| 1 | 1 | | By: Muñoz, Jr. H.B. No. 1364 |
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| 2 | 2 | | |
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| 3 | 3 | | |
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| 4 | 4 | | A BILL TO BE ENTITLED |
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| 5 | 5 | | AN ACT |
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| 6 | 6 | | relating to a direct payment to a health care provider in lieu of a |
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| 7 | 7 | | claim for benefits under a health benefit plan. |
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| 8 | 8 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 9 | 9 | | SECTION 1. Chapter 1204, Insurance Code, is amended by |
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| 10 | 10 | | adding Subchapter G to read as follows: |
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| 11 | 11 | | SUBCHAPTER G. DIRECT PAYMENT TO HEALTH CARE PROVIDER |
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| 12 | 12 | | Sec. 1204.301. DEFINITION. In this subchapter, "health |
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| 13 | 13 | | care provider" means a health care practitioner or health care |
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| 14 | 14 | | facility that provides health care services under a license, |
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| 15 | 15 | | certificate, registration, or other similar evidence of regulation |
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| 16 | 16 | | issued by this or another state of the United States. |
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| 17 | 17 | | Sec. 1204.302. APPLICABILITY OF SUBCHAPTER. (a) This |
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| 18 | 18 | | subchapter applies only to a health benefit plan that provides |
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| 19 | 19 | | benefits for medical or surgical expenses incurred as a result of a |
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| 20 | 20 | | health condition, accident, or sickness, including an individual, |
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| 21 | 21 | | group, blanket, or franchise insurance policy or insurance |
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| 22 | 22 | | agreement, a group hospital service contract, or an individual or |
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| 23 | 23 | | group evidence of coverage or similar coverage document that is |
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| 24 | 24 | | offered by: |
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| 25 | 25 | | (1) an insurance company; |
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| 26 | 26 | | (2) a group hospital service corporation operating |
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| 27 | 27 | | under Chapter 842; |
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| 28 | 28 | | (3) a health maintenance organization operating under |
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| 29 | 29 | | Chapter 843; |
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| 30 | 30 | | (4) an approved nonprofit health corporation that |
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| 31 | 31 | | holds a certificate of authority under Chapter 844; |
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| 32 | 32 | | (5) a multiple employer welfare arrangement that holds |
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| 33 | 33 | | a certificate of authority under Chapter 846; |
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| 34 | 34 | | (6) a stipulated premium company operating under |
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| 35 | 35 | | Chapter 884; |
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| 36 | 36 | | (7) a fraternal benefit society operating under |
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| 37 | 37 | | Chapter 885; |
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| 38 | 38 | | (8) a Lloyd's plan operating under Chapter 941; or |
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| 39 | 39 | | (9) an exchange operating under Chapter 942. |
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| 40 | 40 | | (b) Notwithstanding any other law, this subchapter applies |
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| 41 | 41 | | to: |
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| 42 | 42 | | (1) a small employer health benefit plan subject to |
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| 43 | 43 | | Chapter 1501, including coverage provided through a health group |
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| 44 | 44 | | cooperative under Subchapter B of that chapter; |
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| 45 | 45 | | (2) a standard health benefit plan issued under |
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| 46 | 46 | | Chapter 1507; |
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| 47 | 47 | | (3) a basic coverage plan under Chapter 1551; |
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| 48 | 48 | | (4) a basic plan under Chapter 1575; |
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| 49 | 49 | | (5) a primary care coverage plan under Chapter 1579; |
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| 50 | 50 | | (6) a plan providing basic coverage under Chapter |
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| 51 | 51 | | 1601; |
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| 52 | 52 | | (7) health benefits provided by or through a church |
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| 53 | 53 | | benefits board under Subchapter I, Chapter 22, Business |
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| 54 | 54 | | Organizations Code; |
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| 55 | 55 | | (8) the state Medicaid program, including the Medicaid |
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| 56 | 56 | | managed care program operated under Chapter 533, Government Code; |
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| 57 | 57 | | (9) the child health plan program under Chapter 62, |
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| 58 | 58 | | Health and Safety Code; |
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| 59 | 59 | | (10) a regional or local health care program operated |
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| 60 | 60 | | under Section 75.104, Health and Safety Code; |
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| 61 | 61 | | (11) a self-funded health benefit plan sponsored by a |
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| 62 | 62 | | professional employer organization under Chapter 91, Labor Code; |
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| 63 | 63 | | (12) county employee group health benefits provided |
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| 64 | 64 | | under Chapter 157, Local Government Code; and |
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| 65 | 65 | | (13) health and accident coverage provided by a risk |
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| 66 | 66 | | pool created under Chapter 172, Local Government Code. |
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| 67 | 67 | | Sec. 1204.303. DIRECT PAYMENT IN LIEU OF CLAIM FOR |
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| 68 | 68 | | BENEFITS; EFFECT ON PLAN. (a) A health care provider may not be |
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| 69 | 69 | | prohibited from accepting directly from an enrollee full payment |
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| 70 | 70 | | for a health care service in lieu of submitting a claim to the |
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| 71 | 71 | | enrollee's health benefit plan. |
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| 72 | 72 | | (b) Notwithstanding Section 552.003 or any other law, a |
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| 73 | 73 | | health care provider's discounted cash price for services rendered |
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| 74 | 74 | | is considered full payment for purposes of Subsection (a). |
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| 75 | 75 | | (c) A health benefit plan shall apply the charge for a |
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| 76 | 76 | | health care service for which a health care provider accepts a |
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| 77 | 77 | | payment described by Subsection (a) from an enrollee towards the |
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| 78 | 78 | | enrollee's out-of-pocket maximum if the service is a covered |
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| 79 | 79 | | service under the plan. Payments for uncovered services are |
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| 80 | 80 | | ineligible to apply towards an enrollee's out-of-pocket maximum. |
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| 81 | 81 | | SECTION 2. If before implementing any provision of this Act |
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| 82 | 82 | | a state agency determines that a waiver or authorization from a |
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| 83 | 83 | | federal agency is necessary for implementation of that provision, |
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| 84 | 84 | | the agency affected by the provision shall request the waiver or |
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| 85 | 85 | | authorization and may delay implementing that provision until the |
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| 86 | 86 | | waiver or authorization is granted. |
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| 87 | 87 | | SECTION 3. Section 1204.303, Insurance Code, as added by |
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| 88 | 88 | | this Act, applies only to a health benefit plan delivered, issued |
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| 89 | 89 | | for delivery, or renewed on or after January 1, 2024. |
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| 90 | 90 | | SECTION 4. This Act takes effect September 1, 2023. |
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