility-based provider, or emergency care provider
27	27	or the laboratory's or provider's representative to settle a health
28	28	benefit claim of an enrollee.
29	29	(7) "Party" means an insurer offering a preferred
30	30	provider benefit plan, an administrator, or a laboratory,
31	31	facility-based provider, or emergency care provider or the
32	32	laboratory's or provider's representative who participates in a
33	33	mediation conducted under this chapter. The enrollee is also
34	34	considered a party to the mediation.
35	35	SECTION 2. Section 1467.005, Insurance Code, is amended to
36	36	read as follows:
37	37	Sec. 1467.005. REFORM. This chapter may not be construed
38	38	to prohibit:
39	39	(1) an insurer offering a preferred provider benefit
40	40	plan or administrator from, at any time, offering a reformed claim
41	41	settlement; or
42	42	(2) a laboratory, facility-based provider, or
43	43	emergency care provider from, at any time, offering a reformed
44	44	charge for health care [or medical] services [or supplies].
45	45	SECTION 3. Section 1467.051, Insurance Code, is amended to
46	46	read as follows:
47	47	Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION;
48	48	EXCEPTION. (a) An enrollee may request mediation of a settlement
49	49	of an out-of-network health benefit claim if:
50	50	(1) the amount for which the enrollee is responsible
51	51	to a laboratory, facility-based provider, or emergency care
52	52	provider, after copayments, deductibles, and coinsurance,
53	53	including the amount unpaid by the administrator or insurer, is
54	54	greater than $500; and
55	55	(2) the health benefit claim is for:
56	56	(A) emergency care; [or]
57	57	(B) a health care [or medical] service [or
58	58	supply] provided by a facility-based provider in a facility that is
59	59	a preferred provider or that has a contract with the administrator;
60	60	or
61	61	(C) a laboratory service, if:
62	62	(i) the specimen evaluated by the
63	63	laboratory is collected by an in-network physician, health care
64	64	practitioner, or health care provider;
65	65	(ii) the laboratory is an out-of-network
66	66	laboratory; and
67	67	(iii) the enrollee did not have a
68	68	reasonable opportunity to inquire about the laboratory's network
69	69	status.
70	70	(b) Except as provided by Subsections (c) and (d), if an
71	71	enrollee requests mediation under this subchapter, the laboratory,
72	72	facility-based provider, or emergency care provider, or the
73	73	laboratory's or provider's representative, and the insurer or the
74	74	administrator, as appropriate, shall participate in the mediation.
75	75	(c) Except in the case of an emergency and if requested by
76	76	the enrollee, a laboratory or facility-based provider shall, before
77	77	providing a health care [or medical] service [or supply], provide a
78	78	complete disclosure to an enrollee that:
79	79	(1) explains that the laboratory or facility-based
80	80	provider does not have a contract with the enrollee's health
81	81	benefit plan;
82	82	(2) discloses projected amounts for which the enrollee
83	83	may be responsible; and
84	84	(3) discloses the circumstances under which the
85	85	enrollee would be responsible for those amounts.
86	86	(d) A laboratory or facility-based provider who makes a
87	87	disclosure under Subsection (c) and obtains the enrollee's written
88	88	acknowledgment of that disclosure may not be required to mediate a
89	89	billed charge under this subchapter if the amount billed is less
90	90	than or equal to the maximum amount projected in the disclosure.
91	91	SECTION 4. Section 1467.0511, Insurance Code, is amended to
92	92	read as follows:
93	93	Sec. 1467.0511. NOTICE AND INFORMATION PROVIDED TO
94	94	ENROLLEE. (a) A bill sent to an enrollee by a laboratory,
95	95	facility-based provider, or emergency care provider or an
96	96	explanation of benefits sent to an enrollee by an insurer or
97	97	administrator for an out-of-network health benefit claim eligible
98	98	for mediation under this chapter must contain, in not less than
99	99	10-point boldface type, a conspicuous, plain-language explanation
100	100	of the mediation process available under this chapter, including
101	101	information on how to request mediation and a statement that is
102	102	substantially similar to the following:
103	103	"You may be able to reduce some of your out-of-pocket costs
104	104	for an out-of-network laboratory, medical, or health care claim
105	105	that is eligible for mediation by contacting the Texas Department
106	106	of Insurance at (website) and (phone number)."
107	107	(b) If an enrollee contacts an insurer, administrator,
108	108	laboratory, facility-based provider, or emergency care provider
109	109	about a bill that may be eligible for mediation under this chapter,
110	110	the insurer, administrator, laboratory, facility-based provider,
111	111	or emergency care provider is encouraged to:
112	112	(1) inform the enrollee about mediation under this
113	113	chapter; and
114	114	(2) provide the enrollee with the department's
115	115	toll-free telephone number and Internet website address.
116	116	SECTION 5. Section 1467.052(c), Insurance Code, is amended
117	117	to read as follows:
118	118	(c) A person may not act as mediator for a claim settlement
119	119	dispute if the person has been employed by, consulted for, or
120	120	otherwise had a business relationship with an insurer offering the
121	121	preferred provider benefit plan or a physician, laboratory, health
122	122	care practitioner, or other health care provider during the three
123	123	years immediately preceding the request for mediation.
124	124	SECTION 6. Section 1467.053(d), Insurance Code, is amended
125	125	to read as follows:
126	126	(d) The mediator's fees shall be split evenly and paid by
127	127	the insurer or administrator and the laboratory, facility-based
128	128	provider, or emergency care provider.
129	129	SECTION 7. Sections 1467.054(b), (c), and (e), Insurance
130	130	Code, are amended to read as follows:
131	131	(b) A request for mandatory mediation must be provided to
132	132	the department on a form prescribed by the commissioner and must
133	133	include:
134	134	(1) the name of the enrollee requesting mediation;
135	135	(2) a brief description of the claim to be mediated;
136	136	(3) contact information, including a telephone
137	137	number, for the requesting enrollee and the enrollee's counsel, if
138	138	the enrollee retains counsel;
139	139	(4) the name of the laboratory, facility-based
140	140	provider, or emergency care provider and name of the insurer or
141	141	administrator; and
142	142	(5) any other information the commissioner may require
143	143	by rule.
144	144	(c) On receipt of a request for mediation, the department
145	145	shall notify the laboratory, facility-based provider, or emergency
146	146	care provider and insurer or administrator of the request.
147	147	(e) A dispute to be mediated under this chapter that does
148	148	not settle as a result of a teleconference conducted under
149	149	Subsection (d) must be conducted in the county in which the health
150	150	care [or medical] services were rendered.
151	151	SECTION 8. Sections 1467.055(d), (h), and (i), Insurance
152	152	Code, are amended to read as follows:
153	153	(d) If the enrollee is participating in the mediation in
154	154	person, at the beginning of the mediation the mediator shall inform
155	155	the enrollee that if the enrollee is not satisfied with the mediated
156	156	agreement, the enrollee may file a complaint with:
157	157	(1) the Texas Medical Board or other appropriate
158	158	regulatory agency against the laboratory, facility-based provider,
159	159	or emergency care provider for improper billing; and
160	160	(2) the department for unfair claim settlement
161	161	practices.
162	162	(h) On receipt of notice from the department that an
163	163	enrollee has made a request for mediation that meets the
164	164	requirements of this chapter, the laboratory, facility-based
165	165	provider, or emergency care provider may not pursue any collection
166	166	effort against the enrollee who has requested mediation for amounts
167	167	other than copayments, deductibles, and coinsurance before the
168	168	earlier of:
169	169	(1) the date the mediation is completed; or
170	170	(2) the date the request to mediate is withdrawn.
171	171	(i) A health care [or medical] service [or supply] provided
172	172	by a laboratory, facility-based provider, or emergency care
173	173	provider may not be summarily disallowed. This subsection does not
174	174	require an insurer or administrator to pay for an uncovered service
175	175	[or supply].
176	176	SECTION 9. Sections 1467.056(a), (b), and (d), Insurance
177	177	Code, are amended to read as follows:
178	178	(a) In a mediation under this chapter, the parties shall:
179	179	(1) evaluate whether:
180	180	(A) the amount charged by the laboratory,
181	181	facility-based provider, or emergency care provider for the health
182	182	care [or medical] service [or supply] is excessive; and
183	183	(B) the amount paid by the insurer or
184	184	administrator represents the usual and customary rate for the
185	185	health care [or medical] service [or supply] or is unreasonably
186	186	low; and
187	187	(2) as a result of the amounts described by
188	188	Subdivision (1), determine the amount, after copayments,
189	189	deductibles, and coinsurance are applied, for which an enrollee is
190	190	responsible to the laboratory, facility-based provider, or
191	191	emergency care provider.
192	192	(b) The laboratory, facility-based provider, or emergency
193	193	care provider may present information regarding the amount charged
194	194	for the health care [or medical] service [or supply]. The insurer
195	195	or administrator may present information regarding the amount paid
196	196	by the insurer or administrator.
197	197	(d) The goal of the mediation is to reach an agreement among
198	198	the enrollee, the laboratory, facility-based provider, or
199	199	emergency care provider, and the insurer or administrator, as
200	200	applicable, as to the amount paid by the insurer or administrator to
201	201	the laboratory, facility-based provider, or emergency care
202	202	provider, the amount charged by the laboratory, facility-based
203	203	provider, or emergency care provider, and the amount paid to the
204	204	laboratory, facility-based provider, or emergency care provider by
205	205	the enrollee.
206	206	SECTION 10. Section 1467.058, Insurance Code, is amended to
207	207	read as follows:
208	208	Sec. 1467.058. CONTINUATION OF MEDIATION. After a
209	209	referral is made under Section 1467.057, the laboratory,
210	210	facility-based provider, or emergency care provider and the insurer
211	211	or administrator may elect to continue the mediation to further
212	212	determine their responsibilities. Continuation of mediation under
213	213	this section does not affect the amount of the billed charge to the
214	214	enrollee.
215	215	SECTION 11. Section 1467.059, Insurance Code, is amended to
216	216	read as follows:
217	217	Sec. 1467.059. MEDIATION AGREEMENT. The mediator shall
218	218	prepare a confidential mediation agreement and order that states:
219	219	(1) the total amount for which the enrollee will be
220	220	responsible to the laboratory, facility-based provider, or
221	221	emergency care provider, after copayments, deductibles, and
222	222	coinsurance; and
223	223	(2) any agreement reached by the parties under Section
224	224	1467.058.
225	225	SECTION 12. Sections 1467.151(a), (b), and (d), Insurance
226	226	Code, are amended to read as follows:
227	227	(a) The commissioner and the Texas Medical Board or other
228	228	regulatory agency, as appropriate, shall adopt rules regulating the
229	229	investigation and review of a complaint filed that relates to the
230	230	settlement of an out-of-network health benefit claim that is
231	231	subject to this chapter. The rules adopted under this section
232	232	must:
233	233	(1) distinguish among complaints for out-of-network
234	234	coverage or payment and give priority to investigating allegations
235	235	of delayed health care services [or medical care];
236	236	(2) develop a form for filing a complaint and
237	237	establish an outreach effort to inform enrollees of the
238	238	availability of the claims dispute resolution process under this
239	239	chapter;
240	240	(3) ensure that a complaint is not dismissed without
241	241	appropriate consideration;
242	242	(4) ensure that enrollees are informed of the
243	243	availability of mandatory mediation; and
244	244	(5) require the administrator to include a notice of
245	245	the claims dispute resolution process available under this chapter
246	246	with the explanation of benefits sent to an enrollee.
247	247	(b) The department and the Texas Medical Board or other
248	248	appropriate regulatory agency shall maintain information:
249	249	(1) on each complaint filed that concerns a claim or
250	250	mediation subject to this chapter; and
251	251	(2) related to a claim that is the basis of an enrollee
252	252	complaint, including:
253	253	(A) the type of services that gave rise to the
254	254	dispute;
255	255	(B) the type and specialty, if any, of the
256	256	laboratory, facility-based provider, or emergency care provider
257	257	who provided the out-of-network service;
258	258	(C) the county and metropolitan area in which the
259	259	health care [or medical] service [or supply] was provided;
260	260	(D) whether the health care [or medical] service
261	261	[or supply] was for emergency care; and
262	262	(E) any other information about:
263	263	(i) the insurer or administrator that the
264	264	commissioner by rule requires; or
265	265	(ii) the laboratory, facility-based
266	266	provider, or emergency care provider that the Texas Medical Board
267	267	or other appropriate regulatory agency by rule requires.
268	268	(d) A laboratory, facility-based provider, or emergency
269	269	care provider who fails to provide a disclosure under Section
270	270	1467.051 or 1467.0511 is not subject to discipline by the Texas
271	271	Medical Board or other appropriate regulatory agency for that
272	272	failure and a cause of action is not created by a failure to
273	273	disclose as required by Section 1467.051 or 1467.0511.
274	274	SECTION 13. The changes in law made by this Act apply only
275	275	to a claim for health care services provided on or after January 1,
276	276	2020. A claim for health care services provided before January 1,
277	277	2020, is governed by the law as it existed immediately before the
278	278	effective date of this Act, and that law is continued in effect for
279	279	that purpose.
280	280	SECTION 14. This Act takes effect September 1, 2019.