Texas 2023 - 88th Regular

Texas House Bill HB5186 Compare Versions

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Version 2 (New)

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1	1	88R23921 JES-F
2	2	By: Bonnen H.B. No. 5186
3	3	Substitute the following for H.B. No. 5186:
4	4	By: Capriglione C.S.H.B. No. 5186
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the establishment of the state health benefit plan
10	10	reimbursement review board and the reimbursement for health care
11	11	services or supplies provided under certain state-funded health
12	12	benefit plans.
13	13	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
14	14	SECTION 1. Subtitle C, Title 3, Government Code, is amended
15	15	by adding Chapter 331 to read as follows:
16	16	CHAPTER 331. STATE HEALTH BENEFIT PLAN REIMBURSEMENT REVIEW BOARD
17	17	Sec. 331.001. DEFINITIONS. In this chapter:
18	18	(1) "Board" means the state health benefit plan
19	19	reimbursement review board.
20	20	(2) "Enrollee" means an individual entitled to health
21	21	benefit coverage under a state health benefit plan.
22	22	(3) "Facility" means:
23	23	(A) a hospital;
24	24	(B) an ambulatory surgical center licensed under
25	25	Chapter 243, Health and Safety Code;
26	26	(C) a birthing center; or
27	27	(D) a freestanding emergency medical care
28	28	facility, as defined by Section 254.001, Health and Safety Code,
29	29	including a freestanding emergency medical care facility that is
30	30	exempt from the licensing requirements of Chapter 254, Health and
31	31	Safety Code, under Section 254.052(8), Health and Safety Code.
32	32	(4) "State health benefit plan" means a health benefit
33	33	plan provided under Chapter 1551, 1575, 1579, or 1601, Insurance
34	34	Code.
35	35	Sec. 331.002. ESTABLISHMENT; PURPOSE. The state health
36	36	benefit plan reimbursement review board is established for the
37	37	purpose of controlling present and future cost growth for state
38	38	health benefit plans while maintaining access for enrollees to
39	39	high-quality health care services and supplies.
40	40	Sec. 331.003. MEMBERSHIP. (a) The board consists of:
41	41	(1) the lieutenant governor;
42	42	(2) the speaker of the house of representatives;
43	43	(3) the chair of the senate finance committee;
44	44	(4) the chair of the house appropriations committee;
45	45	(5) three members of the senate appointed by the
46	46	lieutenant governor; and
47	47	(6) three members of the house appointed by the
48	48	speaker.
49	49	(b) The lieutenant governor and the speaker of the house of
50	50	representatives are joint chairs of the board.
51	51	Sec. 331.004. QUORUM; MEETINGS. (a) A majority of the
52	52	members of the board from each house constitutes a quorum to
53	53	transact business. If a quorum is present, the board may act on any
54	54	matter that is within its jurisdiction by a majority vote.
55	55	(b) The board shall meet as often as necessary to perform
56	56	the board's duties. Meetings may be held at any time at the request
57	57	of either of the joint chairs of the board.
58	58	(c) The board shall meet in Austin, except that if a
59	59	majority of the members of the board from each house agree, the
60	60	board may meet in any location determined by the board.
61	61	(d) As an exception to Chapter 551 and other law, if a
62	62	meeting is located in Austin and the joint chairs of the board are
63	63	physically present at the meeting, then any number of the other
64	64	members of the board may attend the meeting by use of telephone
65	65	conference call, video conference call, or other similar
66	66	telecommunication device. This subsection applies for purposes of
67	67	constituting a quorum, for purposes of voting, and for any other
68	68	purpose allowing a member of the board to otherwise fully
69	69	participate in any meeting of the board. This subsection applies
70	70	without exception with regard to the subject of the meeting or
71	71	topics considered by the members.
72	72	(e) A meeting held by use of telephone conference call,
73	73	video conference call, or other similar telecommunication device:
74	74	(1) is subject to the notice requirements applicable
75	75	to other meetings;
76	76	(2) must specify in the notice of the meeting the
77	77	location in Austin of the meeting at which the joint chairs will be
78	78	physically present;
79	79	(3) must be open to the public and shall be audible to
80	80	the public at the location in Austin specified in the notice of the
81	81	meeting as the location of the meeting at which the joint chairs
82	82	will be physically present; and
83	83	(4) must provide two-way audio communication between
84	84	all members of the board attending the meeting during the entire
85	85	meeting, and if the two-way audio communication link with any
86	86	member attending the meeting is disrupted at any time, the meeting
87	87	may not continue until the two-way audio communication link is
88	88	reestablished.
89	89	Sec. 331.005. DUTY TO ADOPT REIMBURSEMENT STRUCTURE. The
90	90	board shall adopt a provider reimbursement structure, regardless of
91	91	methodology, that each state health benefit plan will use to
92	92	determine reimbursement to a facility for a health care service or
93	93	supply, determined by provider type and class and according to
94	94	whether the facility is an in-network or out-of-network facility.
95	95	The board may not adopt a reimbursement structure that is in excess
96	96	of the aggregated provider reimbursement, regardless of
97	97	methodology, reported by participating state health benefit plans
98	98	under Section 331.006 for that health care service or supply.
99	99	Sec. 331.006. REPORTS BY STATE HEALTH BENEFIT PLANS. (a)
100	100	Each state health benefit plan shall submit to the board in the form
101	101	and manner prescribed by the board a report that includes:
102	102	(1) information on reimbursements and costs for
103	103	applicable provider types and classes paid by that plan during the
104	104	preceding plan year;
105	105	(2) recommendations to the board regarding the
106	106	provider reimbursement structure to be adopted by the board; and
107	107	(3) a summary of public comments received by the plan
108	108	on the recommendations provided to the board under Subdivision (2).
109	109	(b) Each state health benefit plan shall, before submitting
110	110	the report required under Subsection (a), allow for public comment
111	111	on the plan's recommendations to be submitted under that
112	112	subsection.
113	113	Sec. 331.007. REIMBURSEMENT STRUCTURE REPORT. (a) The
114	114	board shall analyze the reports submitted under Section 331.006,
115	115	including the recommendations provided, and issue a report on the
116	116	reimbursement structure for state health benefit plans. The report
117	117	issued by the board must:
118	118	(1) establish a provider reimbursement structure,
119	119	regardless of methodology, in accordance with Section 331.005 that
120	120	provides for reimbursement that a facility that provides health
121	121	care services or supplies to an enrollee under a state health
122	122	benefit plan will receive for those health care services or
123	123	supplies and specify any other requirements or limitations related
124	124	to reimbursement;
125	125	(2) be made publicly available on an Internet website;
126	126	and
127	127	(3) specify that the reimbursement structure in the
128	128	report is applicable to each state health benefit plan for each plan
129	129	year beginning after the date the report is issued until the plan
130	130	year beginning after the date a later report is issued under this
131	131	subsection.
132	132	(b) The reimbursement structure adopted by the board's
133	133	report under Subsection (a) is applicable to a state health benefit
134	134	plan for each plan year beginning after the date the report is
135	135	issued until the plan year beginning after the date a later report
136	136	is issued under Subsection (a).
137	137	SECTION 2. Subchapter A, Chapter 1551, Insurance Code, is
138	138	amended by adding Section 1551.016 to read as follows:
139	139	Sec. 1551.016. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
140	140	In this section:
141	141	(1) "Facility" has the meaning assigned by Section
142	142	331.001, Government Code.
143	143	(2) "Review board" means the state health benefit plan
144	144	reimbursement review board established under Chapter 331,
145	145	Government Code.
146	146	(b) Notwithstanding any other law or a provision of a
147	147	contract to the contrary, and subject to limitations imposed by the
148	148	General Appropriations Act, a facility that bills the group
149	149	benefits program, an administering firm, or a health benefit plan
150	150	provided under this chapter, or a designee of the program, firm, or
151	151	plan, for a health care service or supply provided to a plan
152	152	enrollee must be reimbursed for the health care service or supply in
153	153	accordance with the reimbursement structure adopted for the service
154	154	or supply by the review board for the applicable plan year.
155	155	(c) A facility that receives reimbursement for a health care
156	156	service or supply as provided by Subsection (b) must consider that
157	157	reimbursement as payment in full for the service or supply. Except
158	158	as provided by this subsection, the facility may not charge an
159	159	enrollee to recover from the enrollee the balance of the facility's
160	160	fee for a service or supply received by the enrollee from the
161	161	facility that is not fully reimbursed under Subsection (b). The
162	162	facility may charge the enrollee an applicable copayment,
163	163	coinsurance, or deductible under the enrollee's health benefit
164	164	plan.
165	165	(d) A facility may not discriminate against an enrollee or
166	166	the group benefits program based on the limitation on reimbursement
167	167	under Subsection (b) by:
168	168	(1) refusing to provide health care services or
169	169	supplies to the enrollee; or
170	170	(2) providing health care services or supplies of a
171	171	lower quality to the enrollee than those the facility provides to
172	172	similar patients who are not enrolled in a health benefit plan under
173	173	this chapter.
174	174	SECTION 3. Subchapter A, Chapter 1575, Insurance Code, is
175	175	amended by adding Section 1575.011 to read as follows:
176	176	Sec. 1575.011. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
177	177	In this section:
178	178	(1) "Facility" has the meaning assigned by Section
179	179	331.001, Government Code.
180	180	(2) "Review board" means the state health benefit plan
181	181	reimbursement review board established under Chapter 331,
182	182	Government Code.
183	183	(b) Notwithstanding any other law or a provision of a
184	184	contract to the contrary, and subject to limitations imposed by the
185	185	General Appropriations Act, a facility that bills the group
186	186	program, an administrator of a health benefit plan provided under
187	187	this chapter, or a health benefit plan provided under this chapter,
188	188	or a designee of the program, administrator, or plan, for a health
189	189	care service or supply provided to a plan enrollee must be
190	190	reimbursed for the health care service or supply in accordance with
191	191	the reimbursement structure adopted for the service or supply by
192	192	the review board for the applicable plan year.
193	193	(c) A facility that receives reimbursement for a health care
194	194	service or supply as provided by Subsection (b) must consider that
195	195	reimbursement as payment in full for the service or supply. Except
196	196	as provided by this subsection, the facility may not charge an
197	197	enrollee to recover from the enrollee the balance of the facility's
198	198	fee for a service or supply received by the enrollee from the
199	199	facility that is not fully reimbursed under Subsection (b). The
200	200	facility may charge the enrollee an applicable copayment,
201	201	coinsurance, or deductible under the enrollee's health benefit
202	202	plan.
203	203	(d) A facility may not discriminate against an enrollee or
204	204	the group program based on the limitation on reimbursement under
205	205	Subsection (b) by:
206	206	(1) refusing to provide health care services or
207	207	supplies to the enrollee; or
208	208	(2) providing health care services or supplies of a
209	209	lower quality to the enrollee than those the facility provides to
210	210	similar patients who are not enrolled in a health benefit plan under
211	211	this chapter.
212	212	SECTION 4. Subchapter A, Chapter 1579, Insurance Code, is
213	213	amended by adding Section 1579.011 to read as follows:
214	214	Sec. 1579.011. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
215	215	In this section:
216	216	(1) "Facility" has the meaning assigned by Section
217	217	331.001, Government Code.
218	218	(2) "Review board" means the state health benefit plan
219	219	reimbursement review board established under Chapter 331,
220	220	Government Code.
221	221	(b) Notwithstanding any other law or a provision of a
222	222	contract to the contrary, and subject to limitations imposed by the
223	223	General Appropriations Act, a facility that bills the program, an
224	224	administering firm, or a health coverage plan provided under this
225	225	chapter, or a designee of the program, firm, or plan, for a health
226	226	care service or supply provided to a plan enrollee must be
227	227	reimbursed for the health care service or supply in accordance with
228	228	the reimbursement structure adopted for the service or supply by
229	229	the review board for the applicable plan year.
230	230	(c) A facility that receives reimbursement for a health care
231	231	service or supply as provided by Subsection (b) must consider that
232	232	reimbursement as payment in full for the service or supply. Except
233	233	as provided by this subsection, the facility may not charge an
234	234	enrollee to recover from the enrollee the balance of the facility's
235	235	fee for a service or supply received by the enrollee from the
236	236	facility that is not fully reimbursed under Subsection (b). The
237	237	facility may charge the enrollee an applicable copayment,
238	238	coinsurance, or deductible under the enrollee's health coverage
239	239	plan.
240	240	(d) A facility may not discriminate against an enrollee or
241	241	the program based on the limitation on reimbursement under
242	242	Subsection (b) by:
243	243	(1) refusing to provide health care services or
244	244	supplies to the enrollee; or
245	245	(2) providing health care services or supplies of a
246	246	lower quality to the enrollee than those the facility provides to
247	247	similar patients who are not enrolled in a health coverage plan
248	248	under this chapter.
249	249	SECTION 5. Subchapter A, Chapter 1601, Insurance Code, is
250	250	amended by adding Section 1601.012 to read as follows:
251	251	Sec. 1601.012. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
252	252	In this section:
253	253	(1) "Facility" has the meaning assigned by Section
254	254	331.001, Government Code.
255	255	(2) "Review board" means the state health benefit plan
256	256	reimbursement review board established under Chapter 331,
257	257	Government Code.
258	258	(b) Notwithstanding any other law or a provision of a
259	259	contract to the contrary, and subject to limitations imposed by the
260	260	General Appropriations Act, a facility that bills the uniform
261	261	program, an administering carrier, or a health benefit plan
262	262	provided under this chapter, or a designee of the program, carrier,
263	263	or plan, for a health care service or supply provided to a plan
264	264	enrollee must be reimbursed for the health care service or supply in
265	265	accordance with the reimbursement structure adopted for the service
266	266	or supply by the review board for the applicable plan year.
267	267	(c) A facility that receives reimbursement for a health care
268	268	service or supply as provided by Subsection (b) must consider that
269	269	reimbursement as payment in full for the service or supply. Except
270	270	as provided by this subsection, the facility may not charge an
271	271	enrollee to recover from the enrollee the balance of the facility's
272	272	fee for a service or supply received by the enrollee from the
273	273	facility that is not fully reimbursed under Subsection (b). The
274	274	facility may charge the enrollee an applicable copayment,
275	275	coinsurance, or deductible under the enrollee's health benefit
276	276	plan.
277	277	(d) A facility may not discriminate against an enrollee or
278	278	the uniform program based on the limitation on reimbursement under
279	279	Subsection (b) by:
280	280	(1) refusing to provide health care services or
281	281	supplies to the enrollee; or
282	282	(2) providing health care services or supplies of a
283	283	lower quality to the enrollee than those the facility provides to
284	284	similar patients who are not enrolled in a health benefit plan under
285	285	this chapter.
286	286	SECTION 6. The changes in law made by this Act apply only
287	287	to:
288	288	(1) a plan year beginning on or after September 1,
289	289	2024; and
290	290	(2) a contract entered into or renewed on or after
291	291	September 1, 2023.
292	292	SECTION 7. This Act takes effect September 1, 2023.