H.B. No. 3924
AN ACT
relating to health benefits offered by certain nonprofit
agricultural organizations.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
by adding Chapter 1275 to read as follows:
CHAPTER 1275. BALANCE BILLING PROHIBITIONS AND OUT-OF-NETWORK
CLAIM DISPUTE RESOLUTION FOR CERTAIN PLANS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1275.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual enrolled in a
health benefit plan to which this chapter applies.
(2) "Usual and customary rate" means the relevant
allowable amount as described by the applicable master benefit plan
document.
Sec. 1275.002. APPLICABILITY OF CHAPTER. This chapter
applies to a health benefit plan offered by a nonprofit
agricultural organization under Chapter 1682.
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE.
(a) The administrator of a health benefit plan to which this
chapter applies shall provide written notice in accordance with
this section in an explanation of benefits provided to the enrollee
and the physician or health care provider in connection with a
health care or medical service or supply provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1275.051, 1275.052, or 1275.053, as applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's health benefit plan and an
itemization of copayments, coinsurance, deductibles, and other
amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1275.051, 1275.052, or 1275.053, as
applicable.
Sec. 1275.004. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION.
Chapter 1467 applies to a health benefit plan to which this chapter
applies, and the administrator of a health benefit plan to which
this chapter applies is an administrator for purposes of that
chapter.
SUBCHAPTER B. PAYMENTS FOR CERTAIN SERVICES; BALANCE BILLING
PROHIBITIONS
Sec. 1275.051. EMERGENCY CARE PAYMENTS. (a) In this
section, "emergency care" has the meaning assigned by Section
1301.155.
(b) The administrator of a health benefit plan to which this
chapter applies shall pay for covered emergency care performed by
or a covered supply related to that care provided by an
out-of-network provider at the usual and customary rate or at an
agreed rate. The administrator shall make a payment required by
this subsection directly to the provider not later than, as
applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(c) For emergency care subject to this section or a supply
related to that care, an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an enrollee in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, and deductible under the enrollee's health benefit
plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) if applicable, a modified amount as
determined under the administrator's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
Sec. 1275.052. OUT-OF-NETWORK FACILITY-BASED PROVIDER
PAYMENTS. (a) In this section, "facility-based provider" means a
physician or health care provider who provides health care or
medical services to patients of a health care facility.
(b) Except as provided by Subsection (d), the administrator
of a health benefit plan to which this chapter applies shall pay for
a covered health care or medical service performed for or a covered
supply related to that service provided to an enrollee by an
out-of-network provider who is a facility-based provider at the
usual and customary rate or at an agreed rate if the provider
performed the service at a health care facility that is a
participating provider. The administrator shall make a payment
required by this subsection directly to the provider not later
than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a facility-based provider or a person asserting a
claim as an agent or assignee of the provider may not bill an
enrollee receiving a health care or medical service or supply
described by Subsection (b) in, and the enrollee does not have
financial responsibility for, an amount greater than an applicable
copayment, coinsurance, and deductible under the enrollee's health
benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) if applicable, a modified amount as
determined under the administrator's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) This section does not apply to a nonemergency health
care or medical service:
(1) that an enrollee elects to receive in writing in
advance of the service with respect to each out-of-network provider
providing the service; and
(2) for which an out-of-network provider, before
providing the service, provides a complete written disclosure to
the enrollee that:
(A) explains that the provider does not have a
contract with the enrollee's health benefit plan;
(B) discloses projected amounts for which the
enrollee may be responsible; and
(C) discloses the circumstances under which the
enrollee would be responsible for those amounts.
Sec. 1275.053. OUT-OF-NETWORK DIAGNOSTIC IMAGING PROVIDER
OR LABORATORY SERVICE PROVIDER PAYMENTS. (a) In this section,
"diagnostic imaging provider" and "laboratory service provider"
have the meanings assigned by Section 1467.001.
(b) Except as provided by Subsection (d), the administrator
of a health benefit plan to which this chapter applies shall pay for
a covered health care or medical service performed for or a covered
supply related to that service provided to an enrollee by an
out-of-network provider who is a diagnostic imaging provider or
laboratory service provider at the usual and customary rate or at an
agreed rate if the provider performed the service in connection
with a health care or medical service performed by a participating
provider. The administrator shall make a payment required by this
subsection directly to the provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a diagnostic imaging provider or laboratory service
provider or a person asserting a claim as an agent or assignee of
the provider may not bill an enrollee receiving a health care or
medical service or supply described by Subsection (b) in, and the
enrollee does not have financial responsibility for, an amount
greater than an applicable copayment, coinsurance, and deductible
under the enrollee's health benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) if applicable, the modified amount as
determined under the administrator's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) This section does not apply to a nonemergency health
care or medical service:
(1) that an enrollee elects to receive in writing in
advance of the service with respect to each out-of-network provider
providing the service; and
(2) for which an out-of-network provider, before
providing the service, provides a complete written disclosure to
the enrollee that:
(A) explains that the provider does not have a
contract with the enrollee's health benefit plan;
(B) discloses projected amounts for which the
enrollee may be responsible; and
(C) discloses the circumstances under which the
enrollee would be responsible for those amounts.
SECTION 2. The heading to Subtitle K, Title 8, Insurance
Code, is amended to read as follows:
SUBTITLE K. CERTAIN BENEFITS AND ARRANGEMENTS THAT ARE NOT
INSURANCE [HEALTH CARE SHARING MINISTRIES]
SECTION 3. Subtitle K, Title 8, Insurance Code, is amended
by adding Chapter 1682 to read as follows:
CHAPTER 1682. HEALTH BENEFITS PROVIDED BY CERTAIN NONPROFIT
AGRICULTURAL ORGANIZATIONS
Sec. 1682.001. DEFINITIONS. In this chapter:
(1) "Nonprofit agricultural organization" means an
organization that:
(A) is exempt from taxation under Section 501(a),
Internal Revenue Code of 1986, as an organization described by
Section 501(c)(5) of that code;
(B) is domiciled in this state;
(C) was in existence prior to 1940;
(D) is composed of members who are residents of
at least 98 percent of the counties in this state;
(E) collects annual dues from its members; and
(F) was created to promote and develop the most
profitable and desirable system of agriculture and the most
wholesome and satisfactory conditions of rural life in accordance
with its articles of organization and bylaws.
(2) "Nonprofit agricultural organization health
benefits" means health benefits:
(A) sponsored by a nonprofit agricultural
organization or an affiliate of the organization;
(B) offered only to:
(i) members of the nonprofit agricultural
organization; and
(ii) family members of members of the
nonprofit agricultural organization;
(C) that are not provided through an insurance
policy or other product the offering or issuance of which is
regulated as the business of insurance in this state; and
(D) that are deemed by the nonprofit agricultural
organization to be important in assisting its members to live long
and productive lives.
(3) "Preexisting condition" means a condition present
before the effective date of an individual's enrollment in
nonprofit agricultural organization health benefits.
Sec. 1682.002. NONPROFIT AGRICULTURAL ORGANIZATION HEALTH
BENEFITS AUTHORIZED. A nonprofit agricultural organization or an
affiliate of the organization may offer in this state nonprofit
agricultural organization health benefits.
Sec. 1682.003. WAITING PERIOD FOR PREEXISTING CONDITION.
Notwithstanding any other provision of this chapter, a nonprofit
agricultural organization that offers nonprofit agricultural
organization health benefits may not require a waiting period of
more than six months for treatment of a preexisting condition
otherwise included in nonprofit agricultural organization health
benefits.
Sec. 1682.004. REQUIRED DISCLOSURE BY NONPROFIT
AGRICULTURAL ORGANIZATION. (a) A nonprofit agricultural
organization that offers nonprofit agricultural organization
health benefits must provide to an individual applying for
nonprofit agricultural organization health benefits written notice
that the benefits are not provided through an insurance policy or
other product the offering or issuance of which is regulated as the
business of insurance in this state.
(b) An individual must sign and return to the nonprofit
agricultural organization the notice described by Subsection (a)
before the individual may enroll in nonprofit agricultural
organization health benefits. The nonprofit agricultural
organization must:
(1) maintain a copy of the signed written notice for
the duration of the term during which the nonprofit agricultural
organization health benefits are provided to the individual; and
(2) at the request of the individual, provide a copy of
the written notice to the individual.
Sec. 1682.005. NONPROFIT AGRICULTURAL ORGANIZATION NOT
ENGAGED IN BUSINESS OF HEALTH INSURANCE. Notwithstanding any other
provision of this code, for the purposes of offering nonprofit
agricultural organization health benefits, a nonprofit
agricultural organization that acts in accordance with this chapter
is not a health insurer and is not engaging in the business of
health insurance in this state.
Sec. 1682.006. RISK TRANSFER OR COVERAGE. A nonprofit
agricultural organization that offers nonprofit agricultural
organization health benefits under this chapter may contract with a
company authorized to engage in the business of insurance in this
state that is not under common control with the nonprofit
agricultural organization to:
(1) transfer to that company all or a portion of the
organization's risks arising from nonprofit agricultural
organization health benefits offered under this chapter; or
(2) obtain insurance coverage from the company
guarantying the nonprofit agricultural organization's obligations
arising from nonprofit agricultural organization health benefits
offered under this chapter.
SECTION 4. This Act takes effect September 1, 2021.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 3924 was passed by the House on May 5,
2021, by the following vote: Yeas 106, Nays 39, 1 present, not
voting; and that the House concurred in Senate amendments to H.B.
No. 3924 on May 28, 2021, by the following vote: Yeas 104, Nays 42,
2 present, not voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 3924 was passed by the Senate, with
amendments, on May 22, 2021, by the following vote: Yeas 18, Nays
11.
______________________________
Secretary of the Senate
APPROVED: __________________
Date
__________________
Governor