85R2657 BEE-F
 
  By: Campbell S.B. No. 1485
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to payment standards for preferred provider benefit plans
  to reduce balance billing of insureds for out-of-network health
  care services.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subchapter C-1, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.140 to read as follows:
         Sec. 1301.140.  BALANCE BILLING; PAYMENTS TO OUT-OF-NETWORK
  PROVIDERS. (a)  In this section, "geozip area" means an area that
  includes all zip codes with the identical first three digits. For
  purposes of this section, a covered service performed at a location
  that does not have a zip code is considered to be performed in the
  geozip area closest to the location at which the service is
  performed.
         (b)  A preferred provider benefit plan must provide that the
  insured will not be balance billed because the insurer pays an
  out-of-network provider based on an allowed charge for a covered
  service that is less than the average charge for the service by
  out-of-network providers in the geozip area in which the service
  was provided minus any portion of the charge that is the insured's
  responsibility under the preferred provider benefit plan.
         (c)  If an out-of-network provider submits to an insurer a
  claim for payment for a covered service, the insurer shall pay the
  out-of-network provider an amount that is equal to or greater than
  the average charge for the service by out-of-network providers in
  the geozip area in which the service was provided minus any portion
  of the charge that is the insured's responsibility under the
  preferred provider benefit plan.
         SECTION 2.  Section 1301.140, Insurance Code, as added by
  this Act, applies only to a preferred provider benefit plan that is
  delivered, issued for delivery, or renewed on or after January 1,
  2018. A preferred provider benefit plan that is 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 3.  This Act takes effect September 1, 2017.