88R23921 JES-F
By: Bonnen H.B. No. 5186
Substitute the following for H.B. No. 5186:
By: Capriglione C.S.H.B. No. 5186
A BILL TO BE ENTITLED
AN ACT
relating to the establishment of the state health benefit plan
reimbursement review board and the reimbursement for health care
services or supplies provided under certain state-funded health
benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 3, Government Code, is amended
by adding Chapter 331 to read as follows:
CHAPTER 331. STATE HEALTH BENEFIT PLAN REIMBURSEMENT REVIEW BOARD
Sec. 331.001. DEFINITIONS. In this chapter:
(1) "Board" means the state health benefit plan
reimbursement review board.
(2) "Enrollee" means an individual entitled to health
benefit coverage under a state health benefit plan.
(3) "Facility" means:
(A) a hospital;
(B) an ambulatory surgical center licensed under
Chapter 243, Health and Safety Code;
(C) a birthing center; or
(D) a freestanding emergency medical care
facility, as defined by Section 254.001, Health and Safety Code,
including a freestanding emergency medical care facility that is
exempt from the licensing requirements of Chapter 254, Health and
Safety Code, under Section 254.052(8), Health and Safety Code.
(4) "State health benefit plan" means a health benefit
plan provided under Chapter 1551, 1575, 1579, or 1601, Insurance
Code.
Sec. 331.002. ESTABLISHMENT; PURPOSE. The state health
benefit plan reimbursement review board is established for the
purpose of controlling present and future cost growth for state
health benefit plans while maintaining access for enrollees to
high-quality health care services and supplies.
Sec. 331.003. MEMBERSHIP. (a) The board consists of:
(1) the lieutenant governor;
(2) the speaker of the house of representatives;
(3) the chair of the senate finance committee;
(4) the chair of the house appropriations committee;
(5) three members of the senate appointed by the
lieutenant governor; and
(6) three members of the house appointed by the
speaker.
(b) The lieutenant governor and the speaker of the house of
representatives are joint chairs of the board.
Sec. 331.004. QUORUM; MEETINGS. (a) A majority of the
members of the board from each house constitutes a quorum to
transact business. If a quorum is present, the board may act on any
matter that is within its jurisdiction by a majority vote.
(b) The board shall meet as often as necessary to perform
the board's duties. Meetings may be held at any time at the request
of either of the joint chairs of the board.
(c) The board shall meet in Austin, except that if a
majority of the members of the board from each house agree, the
board may meet in any location determined by the board.
(d) As an exception to Chapter 551 and other law, if a
meeting is located in Austin and the joint chairs of the board are
physically present at the meeting, then any number of the other
members of the board may attend the meeting by use of telephone
conference call, video conference call, or other similar
telecommunication device. This subsection applies for purposes of
constituting a quorum, for purposes of voting, and for any other
purpose allowing a member of the board to otherwise fully
participate in any meeting of the board. This subsection applies
without exception with regard to the subject of the meeting or
topics considered by the members.
(e) A meeting held by use of telephone conference call,
video conference call, or other similar telecommunication device:
(1) is subject to the notice requirements applicable
to other meetings;
(2) must specify in the notice of the meeting the
location in Austin of the meeting at which the joint chairs will be
physically present;
(3) must be open to the public and shall be audible to
the public at the location in Austin specified in the notice of the
meeting as the location of the meeting at which the joint chairs
will be physically present; and
(4) must provide two-way audio communication between
all members of the board attending the meeting during the entire
meeting, and if the two-way audio communication link with any
member attending the meeting is disrupted at any time, the meeting
may not continue until the two-way audio communication link is
reestablished.
Sec. 331.005. DUTY TO ADOPT REIMBURSEMENT STRUCTURE. The
board shall adopt a provider reimbursement structure, regardless of
methodology, that each state health benefit plan will use to
determine reimbursement to a facility for a health care service or
supply, determined by provider type and class and according to
whether the facility is an in-network or out-of-network facility.
The board may not adopt a reimbursement structure that is in excess
of the aggregated provider reimbursement, regardless of
methodology, reported by participating state health benefit plans
under Section 331.006 for that health care service or supply.
Sec. 331.006. REPORTS BY STATE HEALTH BENEFIT PLANS. (a)
Each state health benefit plan shall submit to the board in the form
and manner prescribed by the board a report that includes:
(1) information on reimbursements and costs for
applicable provider types and classes paid by that plan during the
preceding plan year;
(2) recommendations to the board regarding the
provider reimbursement structure to be adopted by the board; and
(3) a summary of public comments received by the plan
on the recommendations provided to the board under Subdivision (2).
(b) Each state health benefit plan shall, before submitting
the report required under Subsection (a), allow for public comment
on the plan's recommendations to be submitted under that
subsection.
Sec. 331.007. REIMBURSEMENT STRUCTURE REPORT. (a) The
board shall analyze the reports submitted under Section 331.006,
including the recommendations provided, and issue a report on the
reimbursement structure for state health benefit plans. The report
issued by the board must:
(1) establish a provider reimbursement structure,
regardless of methodology, in accordance with Section 331.005 that
provides for reimbursement that a facility that provides health
care services or supplies to an enrollee under a state health
benefit plan will receive for those health care services or
supplies and specify any other requirements or limitations related
to reimbursement;
(2) be made publicly available on an Internet website;
and
(3) specify that the reimbursement structure in the
report is applicable to each state health benefit plan for each plan
year beginning after the date the report is issued until the plan
year beginning after the date a later report is issued under this
subsection.
(b) The reimbursement structure adopted by the board's
report under Subsection (a) is applicable to a state health benefit
plan for each plan year beginning after the date the report is
issued until the plan year beginning after the date a later report
is issued under Subsection (a).
SECTION 2. Subchapter A, Chapter 1551, Insurance Code, is
amended by adding Section 1551.016 to read as follows:
Sec. 1551.016. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
In this section:
(1) "Facility" has the meaning assigned by Section
331.001, Government Code.
(2) "Review board" means the state health benefit plan
reimbursement review board established under Chapter 331,
Government Code.
(b) Notwithstanding any other law or a provision of a
contract to the contrary, and subject to limitations imposed by the
General Appropriations Act, a facility that bills the group
benefits program, an administering firm, or a health benefit plan
provided under this chapter, or a designee of the program, firm, or
plan, for a health care service or supply provided to a plan
enrollee must be reimbursed for the health care service or supply in
accordance with the reimbursement structure adopted for the service
or supply by the review board for the applicable plan year.
(c) A facility that receives reimbursement for a health care
service or supply as provided by Subsection (b) must consider that
reimbursement as payment in full for the service or supply. Except
as provided by this subsection, the facility may not charge an
enrollee to recover from the enrollee the balance of the facility's
fee for a service or supply received by the enrollee from the
facility that is not fully reimbursed under Subsection (b). The
facility may charge the enrollee an applicable copayment,
coinsurance, or deductible under the enrollee's health benefit
plan.
(d) A facility may not discriminate against an enrollee or
the group benefits program based on the limitation on reimbursement
under Subsection (b) by:
(1) refusing to provide health care services or
supplies to the enrollee; or
(2) providing health care services or supplies of a
lower quality to the enrollee than those the facility provides to
similar patients who are not enrolled in a health benefit plan under
this chapter.
SECTION 3. Subchapter A, Chapter 1575, Insurance Code, is
amended by adding Section 1575.011 to read as follows:
Sec. 1575.011. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
In this section:
(1) "Facility" has the meaning assigned by Section
331.001, Government Code.
(2) "Review board" means the state health benefit plan
reimbursement review board established under Chapter 331,
Government Code.
(b) Notwithstanding any other law or a provision of a
contract to the contrary, and subject to limitations imposed by the
General Appropriations Act, a facility that bills the group
program, an administrator of a health benefit plan provided under
this chapter, or a health benefit plan provided under this chapter,
or a designee of the program, administrator, or plan, for a health
care service or supply provided to a plan enrollee must be
reimbursed for the health care service or supply in accordance with
the reimbursement structure adopted for the service or supply by
the review board for the applicable plan year.
(c) A facility that receives reimbursement for a health care
service or supply as provided by Subsection (b) must consider that
reimbursement as payment in full for the service or supply. Except
as provided by this subsection, the facility may not charge an
enrollee to recover from the enrollee the balance of the facility's
fee for a service or supply received by the enrollee from the
facility that is not fully reimbursed under Subsection (b). The
facility may charge the enrollee an applicable copayment,
coinsurance, or deductible under the enrollee's health benefit
plan.
(d) A facility may not discriminate against an enrollee or
the group program based on the limitation on reimbursement under
Subsection (b) by:
(1) refusing to provide health care services or
supplies to the enrollee; or
(2) providing health care services or supplies of a
lower quality to the enrollee than those the facility provides to
similar patients who are not enrolled in a health benefit plan under
this chapter.
SECTION 4. Subchapter A, Chapter 1579, Insurance Code, is
amended by adding Section 1579.011 to read as follows:
Sec. 1579.011. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
In this section:
(1) "Facility" has the meaning assigned by Section
331.001, Government Code.
(2) "Review board" means the state health benefit plan
reimbursement review board established under Chapter 331,
Government Code.
(b) Notwithstanding any other law or a provision of a
contract to the contrary, and subject to limitations imposed by the
General Appropriations Act, a facility that bills the program, an
administering firm, or a health coverage plan provided under this
chapter, or a designee of the program, firm, or plan, for a health
care service or supply provided to a plan enrollee must be
reimbursed for the health care service or supply in accordance with
the reimbursement structure adopted for the service or supply by
the review board for the applicable plan year.
(c) A facility that receives reimbursement for a health care
service or supply as provided by Subsection (b) must consider that
reimbursement as payment in full for the service or supply. Except
as provided by this subsection, the facility may not charge an
enrollee to recover from the enrollee the balance of the facility's
fee for a service or supply received by the enrollee from the
facility that is not fully reimbursed under Subsection (b). The
facility may charge the enrollee an applicable copayment,
coinsurance, or deductible under the enrollee's health coverage
plan.
(d) A facility may not discriminate against an enrollee or
the program based on the limitation on reimbursement under
Subsection (b) by:
(1) refusing to provide health care services or
supplies to the enrollee; or
(2) providing health care services or supplies of a
lower quality to the enrollee than those the facility provides to
similar patients who are not enrolled in a health coverage plan
under this chapter.
SECTION 5. Subchapter A, Chapter 1601, Insurance Code, is
amended by adding Section 1601.012 to read as follows:
Sec. 1601.012. REIMBURSEMENT STRUCTURE FOR FACILITIES. (a)
In this section:
(1) "Facility" has the meaning assigned by Section
331.001, Government Code.
(2) "Review board" means the state health benefit plan
reimbursement review board established under Chapter 331,
Government Code.
(b) Notwithstanding any other law or a provision of a
contract to the contrary, and subject to limitations imposed by the
General Appropriations Act, a facility that bills the uniform
program, an administering carrier, or a health benefit plan
provided under this chapter, or a designee of the program, carrier,
or plan, for a health care service or supply provided to a plan
enrollee must be reimbursed for the health care service or supply in
accordance with the reimbursement structure adopted for the service
or supply by the review board for the applicable plan year.
(c) A facility that receives reimbursement for a health care
service or supply as provided by Subsection (b) must consider that
reimbursement as payment in full for the service or supply. Except
as provided by this subsection, the facility may not charge an
enrollee to recover from the enrollee the balance of the facility's
fee for a service or supply received by the enrollee from the
facility that is not fully reimbursed under Subsection (b). The
facility may charge the enrollee an applicable copayment,
coinsurance, or deductible under the enrollee's health benefit
plan.
(d) A facility may not discriminate against an enrollee or
the uniform program based on the limitation on reimbursement under
Subsection (b) by:
(1) refusing to provide health care services or
supplies to the enrollee; or
(2) providing health care services or supplies of a
lower quality to the enrollee than those the facility provides to
similar patients who are not enrolled in a health benefit plan under
this chapter.
SECTION 6. The changes in law made by this Act apply only
to:
(1) a plan year beginning on or after September 1,
2024; and
(2) a contract entered into or renewed on or after
September 1, 2023.
SECTION 7. This Act takes effect September 1, 2023.