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Texas House Bill HB3924

Texas 2021 - 87th Regular

Texas House Bill HB3924 Compare Versions

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1-H.B. No. 3924
1+By: Oliverson, et al. (Senate Sponsor - Springer) H.B. No. 3924
2+ (In the Senate - Received from the House May 5, 2021;
3+ May 10, 2021, read first time and referred to Committee on Business &
4+ Commerce; May 13, 2021, reported favorably by the following vote:
5+ Yeas 5, Nays 3; May 13, 2021, sent to printer.)
6+Click here to see the committee vote
27
38
9+ A BILL TO BE ENTITLED
410 AN ACT
511 relating to health benefits offered by certain nonprofit
612 agricultural organizations.
713 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8- SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
9- by adding Chapter 1275 to read as follows:
10- CHAPTER 1275. BALANCE BILLING PROHIBITIONS AND OUT-OF-NETWORK
11- CLAIM DISPUTE RESOLUTION FOR CERTAIN PLANS
12- SUBCHAPTER A. GENERAL PROVISIONS
13- Sec. 1275.001. DEFINITIONS. In this chapter:
14- (1) "Enrollee" means an individual enrolled in a
15- health benefit plan to which this chapter applies.
16- (2) "Usual and customary rate" means the relevant
17- allowable amount as described by the applicable master benefit plan
18- document.
19- Sec. 1275.002. APPLICABILITY OF CHAPTER. This chapter
20- applies to a health benefit plan offered by a nonprofit
21- agricultural organization under Chapter 1682.
22- Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE.
23- (a) The administrator of a health benefit plan to which this
24- chapter applies shall provide written notice in accordance with
25- this section in an explanation of benefits provided to the enrollee
26- and the physician or health care provider in connection with a
27- health care or medical service or supply provided by an
28- out-of-network provider. The notice must include:
29- (1) a statement of the billing prohibition under
30- Section 1275.051, 1275.052, or 1275.053, as applicable;
31- (2) the total amount the physician or provider may
32- bill the enrollee under the enrollee's health benefit plan and an
33- itemization of copayments, coinsurance, deductibles, and other
34- amounts included in that total; and
35- (3) for an explanation of benefits provided to the
36- physician or provider, information required by commissioner rule
37- advising the physician or provider of the availability of mediation
38- or arbitration, as applicable, under Chapter 1467.
39- (b) The administrator shall provide the explanation of
40- benefits with the notice required by this section to a physician or
41- health care provider not later than the date the administrator
42- makes a payment under Section 1275.051, 1275.052, or 1275.053, as
43- applicable.
44- Sec. 1275.004. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION.
45- Chapter 1467 applies to a health benefit plan to which this chapter
46- applies, and the administrator of a health benefit plan to which
47- this chapter applies is an administrator for purposes of that
48- chapter.
49- SUBCHAPTER B. PAYMENTS FOR CERTAIN SERVICES; BALANCE BILLING
50- PROHIBITIONS
51- Sec. 1275.051. EMERGENCY CARE PAYMENTS. (a) In this
52- section, "emergency care" has the meaning assigned by Section
53- 1301.155.
54- (b) The administrator of a health benefit plan to which this
55- chapter applies shall pay for covered emergency care performed by
56- or a covered supply related to that care provided by an
57- out-of-network provider at the usual and customary rate or at an
58- agreed rate. The administrator shall make a payment required by
59- this subsection directly to the provider not later than, as
60- applicable:
61- (1) the 30th day after the date the administrator
62- receives an electronic claim for those services that includes all
63- information necessary for the administrator to pay the claim; or
64- (2) the 45th day after the date the administrator
65- receives a nonelectronic claim for those services that includes all
66- information necessary for the administrator to pay the claim.
67- (c) For emergency care subject to this section or a supply
68- related to that care, an out-of-network provider or a person
69- asserting a claim as an agent or assignee of the provider may not
70- bill an enrollee in, and the enrollee does not have financial
71- responsibility for, an amount greater than an applicable copayment,
72- coinsurance, and deductible under the enrollee's health benefit
73- plan that:
74- (1) is based on:
75- (A) the amount initially determined payable by
76- the administrator; or
77- (B) if applicable, a modified amount as
78- determined under the administrator's internal appeal process; and
79- (2) is not based on any additional amount determined
80- to be owed to the provider under Chapter 1467.
81- Sec. 1275.052. OUT-OF-NETWORK FACILITY-BASED PROVIDER
82- PAYMENTS. (a) In this section, "facility-based provider" means a
83- physician or health care provider who provides health care or
84- medical services to patients of a health care facility.
85- (b) Except as provided by Subsection (d), the administrator
86- of a health benefit plan to which this chapter applies shall pay for
87- a covered health care or medical service performed for or a covered
88- supply related to that service provided to an enrollee by an
89- out-of-network provider who is a facility-based provider at the
90- usual and customary rate or at an agreed rate if the provider
91- performed the service at a health care facility that is a
92- participating provider. The administrator shall make a payment
93- required by this subsection directly to the provider not later
94- than, as applicable:
95- (1) the 30th day after the date the administrator
96- receives an electronic claim for those services that includes all
97- information necessary for the administrator to pay the claim; or
98- (2) the 45th day after the date the administrator
99- receives a nonelectronic claim for those services that includes all
100- information necessary for the administrator to pay the claim.
101- (c) Except as provided by Subsection (d), an out-of-network
102- provider who is a facility-based provider or a person asserting a
103- claim as an agent or assignee of the provider may not bill an
104- enrollee receiving a health care or medical service or supply
105- described by Subsection (b) in, and the enrollee does not have
106- financial responsibility for, an amount greater than an applicable
107- copayment, coinsurance, and deductible under the enrollee's health
108- benefit plan that:
109- (1) is based on:
110- (A) the amount initially determined payable by
111- the administrator; or
112- (B) if applicable, a modified amount as
113- determined under the administrator's internal appeal process; and
114- (2) is not based on any additional amount determined
115- to be owed to the provider under Chapter 1467.
116- (d) This section does not apply to a nonemergency health
117- care or medical service:
118- (1) that an enrollee elects to receive in writing in
119- advance of the service with respect to each out-of-network provider
120- providing the service; and
121- (2) for which an out-of-network provider, before
122- providing the service, provides a complete written disclosure to
123- the enrollee that:
124- (A) explains that the provider does not have a
125- contract with the enrollee's health benefit plan;
126- (B) discloses projected amounts for which the
127- enrollee may be responsible; and
128- (C) discloses the circumstances under which the
129- enrollee would be responsible for those amounts.
130- Sec. 1275.053. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
131- OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section,
132- "diagnostic imaging provider" and "laboratory service provider"
133- have the meanings assigned by Section 1467.001.
134- (b) Except as provided by Subsection (d), the administrator
135- of a health benefit plan to which this chapter applies shall pay for
136- a covered health care or medical service performed for or a covered
137- supply related to that service provided to an enrollee by an
138- out-of-network provider who is a diagnostic imaging provider or
139- laboratory service provider at the usual and customary rate or at an
140- agreed rate if the provider performed the service in connection
141- with a health care or medical service performed by a participating
142- provider. The administrator shall make a payment required by this
143- subsection directly to the provider not later than, as applicable:
144- (1) the 30th day after the date the administrator
145- receives an electronic claim for those services that includes all
146- information necessary for the administrator to pay the claim; or
147- (2) the 45th day after the date the administrator
148- receives a nonelectronic claim for those services that includes all
149- information necessary for the administrator to pay the claim.
150- (c) Except as provided by Subsection (d), an out-of-network
151- provider who is a diagnostic imaging provider or laboratory service
152- provider or a person asserting a claim as an agent or assignee of
153- the provider may not bill an enrollee receiving a health care or
154- medical service or supply described by Subsection (b) in, and the
155- enrollee does not have financial responsibility for, an amount
156- greater than an applicable copayment, coinsurance, and deductible
157- under the enrollee's health benefit plan that:
158- (1) is based on:
159- (A) the amount initially determined payable by
160- the administrator; or
161- (B) if applicable, the modified amount as
162- determined under the administrator's internal appeal process; and
163- (2) is not based on any additional amount determined
164- to be owed to the provider under Chapter 1467.
165- (d) This section does not apply to a nonemergency health
166- care or medical service:
167- (1) that an enrollee elects to receive in writing in
168- advance of the service with respect to each out-of-network provider
169- providing the service; and
170- (2) for which an out-of-network provider, before
171- providing the service, provides a complete written disclosure to
172- the enrollee that:
173- (A) explains that the provider does not have a
174- contract with the enrollee's health benefit plan;
175- (B) discloses projected amounts for which the
176- enrollee may be responsible; and
177- (C) discloses the circumstances under which the
178- enrollee would be responsible for those amounts.
179- SECTION 2. The heading to Subtitle K, Title 8, Insurance
14+ SECTION 1. The heading to Subtitle K, Title 8, Insurance
18015 Code, is amended to read as follows:
18116 SUBTITLE K. CERTAIN BENEFITS AND ARRANGEMENTS THAT ARE NOT
18217 INSURANCE [HEALTH CARE SHARING MINISTRIES]
183- SECTION 3. Subtitle K, Title 8, Insurance Code, is amended
18+ SECTION 2. Subtitle K, Title 8, Insurance Code, is amended
18419 by adding Chapter 1682 to read as follows:
18520 CHAPTER 1682. HEALTH BENEFITS PROVIDED BY CERTAIN NONPROFIT
18621 AGRICULTURAL ORGANIZATIONS
18722 Sec. 1682.001. DEFINITIONS. In this chapter:
18823 (1) "Nonprofit agricultural organization" means an
18924 organization that:
19025 (A) is exempt from taxation under Section 501(a),
19126 Internal Revenue Code of 1986, as an organization described by
19227 Section 501(c)(5) of that code;
19328 (B) is domiciled in this state;
19429 (C) was in existence prior to 1940;
19530 (D) is composed of members who are residents of
19631 at least 98 percent of the counties in this state;
19732 (E) collects annual dues from its members; and
19833 (F) was created to promote and develop the most
19934 profitable and desirable system of agriculture and the most
20035 wholesome and satisfactory conditions of rural life in accordance
20136 with its articles of organization and bylaws.
20237 (2) "Nonprofit agricultural organization health
20338 benefits" means health benefits:
20439 (A) sponsored by a nonprofit agricultural
20540 organization or an affiliate of the organization;
20641 (B) offered only to:
20742 (i) members of the nonprofit agricultural
20843 organization; and
20944 (ii) family members of members of the
21045 nonprofit agricultural organization;
21146 (C) that are not provided through an insurance
212- policy or other product the offering or issuance of which is
213- regulated as the business of insurance in this state; and
47+ policy or other product the offering or issuance of which
48+ constitutes the business of insurance in this state; and
21449 (D) that are deemed by the nonprofit agricultural
21550 organization to be important in assisting its members to live long
21651 and productive lives.
21752 (3) "Preexisting condition" means a condition present
21853 before the effective date of an individual's enrollment in
21954 nonprofit agricultural organization health benefits.
22055 Sec. 1682.002. NONPROFIT AGRICULTURAL ORGANIZATION HEALTH
22156 BENEFITS AUTHORIZED. A nonprofit agricultural organization or an
22257 affiliate of the organization may offer in this state nonprofit
22358 agricultural organization health benefits.
22459 Sec. 1682.003. WAITING PERIOD FOR PREEXISTING CONDITION.
22560 Notwithstanding any other provision of this chapter, a nonprofit
22661 agricultural organization that offers nonprofit agricultural
22762 organization health benefits may not require a waiting period of
22863 more than six months for treatment of a preexisting condition
22964 otherwise included in nonprofit agricultural organization health
23065 benefits.
23166 Sec. 1682.004. REQUIRED DISCLOSURE BY NONPROFIT
23267 AGRICULTURAL ORGANIZATION. (a) A nonprofit agricultural
23368 organization that offers nonprofit agricultural organization
23469 health benefits must provide to an individual applying for
23570 nonprofit agricultural organization health benefits written notice
23671 that the benefits are not provided through an insurance policy or
23772 other product the offering or issuance of which is regulated as the
23873 business of insurance in this state.
23974 (b) An individual must sign and return to the nonprofit
24075 agricultural organization the notice described by Subsection (a)
24176 before the individual may enroll in nonprofit agricultural
24277 organization health benefits. The nonprofit agricultural
24378 organization must:
24479 (1) maintain a copy of the signed written notice for
24580 the duration of the term during which the nonprofit agricultural
24681 organization health benefits are provided to the individual; and
24782 (2) at the request of the individual, provide a copy of
24883 the written notice to the individual.
24984 Sec. 1682.005. NONPROFIT AGRICULTURAL ORGANIZATION NOT
250- ENGAGED IN BUSINESS OF HEALTH INSURANCE. Notwithstanding any other
85+ ENGAGED IN BUSINESS OF INSURANCE. Notwithstanding any other
25186 provision of this code, for the purposes of offering nonprofit
25287 agricultural organization health benefits, a nonprofit
25388 agricultural organization that acts in accordance with this chapter
254- is not a health insurer and is not engaging in the business of
255- health insurance in this state.
89+ is not an insurer and is not engaging in the business of insurance
90+ in this state.
25691 Sec. 1682.006. RISK TRANSFER OR COVERAGE. A nonprofit
25792 agricultural organization that offers nonprofit agricultural
25893 organization health benefits under this chapter may contract with a
25994 company authorized to engage in the business of insurance in this
26095 state that is not under common control with the nonprofit
26196 agricultural organization to:
26297 (1) transfer to that company all or a portion of the
26398 organization's risks arising from nonprofit agricultural
26499 organization health benefits offered under this chapter; or
265100 (2) obtain insurance coverage from the company
266101 guarantying the nonprofit agricultural organization's obligations
267102 arising from nonprofit agricultural organization health benefits
268103 offered under this chapter.
269- SECTION 4. This Act takes effect September 1, 2021.
270- ______________________________ ______________________________
271- President of the Senate Speaker of the House
272- I certify that H.B. No. 3924 was passed by the House on May 5,
273- 2021, by the following vote: Yeas 106, Nays 39, 1 present, not
274- voting; and that the House concurred in Senate amendments to H.B.
275- No. 3924 on May 28, 2021, by the following vote: Yeas 104, Nays 42,
276- 2 present, not voting.
277- ______________________________
278- Chief Clerk of the House
279- I certify that H.B. No. 3924 was passed by the Senate, with
280- amendments, on May 22, 2021, by the following vote: Yeas 18, Nays
281- 11.
282- ______________________________
283- Secretary of the Senate
284- APPROVED: __________________
285- Date
286- __________________
287- Governor
104+ Sec. 1682.007. APPLICABILITY OF CERTAIN LAWS TO NONPROFIT
105+ AGRICULTURAL ORGANIZATION HEALTH BENEFITS. Notwithstanding
106+ Section 1682.004, a nonprofit agricultural organization that
107+ offers nonprofit agricultural organization health benefits that
108+ are determined by the commissioner to be structured in the manner of
109+ a preferred provider benefit plan or an exclusive provider benefit
110+ plan, as those terms are defined by Section 1301.001, is subject to
111+ the following laws and rules as if the nonprofit agricultural
112+ organization were an insurer, individuals entitled to nonprofit
113+ agricultural organization health benefits were insureds, and the
114+ nonprofit agricultural organization health benefits were provided
115+ through an insurance policy subject to Chapter 1301:
116+ (1) Section 1301.005;
117+ (2) Section 1301.0053;
118+ (3) Section 1301.0055;
119+ (4) Section 1301.006;
120+ (5) Section 1301.010;
121+ (6) Section 1301.155;
122+ (7) Section 1301.164;
123+ (8) Section 1301.165;
124+ (9) Chapter 1467; and
125+ (10) 28 T.A.C. Chapter 3, Subchapter X.
126+ SECTION 3. This Act takes effect September 1, 2021.
127+ * * * * *