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  85R3983 LED-F
 
  By: Burrows H.B. No. 307
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to disclosure of certain health care costs and shared
  savings between certain health benefit plans and enrollees.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Title 2, Health and Safety Code, is amended by
  adding Subtitle J to read as follows:
  SUBTITLE J. HEALTH CARE PRICE DISCLOSURES
  CHAPTER 185. HEALTH CARE PRICE DISCLOSURES
         Sec. 185.001.  DEFINITIONS. In this chapter:
               (1)  "Facility" means a hospital, outpatient clinic,
  birthing center, ambulatory surgical center, or other licensed
  facility providing health care services. The term does not include
  an emergency clinic, a freestanding emergency medical care
  facility, or other facility providing only emergency care.
               (2)  "Patient" includes a prospective patient and a
  personal representative of the patient.
               (3)  "Practitioner" means an individual who is licensed
  to provide and provides medical or other health care services.
         Sec. 185.002.  PRICE DISCLOSURE OR ESTIMATE. (a)  Before
  providing a nonemergency health care service offered to the patient
  by the facility or practitioner, a facility or practitioner shall
  provide a price disclosure described by Subsection (b) or an
  estimate described by Subsection (c), as applicable, unless
  declined by the patient.
         (b)  Except as provided by Subsection (c), a facility or
  practitioner required to provide a price disclosure under
  Subsection (a) shall disclose to the patient the amount, including
  facility fees, that:
               (1)  the patient's health benefit plan will reimburse
  the facility or practitioner for the service, if the facility or
  practitioner is a participating provider under the patient's health
  benefit plan; or
               (2)  the facility or practitioner will charge for the
  service, if the facility or practitioner is not a participating
  provider under the patient's health benefit plan. 
         (c)  If a facility or practitioner is unable to quote a
  specific amount under Subsection (b) because of the facility's or
  practitioner's inability to predict the specific service the
  patient will need, the facility or practitioner shall provide an
  estimate of the amount, including facility fees, that:
               (1)  the patient's health benefit plan will reimburse
  the facility or practitioner for the predicted service, if the
  facility or practitioner is a participating provider under the
  patient's health benefit plan; or
               (2)  the facility or practitioner will charge for the
  predicted service, if the facility or practitioner is not a
  participating provider under the patient's health benefit plan.
         (d)  A facility or practitioner that provides an estimate
  described by Subsection (c) shall:
               (1)  disclose the incomplete nature of the estimate;
  and 
               (2)  inform the patient that the facility or
  practitioner may be able to provide an updated estimate after the
  facility or practitioner obtains additional information. 
         (e)  Notwithstanding any other law, a facility or
  practitioner that does not provide the price disclosure or estimate
  required by this section before providing a health care service for
  which the price disclosure or estimate is required may not bill the
  patient or the patient's health benefit plan for the service.
         Sec. 185.003.  EFFECT OF OTHER LAW. A facility that provides
  an estimate under Section 324.101(d) is not relieved of the
  obligation to provide a price disclosure or estimate under Section
  185.002.
         Sec. 185.004.  PATIENT INFORMATION. On request, a facility
  or practitioner shall provide a patient with sufficient information
  about a proposed nonemergency health care service to enable the
  patient to determine the amount for which the patient will be
  personally liable by using the patient's health benefit plan's
  toll-free telephone number or Internet website. The facility or
  practitioner shall provide the information to the patient based on
  the information that is available to the facility or practitioner
  at the time of the request. The facility or practitioner may assist
  the patient in using the telephone number or website.
         SECTION 2.  Section 324.101, Health and Safety Code, is
  amended by adding Subsection (d-1) and amending Subsection (e) to
  read as follows:
         (d-1)  A facility that provides a price disclosure or
  estimate under Section 185.002 is not relieved of the obligation to
  provide an estimate under Subsection (d).
         (e)  A facility shall provide to the consumer at the
  consumer's request an itemized statement in plain language of the
  billed services if the consumer requests the statement not later
  than the first anniversary of the date the person is discharged from
  the facility.  The facility shall provide the statement to the
  consumer not later than the 10th business day after the date on
  which the statement is requested.
         SECTION 3.  The heading to Chapter 1456, Insurance Code, is
  amended to read as follows:
  CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS AND COSTS OF HEALTH
  CARE SERVICES; SHARED SAVINGS
         SECTION 4.  Section 1456.003, Insurance Code, is amended by
  amending Subsection (a) and adding Subsection (a-1) to read as
  follows:
         (a)  Each health benefit plan that provides health care
  through a provider network shall provide notice to its enrollees
  that:
               (1)  a facility-based physician or other health care
  practitioner may not be included in the health benefit plan's
  provider network; and
               (2)  subject to Chapter 185, Health and Safety Code, a
  health care practitioner described by Subdivision (1) may balance
  bill the enrollee for amounts not paid by the health benefit plan.
         (a-1)  A health benefit plan shall provide notice to its
  enrollees that an enrollee may be eligible for a cost-sharing
  payment to the enrollee if the enrollee elects to receive a health
  care service that costs less than the average amount quoted for that
  service by the health benefit plan's telephone number or website
  established for that purpose.
         SECTION 5.  Sections 1456.006 and 1456.007, Insurance Code,
  are amended to read as follows:
         Sec. 1456.006.  COMMISSIONER RULES; FORM OF DISCLOSURE. The
  commissioner by rule may prescribe specific requirements for the
  disclosure required under Section 1456.003.  The form of the
  disclosure under Section 1456.003(a) must be substantially as
  follows:
         NOTICE:  "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN
  PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE
  PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER
  PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH THE
  FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS WHO ARE
  NOT MEMBERS OF THAT NETWORK.  YOU MAY BE RESPONSIBLE FOR PAYMENT OF
  ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL SERVICES THAT ARE NOT
  PAID OR COVERED BY YOUR HEALTH BENEFIT PLAN."
         Sec. 1456.007.  HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.  
  (a)  A health benefit plan that must comply with this chapter under
  Section 1456.002 shall, on the request of an enrollee, provide a
  binding [an] estimate of payments that will be made for any health
  care service or supply and shall also specify any deductibles,
  copayments, coinsurance, or other amounts for which the enrollee is
  responsible, based on the information available to the health
  benefit plan at the time the estimate was requested.  The estimate
  must be provided not later than the 10th business day after the date
  on which the estimate was requested.  A health benefit plan must
  advise the enrollee that:
               (1)  the actual payment and charges for the services or
  supplies may [will] vary based upon the enrollee's actual medical
  condition and other factors associated with performance of medical
  services, including any factors unknown to or unforeseeable by the
  health benefit plan or provider at the time the estimate was
  requested; and
               (2)  subject to Subsection (b) and Chapter 185, Health
  and Safety Code, the enrollee may be personally liable for the
  payment of services or supplies based upon the enrollee's health
  benefit plan coverage.
         (b)  Except as provided by Subsection (c), a health benefit
  plan may not require an enrollee to pay more than the amount
  estimated under Subsection (a) for a health care service or supply
  that was actually provided.
         (c)  A health benefit plan may require an enrollee to pay any
  deductibles, copayments, coinsurance, or other amounts disclosed
  in the enrollee's policy, certificate of coverage, or evidence of
  coverage for an unforeseen health care service or supply that
  arises out of the provision of the proposed health care service or
  supply.
         SECTION 6.  Chapter 1456, Insurance Code, is amended by
  adding Sections 1456.008, 1456.009, and 1456.010 to read as
  follows:
         Sec. 1456.008.  PRICE DISCLOSURE TELEPHONE NUMBER AND
  WEBSITE. (a)  A health benefit plan shall establish and operate a
  toll-free telephone number and publicly accessible Internet
  website for an enrollee to:
               (1)  request and obtain the average amount paid under
  the health benefit plan to a provider in the health benefit plan
  provider network for a particular health care service or supply in
  the preceding 12 months in the enrollee's geographic rating area;
  and
               (2)  request an estimate described by Section 1456.007.
         (b)  A health benefit plan shall maintain a written record of
  the average amount quoted to an enrollee under Subsection (a)(1).
         Sec. 1456.009.  SHARED SAVINGS. (a) Except as provided by
  Subsection (b), if an enrollee elects and receives a health care
  service or supply the total cost of which is less than the average
  amount quoted under Section 1456.008, a health benefit plan shall
  pay to the enrollee the lesser of:
               (1)  50 percent of the difference between the average
  amount and the actual cost, minus any applicable deductible,
  copayment, or coinsurance; or
               (2)  $7,500.
         (b)  A health benefit plan is not required to pay an enrollee
  under Subsection (a) if the plan's saved cost is $50 or less.
         (c)  A health benefit plan shall pay an enrollee not later
  than the 30th day after the day on which the enrollee submits a
  claim for shared savings under this section.
         (d)  If an enrollee elects and receives a health care service
  or supply from a provider outside the health benefit plan provider
  network the total cost of which is less than the average amount
  quoted under Section 1456.008, a health benefit plan may hold the
  enrollee responsible only for any deductible, copayment, or
  coinsurance that would be due if the service were provided by a
  provider in the health benefit plan provider network.
         Sec. 1456.010.  SHARED SAVINGS REPORTING. Not later than
  February 1 of each year, a health benefit plan shall submit to the
  commissioner a report for the preceding calendar year stating:
               (1)  the total number of requests for a binding
  estimate received for the plan under Section 1456.007;
               (2)  the total number of health care services or
  supplies for which an enrollee is eligible for a payment under
  Section 1456.009 and the average cost of each service or supply by
  category;
               (3)  the difference between the average cost of health
  care services or supplies for which an enrollee is eligible for a
  payment under Section 1456.009 and the average amount for the same
  service or supply quoted under Section 1456.008;
               (4)  the total payments made under Section 1456.009 to
  enrollees; and
               (5)  the total number and percentage of the health
  benefit plan's enrollees who received a payment under Section
  1456.009.
         SECTION 7.  (a)  Chapter 185, Health and Safety Code, as
  added by this Act, and Section 324.101(e), Health and Safety Code,
  as amended by this Act, apply only to a service provided by a
  facility or practitioner on or after January 1, 2018. A service
  provided before January 1, 2018, is governed by the law as it
  existed immediately before the effective date of this Act, and that
  law is continued in effect for that purpose.
         (b)  Chapter 1456, Insurance Code, as amended by this Act,
  applies only to a health benefit plan delivered, issued for
  delivery, or renewed on or after January 1, 2018.  A health benefit
  plan delivered, issued for delivery, or renewed before January 1,
  2018, is governed by the law as it existed immediately before the
  effective date of this Act, and that law is continued in effect for
  that purpose.
         SECTION 8.  This Act takes effect September 1, 2017.