H.B. No. 2090
AN ACT
relating to the establishment of a statewide all payor claims
database and health care cost disclosures by health benefit plan
issuers and third-party administrators.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 38, Insurance Code, is amended by adding
Subchapter I to read as follows:
SUBCHAPTER I. TEXAS ALL PAYOR CLAIMS DATABASE
Sec. 38.401. PURPOSE OF SUBCHAPTER. The purpose of this
subchapter is to authorize the department to establish an all payor
claims database in this state to increase public transparency of
health care information and improve the quality of health care in
this state.
Sec. 38.402. DEFINITIONS. In this subchapter:
(1) "Allowed amount" means the amount of a billed
charge that a health benefit plan issuer determines to be covered
for services provided by a non-network provider. The allowed amount
includes both the insurer's payment and any applicable deductible,
copayment, or coinsurance amounts for which the insured is
responsible.
(2) "Center" means the Center for Healthcare Data at
The University of Texas Health Science Center at Houston.
(3) "Contracted rate" means the fee or reimbursement
amount for a network provider's services, treatments, or supplies
as established by agreement between the provider and health benefit
plan issuer.
(4) "Data" means the specific claims and encounters,
enrollment, and benefit information submitted to the center under
this subchapter.
(5) "Database" means the Texas All Payor Claims
Database established under this subchapter.
(6) "Geozip" means an area that includes all zip codes
with identical first three digits.
(7) "Payor" means any of the following entities that
pay, reimburse, or otherwise contract with a health care provider
for the provision of health care services, supplies, or devices to a
patient:
(A) an insurance company providing health or
dental insurance;
(B) the sponsor or administrator of a health or
dental plan;
(C) a health maintenance organization operating
under Chapter 843;
(D) the state Medicaid program, including the
Medicaid managed care program operating under Chapter 533,
Government Code;
(E) a health benefit plan offered or administered
by or on behalf of this state or a political subdivision of this
state or an agency or instrumentality of the state or a political
subdivision of this state, including:
(i) a basic coverage plan under Chapter
1551;
(ii) a basic plan under Chapter 1575; and
(iii) a primary care coverage plan under
Chapter 1579; or
(F) any other entity providing a health insurance
or health benefit plan subject to regulation by the department.
(8) "Protected health information" has the meaning
assigned by 45 C.F.R. Section 160.103.
(9) "Qualified research entity" means:
(A) an organization engaging in public interest
research for the purpose of analyzing the delivery of health care in
this state that is exempt from federal income tax under Section
501(a), Internal Revenue Code of 1986, by being listed as an exempt
organization in Section 501(c)(3) of that code;
(B) an institution of higher education engaged in
public interest research related to the delivery of health care in
this state; or
(C) a health care provider in this state engaging
in efforts to improve the quality and cost of health care.
(10) "Stakeholder advisory group" means the
stakeholder advisory group established under Section 38.403.
Sec. 38.403. STAKEHOLDER ADVISORY GROUP. (a) The center
shall establish a stakeholder advisory group to assist the center
as provided by this subchapter, including assistance in:
(1) establishing and updating the standards,
requirements, policies, and procedures relating to the collection
and use of data contained in the database required by Sections
38.404(e) and (f);
(2) evaluating and prioritizing the types of reports
the center should publish under Section 38.404(e);
(3) evaluating data requests from qualified research
entities under Section 38.404(e)(2); and
(4) assisting the center in developing the center's
recommendations under Section 38.408(3).
(b) The advisory group created under this section must be
composed of:
(1) the state Medicaid director or the director's
designee;
(2) a member designated by the Teacher Retirement
System of Texas;
(3) a member designated by the Employees Retirement
System of Texas; and
(4) 12 members designated by the center, including:
(A) two members representing the business
community, with at least one of those members representing small
businesses that purchase health benefits but are not involved in
the provision of health care services, supplies, or devices or
health benefit plans;
(B) two members who represent consumers and who
are not professionally involved in the purchase, provision,
administration, or review of health care services, supplies, or
devices or health benefit plans, with at least one member
representing the behavioral health community;
(C) two members representing hospitals that are
licensed in this state;
(D) two members representing health benefit plan
issuers that are regulated by the department;
(E) two members who are physicians licensed to
practice medicine in this state, one of whom is a primary care
physician; and
(F) two members who are not professionally
involved in the purchase, provision, administration, or review of
health care services, supplies, or devices or health benefit plans
and who have expertise in:
(i) health planning;
(ii) health economics;
(iii) provider quality assurance;
(iv) statistics or health data management;
or
(v) medical privacy laws.
(c) A person serving on the stakeholder advisory group must
disclose any conflict of interest.
(d) Members of the stakeholder advisory group serve fixed
terms as prescribed by commissioner rules adopted under this
subchapter.
Sec. 38.404. ESTABLISHMENT AND ADMINISTRATION OF DATABASE.
(a) The department shall collaborate with the center under this
subchapter to aid in the center's establishment of the database.
The center shall leverage the existing resources and infrastructure
of the center to establish the database to collect, process,
analyze, and store data relating to medical, dental,
pharmaceutical, and other relevant health care claims and
encounters, enrollment, and benefit information for the purposes of
increasing transparency of health care costs, utilization, and
access and improving the affordability, availability, and quality
of health care in this state, including by improving population
health in this state.
(b) The center shall serve as the administrator of the
database, design, build, and secure the database infrastructure,
and determine the accuracy of the data submitted for inclusion in
the database.
(c) In determining the information a payor is required to
submit to the center under this subchapter, the center must
consider requiring inclusion of information useful to health policy
makers, employers, and consumers for purposes of improving health
care quality and outcomes, improving population health, and
controlling health care costs. The required information at a
minimum must include the following information as it relates to all
health care services, supplies, and devices paid or otherwise
adjudicated by the payor:
(1) the name and National Provider Identifier, as
described in 45 C.F.R. Section 162.410, of each health care
provider paid by the payor;
(2) the claim line detail that documents the health
care services, supplies, or devices provided by the health care
provider;
(3) the amount of charges billed by the health care
provider and the payor's:
(A) allowed amount or contracted rate for the
health care services, supplies, or devices; and
(B) adjudicated claim amount for the health care
services, supplies, or devices;
(4) the name of the payor, the name of the health
benefit plan, and the type of health benefit plan, including
whether health care services, supplies, or devices were provided to
an individual through:
(A) a Medicaid or Medicare program;
(B) workers' compensation insurance;
(C) a health maintenance organization operating
under Chapter 843;
(D) a preferred provider benefit plan offered by
an insurer under Chapter 1301;
(E) a basic coverage plan under Chapter 1551;
(F) a basic plan under Chapter 1575;
(G) a primary care coverage plan under Chapter
1579; or
(H) a health benefit plan that is subject to the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
1001 et seq.); and
(5) claim level information that allows the center to
identify the geozip where the health care services, supplies, or
devices were provided.
(d) Each payor shall submit the required data under
Subsection (c) at a schedule and frequency determined by the center
and adopted by the commissioner by rule.
(e) In the manner and subject to the standards,
requirements, policies, and procedures relating to the use of data
contained in the database established by the center in consultation
with the stakeholder advisory group, the center may use the data
contained in the database for a noncommercial purpose:
(1) to produce statewide, regional, and geozip
consumer reports available through the public access portal
described in Section 38.405 that address:
(A) health care costs, quality, utilization,
outcomes, and disparities;
(B) population health; or
(C) the availability of health care services; and
(2) for research and other analysis conducted by the
center or a qualified research entity to the extent that such use is
consistent with all applicable federal and state law, including the
data privacy and security requirements of Section 38.406 and the
purposes of this subchapter.
(f) The center shall establish data collection procedures
and evaluate and update data collection procedures established
under this section. The center shall test the quality of data
collected by and reported to the center under this section to ensure
that the data is accurate, reliable, and complete.
Sec. 38.405. PUBLIC ACCESS PORTAL. (a) Except as provided
by this section and Sections 38.404 and 38.406 and in a manner
consistent with all applicable federal and state law, the center
shall collect, compile, and analyze data submitted to or stored in
the database and disseminate the information described in Section
38.404(e)(1) in a format that allows the public to easily access and
navigate the information. The information must be accessible
through an open access Internet portal that may be accessed by the
public through an Internet website.
(b) The portal created under this section must allow the
public to easily search and retrieve the information disseminated
under Subsection (a), subject to data privacy and security
restrictions described in this subchapter and consistent with all
applicable federal and state law.
(c) Any information or data that is accessible through the
portal created under this section:
(1) must be segmented by type of insurance or health
benefit plan in a manner that does not combine payment rates
relating to different types of insurance or health benefit plans;
(2) must be aggregated by like Current Procedural
Terminology codes and health care services in a statewide,
regional, or geozip area; and
(3) may not identify a specific patient, health care
provider, health benefit plan, health benefit plan issuer, or other
payor.
(d) Before making information or data accessible through
the portal, the center shall remove any data or information that may
identify a specific patient in accordance with the
de-identification standards described in 45 C.F.R. Section
164.514.
Sec. 38.406. DATA PRIVACY AND SECURITY. (a) Any
information that may identify a patient, health care provider,
health benefit plan, health benefit plan issuer, or other payor is
confidential and subject to applicable state and federal law
relating to records privacy and protected health information,
including Chapter 181, Health and Safety Code, and is not subject to
disclosure under Chapter 552, Government Code.
(b) A qualified research entity with access to data or
information that is contained in the database but not accessible
through the portal described in Section 38.405:
(1) may use information contained in the database only
for purposes consistent with the purposes of this subchapter and
must use the information in accordance with standards,
requirements, policies, and procedures established by the center in
consultation with the stakeholder advisory group;
(2) may not sell or share any information contained in
the database; and
(3) may not use the information contained in the
database for a commercial purpose.
(c) A qualified research entity with access to information
that is contained in the database but not accessible through the
portal must execute an agreement with the center relating to the
qualified research entity's compliance with the requirements of
Subsections (a) and (b), including the confidentiality of
information contained in the database but not accessible through
the portal.
(d) Notwithstanding any provision of this subchapter, the
department and the center may not disclose an individual's
protected health information in violation of any state or federal
law.
(e) The center shall include in the database only the
minimum amount of protected health information identifiers
necessary to link public and private data sources and the
geographic and services data to undertake studies.
(f) The center shall maintain protected health information
identifiers collected under this subchapter but excluded from the
database under Subsection (e) in a separate database. The separate
database may not be aggregated with any other information and must
use a proxy or encrypted record identifier for analysis.
Sec. 38.407. CERTAIN ENTITIES NOT REQUIRED TO SUBMIT DATA.
Any sponsor or administrator of a health benefit plan subject to the
Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
1001 et seq.) may elect or decline to participate in or submit data
to the center for inclusion in the database as consistent with
federal law.
Sec. 38.408. REPORT TO LEGISLATURE. Not later than
September 1 of each even-numbered year, the center shall submit to
the legislature a written report containing:
(1) an analysis of the data submitted to the center for
use in the database;
(2) information regarding the submission of data to
the center for use in the database and the maintenance, analysis,
and use of the data;
(3) recommendations from the center, in consultation
with the stakeholder advisory group, to further improve the
transparency, cost-effectiveness, accessibility, and quality of
health care in this state; and
(4) an analysis of the trends of health care
affordability, availability, quality, and utilization.
Sec. 38.409. RULES. (a) The commissioner, in consultation
with the center, shall adopt rules:
(1) specifying the types of data a payor is required to
provide to the center under Section 38.404 to determine health
benefits costs and other reporting metrics, including, if
necessary, types of data not expressly identified in that section;
(2) specifying the schedule, frequency, and manner in
which a payor must provide data to the center under Section 38.404,
which must:
(A) require the payor to provide data to the
center not less frequently than quarterly; and
(B) include provisions relating to data layout,
data governance, historical data, data submission, use and sharing,
information security, and privacy protection in data submissions;
and
(3) establishing oversight and enforcement mechanisms
to ensure that payors submit data to the database in accordance with
this subchapter.
(b) In adopting rules governing methods for data
submission, the commissioner shall to the maximum extent
practicable use methods that are reasonable and cost-effective for
payors.
SECTION 2. The heading to Subtitle J, Title 8, Insurance
Code, is amended to read as follows:
SUBTITLE J. HEALTH INFORMATION TECHNOLOGY AND AVAILABILITY
SECTION 3. Subtitle J, Title 8, Insurance Code, is amended
by adding Chapter 1662 to read as follows:
CHAPTER 1662. HEALTH CARE COST TRANSPARENCY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1662.001. DEFINITIONS. In this chapter:
(1) "Billed charge" means the total charges for a
health care service or supply billed to a health benefit plan by a
health care provider.
(2) "Billing code" means the code used by a health
benefit plan issuer or administrator or health care provider to
identify a health care service or supply for the purposes of
billing, adjudicating, and paying claims for a covered health care
service or supply, including the Current Procedural Terminology
code, the Healthcare Common Procedure Coding System code, the
Diagnosis-Related Group code, the National Drug Code, or other
common payer identifier.
(3) "Bundled payment arrangement" means a payment
model under which a health care provider is paid a single payment
for all covered health care services and supplies provided to an
enrollee for a specific treatment or procedure.
(4) "Copayment assistance" means the financial
assistance an enrollee receives from a prescription drug or medical
supply manufacturer toward the purchase of a covered health care
service or supply.
(5) "Cost-sharing information" means information
related to any expenditure required by or on behalf of an enrollee
with respect to health care benefits that are relevant to a
determination of the enrollee's cost-sharing liability for a
particular covered health care service or supply.
(6) "Cost-sharing liability" means the amount an
enrollee is responsible for paying for a covered health care
service or supply under the terms of a health benefit plan. The term
generally includes deductibles, coinsurance, and copayments but
does not include premiums, balance billing amounts by
out-of-network providers, or the cost of health care services or
supplies that are not covered under a health benefit plan.
(7) "Covered health care service or supply" means a
health care service or supply, including a prescription drug, for
which the costs are payable, wholly or partly, under the terms of a
health benefit plan.
(8) "Derived amount" means the price that a health
benefit plan assigns to a health care service or supply for the
purpose of internal accounting, reconciliation with health care
providers, or submitting data in accordance with state or federal
regulations.
(9) "Enrollee" means an individual, including a
dependent, entitled to coverage under a health benefit plan.
(10) "Health care service or supply" means any
encounter, procedure, medical test, supply, prescription drug,
durable medical equipment, and fee, including a facility fee,
provided or assessed in connection with the provision of health
care.
(11) "Historical net price" means the retrospective
average amount a health benefit plan paid for a prescription drug,
inclusive of any reasonably allocated rebates, discounts,
chargebacks, and fees and any additional price concessions received
by the plan or plan issuer or administrator with respect to the
prescription drug, determined in accordance with Section 1662.106.
(12) "Machine-readable file" means a digital
representation of data in a file that can be imported or read by a
computer system for further processing without human intervention
while ensuring no semantic meaning is lost.
(13) "National drug code" means the unique 10- or
11-digit 3-segment number assigned by the United States Food and
Drug Administration that is a universal product identifier for
drugs in the United States.
(14) "Negotiated rate" means the amount a health
benefit plan issuer or administrator has contractually agreed to
pay a network provider, including a network pharmacy or other
prescription drug dispenser, for covered health care services and
supplies, whether directly or indirectly, including through a
third-party administrator or pharmacy benefit manager.
(15) "Network provider" means any health care provider
of a health care service or supply with which a health benefit plan
issuer or administrator or a third party for the issuer or
administrator has a contract with the terms on which a relevant
health care service or supply is provided to an enrollee.
(16) "Out-of-network allowed amount" means the
maximum amount a health benefit plan issuer or administrator will
pay for a covered health care service or supply provided by an
out-of-network provider.
(17) "Out-of-network provider" means a health care
provider of any health care service or supply that does not have a
contract under an enrollee's health benefit plan.
(18) "Out-of-pocket limit" means the maximum amount
that an enrollee is required to pay during a coverage period for the
enrollee's share of the costs of covered health care services and
supplies under the enrollee's health benefit plan, including for
self-only and other than self-only coverage, as applicable.
(19) "Prerequisite" means concurrent review, prior
authorization, or a step-therapy or fail-first protocol related to
a covered health care service or supply that must be satisfied
before a health benefit plan issuer or administrator will cover the
service or supply. The term does not include a medical necessity
determination generally or another form of medical management
technique.
(20) "Underlying fee schedule rate" means the rate for
a covered health care service or supply from a particular network
provider or health care provider that a health benefit plan issuer
or administrator uses to determine an enrollee's cost-sharing
liability for the service or supply when that rate is different from
the negotiated rate or derived amount.
Sec. 1662.002. DEFINITION OF ACCUMULATED AMOUNTS. (a) In
this chapter, "accumulated amounts" means:
(1) the amount of financial responsibility an enrollee
has incurred at the time a request for cost-sharing information is
made, with respect to a deductible or out-of-pocket limit; and
(2) to the extent a health benefit plan imposes a
cumulative treatment limitation, including a limitation on the
number of health care supplies, days, units, visits, or hours
covered in a defined period, on a particular covered health care
service or supply independent of individual medical necessity
determinations, the amount that has accrued toward the limit on the
health care service or supply.
(b) For an individual enrolled in coverage other than
self-only coverage, the term includes the financial responsibility
the individual has incurred toward meeting the individual's own
deductible or out-of-pocket limit and the amount of financial
responsibility that all individuals enrolled in the individual's
coverage have incurred, in aggregate, toward meeting the plan's
other than self-only deductible or out-of-pocket limit, as
applicable.
(c) The term includes any expense that counts toward a
deductible or out-of-pocket limit, including a copayment or
coinsurance, but excludes any expense that does not count toward a
deductible or out-of-pocket limit, including a premium payment,
out-of-pocket expense for out-of-network health care services or
supplies, or an amount for a health care service or supply not
covered by the health benefit plan.
Sec. 1662.003. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575;
(5) a primary care coverage plan under Chapter 1579;
(6) a plan providing basic coverage under Chapter
1601;
(7) a regional or local health care program operated
under Section 75.104, Health and Safety Code; and
(8) a self-funded health benefit plan sponsored by a
professional employer organization under Chapter 91, Labor Code.
(c) This chapter does not apply to a health reimbursement
arrangement or other account-based health benefit plan or a
workers' compensation insurance policy.
Sec. 1662.004. RULES. The commissioner may adopt rules
necessary to implement this chapter.
SUBCHAPTER B. REQUIRED DISCLOSURES TO ENROLLEES
Sec. 1662.051. REQUIRED DISCLOSURE TO ENROLLEE ON REQUEST.
(a) On request of a health benefit plan enrollee, the health benefit
plan issuer or administrator shall provide to the enrollee a
disclosure in accordance with this subchapter.
(b) A health benefit plan issuer or administrator may allow
an enrollee to request cost-sharing information for a specific
preventive or non-preventive health care service or supply by
including terms such as "preventive," "non-preventive," or
"diagnostic" when requesting information under Subsection (a).
Sec. 1662.052. REQUIRED DISCLOSURE INFORMATION. (a) A
disclosure provided under this subchapter must have the following
information that is accurate at the time the disclosure request is
made, with respect to the requesting enrollee's cost-sharing
liability for a covered health care service and supply:
(1) an estimate of the enrollee's cost-sharing
liability for the requested service or supply provided by a health
care provider that is calculated based on the information described
by Subdivisions (4), (5), and (6);
(2) except as provided by Subsection (b), if the
request relates to a service or supply that is provided within a
bundled payment arrangement and the arrangement includes a service
or supply that has a separate cost-sharing liability, an estimate
of the cost-sharing liability for:
(A) the requested covered service or supply; and
(B) each service or supply in the arrangement
that has a separate cost-sharing liability;
(3) for a requested service or supply that is a
recommended preventive service under Section 2713, Public Health
Service Act (42 U.S.C. Section 300gg-13), if the health benefit
plan issuer or administrator cannot determine whether the request
is for preventive or non-preventive purposes, the cost-sharing
liability for non-preventive purposes;
(4) accumulated amounts;
(5) the network provider rate that is composed of the
following that are applicable to the health benefit plan's payment
model:
(A) the negotiated rate, reflected as a dollar
amount, for a network provider for the requested service or supply
regardless of whether the issuer or administrator uses the rate to
calculate the enrollee's cost-sharing liability; and
(B) the underlying fee schedule rate, reflected
as a dollar amount, for the requested service or supply, to the
extent that is different from the negotiated rate;
(6) the out-of-network allowed amount or any other
rate that provides a more accurate estimate of an amount a health
benefit plan issuer or administrator will pay for the requested
service or supply, reflected as a dollar amount, if the request for
cost-sharing information is for a covered service or supply
provided by an out-of-network provider;
(7) if an enrollee requests information for a service
or supply subject to a bundled payment arrangement, a list of the
services and supplies included in the arrangement;
(8) if applicable, notification that coverage of a
specific service or supply is subject to a prerequisite; and
(9) notice that includes the following information in
plain language:
(A) unless balance billing is prohibited for the
requested service or supply, a statement that out-of-network
providers may bill an enrollee for the difference between a
provider's billed charges and the sum of the amount collected from
the health benefit plan issuer or administrator and from the
enrollee in the form of a copayment or coinsurance amount and that
the cost-sharing information provided for the service or supply
does not account for that potential additional charge;
(B) a statement that the actual charges to the
enrollee for the requested service or supply may be different from
the estimate provided, depending on the actual services or supplies
the enrollee receives at the point of care;
(C) a statement that the estimate of cost-sharing
liability for the requested service or supply is not a guarantee
that benefits will be provided for that service or supply;
(D) a statement disclosing whether the health
benefit plan counts copayment assistance and other third-party
payments in the calculation of the enrollee's deductible and
out-of-pocket maximum;
(E) for a service or supply that is a recommended
preventive service under Section 2713, Public Health Service Act
(42 U.S.C. Section 300gg-13), a statement that a service or supply
provided by a network provider may not be subject to cost sharing if
it is billed as a preventive service or supply when the health
benefit plan issuer or administrator cannot determine whether the
request is for a preventive or non-preventive service or supply;
and
(F) any additional information, including other
disclosures, that the health benefit plan issuer or administrator
determines is appropriate provided that the additional information
does not conflict with the information required to be provided
under this section.
(b) A health benefit plan issuer or administrator is not
required to provide an estimate of cost-sharing liability for a
bundled payment arrangement in which the cost sharing is imposed
separately for each health care service or supply included in the
arrangement. If an issuer or administrator provides an estimate for
multiple health care services or supplies in a situation in which
the estimate could be relevant to an enrollee, the issuer or
administrator must disclose information about the relevant
services or supplies individually as required by Subsection (a).
(c) If a health benefit plan issuer or administrator
reimburses an out-of-network provider with a percentage of the
billed charge for a covered health care service or supply, the
out-of-network allowed amount described by Subsection (a) is that
reimbursed percentage.
Sec. 1662.053. METHOD AND FORMAT FOR DISCLOSURE. A health
benefit plan issuer or administrator shall provide the disclosure
required under this subchapter through an Internet-based
self-service tool described by Section 1662.054, a physical copy in
accordance with Section 1662.055, or another means authorized by
Section 1662.056.
Sec. 1662.054. INTERNET-BASED SELF-SERVICE TOOL. (a) A
health benefit plan issuer or administrator may develop and
maintain an Internet-based self-service tool to provide a
disclosure required under this subchapter.
(b) Information provided on the self-service tool must be
made available in plain language, without a subscription or other
fee, on an Internet website that provides real-time responses based
on cost-sharing information that is accurate at the time of the
request.
(c) A health benefit plan issuer or administrator shall
ensure that the self-service tool allows a user to:
(1) search for cost-sharing information for a covered
health care service or supply by a specific network provider or by
all network providers by inputting:
(A) a billing code or descriptive term at the
option of the user;
(B) the name of the network provider if the user
seeks cost-sharing information with respect to a specific network
provider; or
(C) other factors used by the issuer or
administrator that are relevant for determining the applicable
cost-sharing information, including the location in which the
service or supply will be sought or provided, the facility name, or
the dosage;
(2) search for an out-of-network allowed amount,
percentage of billed charges, or other rate that provides a
reasonably accurate estimate of the amount the issuer or
administrator will pay for a covered health care service or supply
provided by an out-of-network provider by inputting:
(A) a billing code or descriptive term at the
option of the user; or
(B) other factors used by the issuer or
administrator that are relevant for determining the applicable
out-of-network allowed amount or other rate, including the location
in which the covered health care service or supply will be sought or
provided; and
(3) refine and reorder search results based on
geographic proximity of network providers and the amount of the
enrollee's estimated cost-sharing liability for the covered health
care service or supply if the search returns multiple results.
Sec. 1662.055. PHYSICAL COPY OF DISCLOSURE. (a) A health
benefit plan issuer or administrator shall make the disclosure
required under this subchapter available in a physical form. A
disclosure under this section must be made available in plain
language, without a fee, at the request of the enrollee.
(b) In providing a disclosure under this section, a health
benefit plan issuer or administrator may limit the number of health
care providers with respect to which cost-sharing information for a
covered health care service or supply is provided to no fewer than
20 providers per request.
(c) A health benefit plan issuer or administrator providing
a disclosure under this section shall:
(1) disclose any applicable provider-per-request
limit described by Subsection (b) to the enrollee;
(2) provide the cost-sharing information in a physical
form in accordance with the enrollee's request as if the request was
made using a self-service tool under Section 1662.054; and
(3) mail the disclosure not later than two business
days after the date the enrollee's request is received.
Sec. 1662.056. OTHER MEANS OF DISCLOSURE. If an enrollee
requests the disclosure required by this subchapter by a means
other than a physical copy or the self-service tool described by
Section 1662.054, a health benefit plan issuer or administrator may
provide the disclosure through the requested means if:
(1) the enrollee agrees that disclosure through that
means is sufficient to satisfy the request;
(2) the request is fulfilled at least as rapidly as
required for the physical copy; and
(3) the disclosure includes the information required
for a physical copy under Section 1662.055.
Sec. 1662.057. OTHER CONTRACTUAL AGREEMENTS. (a) A health
benefit plan issuer or administrator may satisfy the requirements
of this subchapter by entering into a written agreement under which
another person, including a pharmacy benefit manager or other third
party, provides the disclosure required under this subchapter.
(b) If a health benefit plan issuer or administrator and
another person enter into an agreement under Subsection (a), the
issuer or administrator is subject to an enforcement action for
failure to provide a required disclosure in accordance with this
subchapter.
Sec. 1662.058. COMPLIANCE WITH SUBCHAPTER. (a) A health
benefit plan issuer or administrator that, acting in good faith and
with reasonable diligence, makes an error or omission in a
disclosure required under this subchapter does not fail to comply
with this subchapter solely because of the error or omission if the
issuer or administrator corrects the error or omission as soon as
practicable.
(b) A health benefit plan issuer or administrator, acting in
good faith and with reasonable diligence, does not fail to comply
with this subchapter solely because the issuer's or administrator's
Internet website is temporarily inaccessible if the issuer or
administrator makes the information available as soon as
practicable.
(c) To the extent compliance with this subchapter requires a
health benefit plan issuer or administrator to obtain information
from another person, the issuer or administrator does not fail to
comply with the subchapter because the issuer or administrator
relies in good faith on information from the other person unless the
issuer or administrator knows or reasonably should have known that
the information is incomplete or inaccurate.
SUBCHAPTER C. REQUIRED PUBLIC DISCLOSURES
Sec. 1662.101. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only to a health benefit plan for which federal
reporting requirements under 26 C.F.R. Part 54, 29 C.F.R. Part
2590, and 45 C.F.R. Parts 147 and 158 do not apply.
Sec. 1662.102. PUBLICATION REQUIRED. A health benefit plan
issuer or administrator shall publish on an Internet website the
information required under Section 1662.103 in three
machine-readable files in accordance with this subchapter.
Sec. 1662.103. REQUIRED INFORMATION. (a) A health benefit
plan issuer or administrator shall publish the following
information:
(1) a network rate machine-readable file that includes
the following information for all covered health care services and
supplies, except for prescription drugs that are subject to a
fee-for-service reimbursement arrangement:
(A) for each coverage option offered by a health
benefit plan issuer or administered by a health benefit plan
administrator, the option's name and:
(i) the option's 14-digit health insurance
oversight system identifier;
(ii) if the 14-digit identifier is not
available, the option's 5-digit health insurance oversight system
identifier; or
(iii) if the 14- and 5-digit identifiers
are not available, the employer identification number associated
with the option;
(B) a billing code, which must be the national
drug code for a prescription drug, and a plain-language description
for each billing code for each covered service or supply under each
coverage option offered by the issuer or administered by the
administrator; and
(C) all applicable rates, including negotiated
rates, underlying fee schedules, or derived amounts, provided in
accordance with Section 1662.104;
(2) an out-of-network allowed amount machine-readable
file, including:
(A) for each coverage option offered by a health
benefit plan issuer or administered by a health benefit plan
administrator, the option's name and:
(i) the option's 14-digit health insurance
oversight system identifier;
(ii) if the 14-digit identifier is not
available, the option's 5-digit health insurance oversight system
identifier; or
(iii) if the 14- and 5-digit identifiers
are not available, the employer identification number associated
with the option;
(B) a billing code, which must be the national
drug code for a prescription drug, and a plain-language description
for each billing code for each covered service or supply under each
coverage option offered by the issuer or administered by the
administrator; and
(C) except as provided by Subsection (b), unique
out-of-network billed charges and allowed amounts provided in
accordance with Section 1662.105 for covered health care services
or supplies provided by out-of-network providers during the 90-day
period that begins on the 180th day before the date the
machine-readable file is published; and
(3) a prescription drug machine-readable file that
includes:
(A) for each coverage option offered by a health
benefit plan issuer or administered by a health benefit plan
administrator, the option's name and:
(i) the option's 14-digit health insurance
oversight system identifier;
(ii) if the 14-digit identifier is not
available, the option's 5-digit health insurance oversight system
identifier; or
(iii) if the 14- and 5-digit identifiers
are not available, the employer identification number associated
with the option;
(B) the national drug code and the proprietary
and nonproprietary name assigned to the national drug code by the
United States Food and Drug Administration for each covered
prescription drug provided under each coverage option offered by
the issuer or administered by the administrator;
(C) the negotiated rates, which must be:
(i) reflected as a dollar amount with
respect to each national drug code that is provided by a network
provider, including a network pharmacy or other prescription drug
dispenser;
(ii) associated with the national provider
identifier, tax identification number, and place of service code
for each network provider, including each network pharmacy or other
prescription drug dispenser; and
(iii) associated with the last date of the
contract term for each provider-specific negotiated rate that
applies to each national drug code; and
(D) except as provided by Subsection (b),
historical net prices, which must be:
(i) reflected as a dollar amount with
respect to each national drug code that is provided by a network
provider, including a network pharmacy or other prescription drug
dispenser;
(ii) associated with the national provider
identifier, tax identification number, and place of service code
for each network provider, including each network pharmacy or other
prescription drug dispenser; and
(iii) associated with the 90-day period
that begins on the 180th day before the date the machine-readable
file is published for each provider-specific historical net price
calculated in accordance with Section 1662.106 that applies to each
national drug code.
(b) A health benefit plan issuer or administrator shall omit
information described by Subsection (a)(2)(C) or (a)(3)(D) in
relation to a particular health care service or supply if
compliance with that subsection would require the issuer to report
payment information in connection with fewer than 20 different
claims for payments under a single health benefit plan.
(c) This section does not require the disclosure of
information that would violate any applicable health information
privacy law.
Sec. 1662.104. NETWORK RATE DISCLOSURES. (a) If a health
benefit plan issuer or administrator does not use negotiated rates
for health care provider reimbursement, the issuer or administrator
shall disclose for purposes of Section 1662.103(a)(1)(C) derived
amounts to the extent those amounts are already calculated in the
normal course of business.
(b) If a health benefit plan issuer or administrator uses
underlying fee schedule rates for calculating cost sharing, the
issuer or administrator shall disclose for purposes of Section
1662.103(a)(1)(C) the underlying fee schedule rates in addition to
the negotiated rate or derived amount.
(c) The applicable rates, including for both individual
health care services and supplies and services and supplies in a
bundled payment arrangement, that a health benefit plan issuer or
administrator must provide under Section 1662.103(a)(1)(C) must
be:
(1) except as provided by Subdivision (2), reflected
as dollar amounts with respect to each covered health care service
or supply that is provided by a network provider;
(2) the base negotiated rate applicable to the service
or supply before an adjustment for enrollee characteristics if the
rate is a negotiated rate subject to change based on enrollee
characteristics;
(3) associated with the national provider identifier,
tax identification number, and place of service code for each
network provider;
(4) associated with the last date of the contract term
or expiration date for each health care provider-specific
applicable rate that applies to each covered service or supply; and
(5) indicated with a notation where a reimbursement
arrangement other than a standard fee-for-service model, including
capitation or a bundled payment arrangement, applies.
Sec. 1662.105. OUT-OF-NETWORK ALLOWED AMOUNTS. (a) An
out-of-network allowed amount provided under Section
1662.103(a)(2)(C) must be:
(1) reflected as a dollar amount with respect to each
covered health care service or supply that is provided by an
out-of-network provider; and
(2) associated with the national provider identifier,
tax identification number, and place of service code for each
out-of-network provider.
(b) This subchapter does not prohibit a health benefit plan
issuer or administrator from satisfying the disclosure
requirements described by Section 1662.103(a)(2)(C) by disclosing
out-of-network allowed amounts made available by, or otherwise
obtained from, an issuer, a health care provider, or other party
with which the issuer or administrator has entered into a written
agreement to provide the information if the minimum claim threshold
described by Section 1662.103(b) is independently met for each
health care service or supply and for each plan included in an
aggregated allowed amount file.
(c) If a health benefit plan issuer or administrator enters
into an agreement under Subsection (b), the health benefit plan
issuers, health care providers, or other persons with which the
issuer or administrator has contracted may aggregate
out-of-network allowed amounts for more than one plan.
(d) This subchapter does not prohibit a third party from
hosting an allowed amount file on its Internet website or a health
benefit plan issuer or administrator from contracting with a third
party to post the file. If the issuer or administrator does not host
the file separately on its Internet website, the issuer or
administrator shall provide a link on its Internet website to the
location where the file is made publicly available.
Sec. 1662.106. HISTORICAL NET PRICE. (a) For purposes of
determining the historical net price for a prescription drug, the
allocation of price concessions is determined by the dollar value
for non-product specific and product-specific rebates, discounts,
chargebacks, fees, and other price concessions to the extent that
the total amount of any such price concession is known to the health
benefit plan issuer or administrator at the time of publication of
the historical net price under Section 1662.103(a)(3)(D).
(b) To the extent that the total amount of any non-product
specific and product-specific rebates, discounts, chargebacks,
fees, or other price concessions is not known to a health benefit
plan issuer or administrator at the time of publication of the
historical net price under Section 1662.103(a)(3)(D), the issuer or
administrator shall allocate those price concessions by using a
good faith, reasonable estimate of the average price concessions
based on the price concessions received over a period before the
current reporting period and of equal duration to the current
reporting period.
Sec. 1662.107. REQUIRED METHOD AND FORMAT FOR DISCLOSURE.
The machine-readable files described by Section 1662.103 must be
available in a form and manner prescribed by department rule. The
files must be available and accessible to any person free of charge
and without conditions, including establishment of a user account,
password, or other credentials, or submission of personally
identifiable information to access the file.
Sec. 1662.108. FILE UPDATES. A health benefit plan issuer
or administrator shall update the machine-readable files described
by Section 1662.103 and the information described by this
subchapter monthly. The issuer or administrator must clearly
indicate in the files the date that the files were most recently
updated.
Sec. 1662.109. OTHER CONTRACTUAL AGREEMENTS. (a) A health
benefit plan issuer or administrator may satisfy the requirements
of this subchapter by entering into a written agreement under which
another person, including a third-party administrator or health
care claims clearinghouse, provides the disclosure required under
this subchapter in compliance with this subchapter.
(b) If a health benefit plan issuer or administrator and
another person enter into an agreement under Subsection (a), the
issuer or administrator is subject to an enforcement action for
failure to provide a required disclosure in accordance with this
subchapter.
Sec. 1662.110. COMPLIANCE WITH SUBCHAPTER. (a) A health
benefit plan issuer or administrator that, acting in good faith and
with reasonable diligence, makes an error or omission in a
disclosure required under this subchapter does not fail to comply
with this subchapter solely because of the error or omission if the
issuer or administrator corrects the error or omission as soon as
practicable.
(b) A health benefit plan issuer or administrator, acting in
good faith and with reasonable diligence, does not fail to comply
with this subchapter solely because the issuer's or administrator's
Internet website is temporarily inaccessible if the issuer or
administrator makes the information available as soon as
practicable.
(c) To the extent compliance with this subchapter requires a
health benefit plan issuer or administrator to obtain information
from another person, the issuer or administrator does not fail to
comply with the subchapter because the issuer or administrator
relies in good faith on information from the other person unless the
issuer or administrator knows or reasonably should have known that
the information is incomplete or inaccurate.
SECTION 4. (a) Not later than January 1, 2022, the Center
for Healthcare Data at The University of Texas Health Science
Center at Houston shall establish the stakeholder advisory group in
accordance with Section 38.403, Insurance Code, as added by this
Act.
(b) Not later than June 1, 2022, the Texas Department of
Insurance shall adopt rules, and the Center for Healthcare Data at
The University of Texas Health Science Center at Houston shall
adopt, in consultation with the stakeholder advisory group,
standards, requirements, policies, and procedures, necessary to
implement Subchapter I, Chapter 38, Insurance Code, as added by
this Act.
SECTION 5. As soon as practicable after the effective date
of this Act, the Center for Healthcare Data at The University of
Texas Health Science Center at Houston shall actively seek
financial support from the federal grant program for development of
state all payer claims databases established under the Consolidated
Appropriations Act, 2021 (Pub. L. No. 116-260) and from any other
available source of financial support provided by the federal
government for purposes of implementing Subchapter I, Chapter 38,
Insurance Code, as added by this Act.
SECTION 6. If before implementing any provision of
Subchapter I, Chapter 38, Insurance Code, as added by this Act, the
commissioner of insurance determines that a waiver or authorization
from a federal agency is necessary for implementation of that
provision, the commissioner shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 7. (a) Subchapter B, Chapter 1662, Insurance Code,
as added by this Act, applies only to a health benefit plan
delivered, issued for delivery, or renewed on or after January 1,
2024, or for a plan year that begins on or after that date.
(b) Subchapter C, Chapter 1662, Insurance Code, as added by
this Act, applies only to a health benefit plan delivered, issued
for delivery, or renewed on or after January 1, 2022, or for a plan
year that begins on or after that date.
SECTION 8. This Act takes effect September 1, 2021.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 2090 was passed by the House on April
15, 2021, by the following vote: Yeas 144, Nays 0, 1 present, not
voting; and that the House concurred in Senate amendments to H.B.
No. 2090 on May 24, 2021, by the following vote: Yeas 145, Nays 1,
1 present, not voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 2090 was passed by the Senate, with
amendments, on May 19, 2021, by the following vote: Yeas 31, Nays
0.
______________________________
Secretary of the Senate
APPROVED: __________________
Date
__________________
Governor