86R9268 SMT-D
By: Johnson S.B. No. 1914
A BILL TO BE ENTITLED
AN ACT
relating to the mediation of the settlement of certain health
benefit claims involving balance billing by out-of-network
laboratories.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1467.001, Insurance Code, is amended by
amending Subdivisions (4), (5), and (7) and adding Subdivisions
(4-b) and (4-c) to read as follows:
(4) "Facility-based provider" means a physician,
health care practitioner, or other health care provider who
provides health care [or medical] services to patients of a
facility.
(4-b) "Health care services" has the meaning assigned
by Section 562.002.
(4-c) "Laboratory" means an accredited facility in
which a specimen taken from a human body is interpreted and
pathological diagnoses are made.
(5) "Mediation" means a process in which an impartial
mediator facilitates and promotes agreement between the insurer
offering a preferred provider benefit plan or the administrator and
a laboratory, facility-based provider, or emergency care provider
or the laboratory's or provider's representative to settle a health
benefit claim of an enrollee.
(7) "Party" means an insurer offering a preferred
provider benefit plan, an administrator, or a laboratory,
facility-based provider, or emergency care provider or the
laboratory's or provider's representative who participates in a
mediation conducted under this chapter. The enrollee is also
considered a party to the mediation.
SECTION 2. Section 1467.005, Insurance Code, is amended to
read as follows:
Sec. 1467.005. REFORM. This chapter may not be construed
to prohibit:
(1) an insurer offering a preferred provider benefit
plan or administrator from, at any time, offering a reformed claim
settlement; or
(2) a laboratory, facility-based provider, or
emergency care provider from, at any time, offering a reformed
charge for health care [or medical] services [or supplies].
SECTION 3. Section 1467.051, Insurance Code, is amended to
read as follows:
Sec. 1467.051. AVAILABILITY OF MANDATORY MEDIATION;
EXCEPTION. (a) An enrollee may request mediation of a settlement
of an out-of-network health benefit claim if:
(1) the amount for which the enrollee is responsible
to a laboratory, facility-based provider, or emergency care
provider, after copayments, deductibles, and coinsurance,
including the amount unpaid by the administrator or insurer, is
greater than $500; and
(2) the health benefit claim is for:
(A) emergency care; [or]
(B) a health care [or medical] service [or
supply] provided by a facility-based provider in a facility that is
a preferred provider or that has a contract with the administrator;
or
(C) a laboratory service, if:
(i) the specimen evaluated by the
laboratory is collected by an in-network physician, health care
practitioner, or health care provider;
(ii) the laboratory is an out-of-network
laboratory; and
(iii) the enrollee did not have a
reasonable opportunity to inquire about the laboratory's network
status.
(b) Except as provided by Subsections (c) and (d), if an
enrollee requests mediation under this subchapter, the laboratory,
facility-based provider, or emergency care provider, or the
laboratory's or provider's representative, and the insurer or the
administrator, as appropriate, shall participate in the mediation.
(c) Except in the case of an emergency and if requested by
the enrollee, a laboratory or facility-based provider shall, before
providing a health care [or medical] service [or supply], provide a
complete disclosure to an enrollee that:
(1) explains that the laboratory or facility-based
provider does not have a contract with the enrollee's health
benefit plan;
(2) discloses projected amounts for which the enrollee
may be responsible; and
(3) discloses the circumstances under which the
enrollee would be responsible for those amounts.
(d) A laboratory or facility-based provider who makes a
disclosure under Subsection (c) and obtains the enrollee's written
acknowledgment of that disclosure may not be required to mediate a
billed charge under this subchapter if the amount billed is less
than or equal to the maximum amount projected in the disclosure.
SECTION 4. Section 1467.0511, Insurance Code, is amended to
read as follows:
Sec. 1467.0511. NOTICE AND INFORMATION PROVIDED TO
ENROLLEE. (a) A bill sent to an enrollee by a laboratory,
facility-based provider, or emergency care provider or an
explanation of benefits sent to an enrollee by an insurer or
administrator for an out-of-network health benefit claim eligible
for mediation under this chapter must contain, in not less than
10-point boldface type, a conspicuous, plain-language explanation
of the mediation process available under this chapter, including
information on how to request mediation and a statement that is
substantially similar to the following:
"You may be able to reduce some of your out-of-pocket costs
for an out-of-network laboratory, medical, or health care claim
that is eligible for mediation by contacting the Texas Department
of Insurance at (website) and (phone number)."
(b) If an enrollee contacts an insurer, administrator,
laboratory, facility-based provider, or emergency care provider
about a bill that may be eligible for mediation under this chapter,
the insurer, administrator, laboratory, facility-based provider,
or emergency care provider is encouraged to:
(1) inform the enrollee about mediation under this
chapter; and
(2) provide the enrollee with the department's
toll-free telephone number and Internet website address.
SECTION 5. Section 1467.052(c), Insurance Code, is amended
to read as follows:
(c) A person may not act as mediator for a claim settlement
dispute if the person has been employed by, consulted for, or
otherwise had a business relationship with an insurer offering the
preferred provider benefit plan or a physician, laboratory, health
care practitioner, or other health care provider during the three
years immediately preceding the request for mediation.
SECTION 6. Section 1467.053(d), Insurance Code, is amended
to read as follows:
(d) The mediator's fees shall be split evenly and paid by
the insurer or administrator and the laboratory, facility-based
provider, or emergency care provider.
SECTION 7. Sections 1467.054(b), (c), and (e), Insurance
Code, are amended to read as follows:
(b) A request for mandatory mediation must be provided to
the department on a form prescribed by the commissioner and must
include:
(1) the name of the enrollee requesting mediation;
(2) a brief description of the claim to be mediated;
(3) contact information, including a telephone
number, for the requesting enrollee and the enrollee's counsel, if
the enrollee retains counsel;
(4) the name of the laboratory, facility-based
provider, or emergency care provider and name of the insurer or
administrator; and
(5) any other information the commissioner may require
by rule.
(c) On receipt of a request for mediation, the department
shall notify the laboratory, facility-based provider, or emergency
care provider and insurer or administrator of the request.
(e) A dispute to be mediated under this chapter that does
not settle as a result of a teleconference conducted under
Subsection (d) must be conducted in the county in which the health
care [or medical] services were rendered.
SECTION 8. Sections 1467.055(d), (h), and (i), Insurance
Code, are amended to read as follows:
(d) If the enrollee is participating in the mediation in
person, at the beginning of the mediation the mediator shall inform
the enrollee that if the enrollee is not satisfied with the mediated
agreement, the enrollee may file a complaint with:
(1) the Texas Medical Board or other appropriate
regulatory agency against the laboratory, facility-based provider,
or emergency care provider for improper billing; and
(2) the department for unfair claim settlement
practices.
(h) On receipt of notice from the department that an
enrollee has made a request for mediation that meets the
requirements of this chapter, the laboratory, facility-based
provider, or emergency care provider may not pursue any collection
effort against the enrollee who has requested mediation for amounts
other than copayments, deductibles, and coinsurance before the
earlier of:
(1) the date the mediation is completed; or
(2) the date the request to mediate is withdrawn.
(i) A health care [or medical] service [or supply] provided
by a laboratory, facility-based provider, or emergency care
provider may not be summarily disallowed. This subsection does not
require an insurer or administrator to pay for an uncovered service
[or supply].
SECTION 9. Sections 1467.056(a), (b), and (d), Insurance
Code, are amended to read as follows:
(a) In a mediation under this chapter, the parties shall:
(1) evaluate whether:
(A) the amount charged by the laboratory,
facility-based provider, or emergency care provider for the health
care [or medical] service [or supply] is excessive; and
(B) the amount paid by the insurer or
administrator represents the usual and customary rate for the
health care [or medical] service [or supply] or is unreasonably
low; and
(2) as a result of the amounts described by
Subdivision (1), determine the amount, after copayments,
deductibles, and coinsurance are applied, for which an enrollee is
responsible to the laboratory, facility-based provider, or
emergency care provider.
(b) The laboratory, facility-based provider, or emergency
care provider may present information regarding the amount charged
for the health care [or medical] service [or supply]. The insurer
or administrator may present information regarding the amount paid
by the insurer or administrator.
(d) The goal of the mediation is to reach an agreement among
the enrollee, the laboratory, facility-based provider, or
emergency care provider, and the insurer or administrator, as
applicable, as to the amount paid by the insurer or administrator to
the laboratory, facility-based provider, or emergency care
provider, the amount charged by the laboratory, facility-based
provider, or emergency care provider, and the amount paid to the
laboratory, facility-based provider, or emergency care provider by
the enrollee.
SECTION 10. Section 1467.058, Insurance Code, is amended to
read as follows:
Sec. 1467.058. CONTINUATION OF MEDIATION. After a
referral is made under Section 1467.057, the laboratory,
facility-based provider, or emergency care provider and the insurer
or administrator may elect to continue the mediation to further
determine their responsibilities. Continuation of mediation under
this section does not affect the amount of the billed charge to the
enrollee.
SECTION 11. Section 1467.059, Insurance Code, is amended to
read as follows:
Sec. 1467.059. MEDIATION AGREEMENT. The mediator shall
prepare a confidential mediation agreement and order that states:
(1) the total amount for which the enrollee will be
responsible to the laboratory, facility-based provider, or
emergency care provider, after copayments, deductibles, and
coinsurance; and
(2) any agreement reached by the parties under Section
1467.058.
SECTION 12. Sections 1467.151(a), (b), and (d), Insurance
Code, are amended to read as follows:
(a) The commissioner and the Texas Medical Board or other
regulatory agency, as appropriate, shall adopt rules regulating the
investigation and review of a complaint filed that relates to the
settlement of an out-of-network health benefit claim that is
subject to this chapter. The rules adopted under this section
must:
(1) distinguish among complaints for out-of-network
coverage or payment and give priority to investigating allegations
of delayed health care services [or medical care];
(2) develop a form for filing a complaint and
establish an outreach effort to inform enrollees of the
availability of the claims dispute resolution process under this
chapter;
(3) ensure that a complaint is not dismissed without
appropriate consideration;
(4) ensure that enrollees are informed of the
availability of mandatory mediation; and
(5) require the administrator to include a notice of
the claims dispute resolution process available under this chapter
with the explanation of benefits sent to an enrollee.
(b) The department and the Texas Medical Board or other
appropriate regulatory agency shall maintain information:
(1) on each complaint filed that concerns a claim or
mediation subject to this chapter; and
(2) related to a claim that is the basis of an enrollee
complaint, including:
(A) the type of services that gave rise to the
dispute;
(B) the type and specialty, if any, of the
laboratory, facility-based provider, or emergency care provider
who provided the out-of-network service;
(C) the county and metropolitan area in which the
health care [or medical] service [or supply] was provided;
(D) whether the health care [or medical] service
[or supply] was for emergency care; and
(E) any other information about:
(i) the insurer or administrator that the
commissioner by rule requires; or
(ii) the laboratory, facility-based
provider, or emergency care provider that the Texas Medical Board
or other appropriate regulatory agency by rule requires.
(d) A laboratory, facility-based provider, or emergency
care provider who fails to provide a disclosure under Section
1467.051 or 1467.0511 is not subject to discipline by the Texas
Medical Board or other appropriate regulatory agency for that
failure and a cause of action is not created by a failure to
disclose as required by Section 1467.051 or 1467.0511.
SECTION 13. The changes in law made by this Act apply only
to a claim for health care services provided on or after January 1,
2020. A claim for health care services provided before January 1,
2020, is governed by the law as it existed immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.
SECTION 14. This Act takes effect September 1, 2019.