By: Muñoz, Jr. H.B. No. 1718
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to participation in the health care market by managed care
  plan enrollees.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle C, Title 8, Insurance Code, is amended
  by adding Chapter 1275 to read as follows:
  CHAPTER 1275. HEALTH CARE MARKET PARTICIPATION
  SUBCHAPTER A. GENERAL PROVISIONS
         Sec. 1275.0001.  DEFINITIONS. In this chapter:
               (1)  "Allowed amount" means the amount paid by a health
  benefit plan issuer to a participating provider for a covered
  service under a contract between the issuer and provider.
               (2)  "Enrollee" means an individual who is eligible to
  receive benefits for health care services through a health benefit
  plan.
               (3)  "Health benefit plan" means:
                     (A)  an individual, group, blanket, or franchise
  insurance policy, a certificate issued under an individual or group
  policy, or a group hospital service contract that provides benefits
  for health care services; or
                     (B)  a group subscriber contract or group or
  individual evidence of coverage issued by a health maintenance
  organization that provides benefits for health care services.
               (4)  "Health benefit plan issuer" means a health
  maintenance organization operating under Chapter 843, a preferred
  provider organization operating under Chapter 1301, an approved
  nonprofit health corporation that holds a certificate of authority
  under Chapter 844, and any other entity that issues a health benefit
  plan, including:
                     (A)  an insurance company;
                     (B)  a group hospital service corporation
  operating under Chapter 842;
                     (C)  a fraternal benefit society operating under
  Chapter 885; or
                     (D)  a stipulated premium company operating under
  Chapter 884.
               (5)  "Health care provider" means a physician,
  hospital, pharmacy, pharmacist, laboratory, or other person or
  organization that furnishes health care services and that is
  licensed or otherwise authorized to practice in this state.
               (6)  "Health care service" means a service for the
  diagnosis, prevention, treatment, cure, or relief of a health
  condition, illness, injury, or disease.
               (7)  "Managed care plan" means a health benefit plan
  under which health care services are provided to enrollees through
  contracts with health care providers and that requires enrollees to
  use participating providers or that provides a different level of
  coverage for enrollees who use participating providers.
               (8)  "Out-of-network provider," with respect to a
  managed care plan, means a health care provider who is not a
  participating provider of the plan.
               (9)  "Participating provider" means a health care
  provider who has contracted with a health benefit plan issuer to
  provide health care services to enrollees.
         Sec. 1275.0002.  APPLICABILITY OF CHAPTER; EXEMPTION. (a)
  This chapter applies only with respect to nonemergency health care
  services covered under a managed care plan.
         (b)  Notwithstanding Subsection (a), Subchapters B and C do
  not apply to a covered health care service described by Subsection
  (a) for which the commissioner approves an application for
  exemption filed by the issuer with the department in the form and
  manner prescribed by the commissioner that includes sufficient
  evidence to demonstrate that the variation in allowed amounts for
  the service among participating providers is less than $50.
         Sec. 1275.0003.  RULES. The commissioner may adopt rules to
  implement this chapter.
  SUBCHAPTER B. TRANSPARENCY TOOLS
         Sec. 1275.0051.  APPLICABILITY OF SUBCHAPTER. This
  subchapter applies only to:
               (1)  a small employer health benefit plan written under
  Chapter 1501; 
               (2)  an individual insurance policy or insurance
  agreement; or
               (3)  an individual evidence of coverage or similar
  coverage document.
         Sec. 1275.0052.  AVAILABILITY OF PRICE AND QUALITY
  INFORMATION. (a) A health benefit plan issuer shall provide on its
  publicly available Internet website an interactive mechanism that,
  for a specific health care service, allows an enrollee to:
               (1)  request and obtain from the issuer:
                     (A)  information on the payments made by the
  issuer to participating providers under the enrollee's health
  benefit plan; and
                     (B)  quality data on participating providers to
  the extent that data is available;
               (2)  compare allowed amounts among participating
  providers;
               (3)  estimate the enrollee's out-of-pocket costs under
  the enrollee's health benefit plan; and
               (4)  view the median or mode amount paid to
  participating providers under the enrollee's health benefit plan
  within a reasonable time not to exceed one year.
         (b)  A health benefit plan issuer may contract with a third
  party to provide the interactive mechanism described by Subsection
  (a).
         Sec. 1275.0053.  ESTIMATE REQUIREMENTS. To satisfy the
  requirement under Section 1275.0052(a)(3), a health benefit plan
  issuer shall provide a good-faith estimate of the amount the
  enrollee will be responsible to pay for a health care service
  provided by a participating provider based on the information
  available to the issuer at the time the estimate is requested.
         Sec. 1275.0054.  NOTICE TO ENROLLEES. A health benefit plan
  issuer shall inform an enrollee requesting an estimate under
  Section 1275.0052(a)(3) that the actual amount of the charges and
  the amount the enrollee is responsible to pay for the service may
  vary based upon unforeseen services that arise from the proposed
  service.
         Sec. 1275.0055.  WAIVER. (a) A health benefit plan issuer
  may file with the department a request for a waiver from compliance
  with this subchapter for a health care service for which the issuer
  determines that the issuer is unable to comply with Section
  1275.0052.
         (b)  A health benefit plan issuer filing a request under
  Subsection (a) must:
               (1)  file the request in the form and manner prescribed
  by the commissioner; and
               (2)  include evidence supporting the issuer's
  determination that the issuer cannot comply with Section 1275.0052
  for the health care service.
         (c)  The commissioner shall approve a waiver request under
  this section if the commissioner determines that the issuer
  provided sufficient evidence to support the waiver. If the
  commissioner approves a waiver request, the commissioner shall
  publicly release the contents of the request.
         Sec. 1275.0056.  EFFECT OF SUBCHAPTER. This subchapter does
  not prohibit a health benefit plan issuer from imposing
  deductibles, copayments, or coinsurance under the health benefit
  plan for an unforeseen health care service:
               (1)  arising from the health care service that is the
  basis for the original estimate to the enrollee provided under
  Section 1275.0052; and
               (2)  that was not included in the original estimate
  provided under Section 1275.0052.
  SUBCHAPTER C. INCENTIVE PROGRAM
         Sec. 1275.0101.  APPLICABILITY OF SUBCHAPTER. (a) This
  subchapter applies only to:
               (1)  a small employer health benefit plan written under
  Chapter 1501;
               (2)  an individual insurance policy or insurance
  agreement; or
               (3)  an individual evidence of coverage or similar
  coverage document.
         (b)  This subchapter does not apply to a health benefit plan
  for which an enrollee receives a premium subsidy under the Patient
  Protection and Affordable Care Act (Pub. L. No. 111-148).
         Sec. 1275.0102.  ESTABLISHMENT OF INCENTIVE PROGRAM. A
  health benefit plan issuer shall establish an incentive program for
  each health benefit plan subject to this subchapter. The program
  must provide an incentive paid in accordance with this subchapter
  to an enrollee who elects to receive a health care service from a
  participating provider who provides that service at a cost that is
  lower than the median or mode allowed amount for that service.
         Sec. 1275.0103.  PROGRAM DESCRIPTION REQUIRED. Before
  offering the program required by this subchapter, a health benefit
  plan issuer shall file a description of the program with the
  department in the form and manner prescribed by the commissioner.
         Sec. 1275.0104.  NOTICE TO ENROLLEES. Annually and at
  enrollment or renewal of a health benefit plan, the health benefit
  plan issuer shall provide written notice to enrollees about:
               (1)  the availability of the program;
               (2)  the program's incentives; and
               (3)  methods to obtain the program's incentives.
         Sec. 1275.0105.  INCENTIVE PAYMENTS. (a) A health benefit
  plan issuer shall pay an incentive under the program regardless of
  whether the enrollee has exceeded the out-of-pocket limit under the
  enrollee's health benefit plan.
         (b)  A health benefit plan issuer may pay a program incentive
  in the form of:
               (1)  cash;
               (2)  a gift card; or
               (3)  a credit or reduction in the health benefit plan's
  premium, deductible, copayment, or coinsurance.
         (c)  An incentive payment made in accordance with this
  section is not an administrative expense of a health benefit plan
  issuer for purposes of rate development or rate filing.
  SUBCHAPTER D. PARTICIPATION IN OUT-OF-NETWORK PROVIDER MARKET
         Sec. 1275.0151.  ENROLLEE ELECTION OF CERTAIN
  OUT-OF-NETWORK CARE; PROVIDER REIMBURSEMENT. (a) If an enrollee
  elects to receive a covered health care service from an
  out-of-network provider who is based in the United States and the
  provider makes the agreement described by Subsection (b), the
  enrollee's health benefit plan issuer shall:
               (1)  allow the enrollee to obtain the service from the
  out-of-network provider; and
               (2)  pay the provider an amount not to exceed the median
  or mode contracted amount for the service during a reasonable
  period not to exceed one year.
         (b)  An out-of-network provider may elect to receive a
  payment under Subsection (a) if the provider agrees to not charge
  the enrollee an amount that exceeds the enrollee's responsibility
  under the health benefit plan for the same service provided by a
  participating provider.
         Sec. 1275.0152.  APPLICATION OF ENROLLEE PAYMENT. (a) An
  enrollee who makes an election under Section 1275.0151(a) may file
  with a health benefit plan issuer a request for the enrollee's
  payment to the out-of-network provider to be treated as a payment to
  a participating provider under the enrollee's health benefit plan
  for purposes of a deductible or out-of-pocket maximum if:
               (1)  the out-of-network provider made the election
  described by Section 1275.0151(b) with respect to the service that
  is the basis for the request; and
               (2)  the enrollee provides proof of payment to the
  out-of-network provider.
         (b)  A health benefit plan issuer shall provide a
  downloadable or interactive online form for submitting a request
  under Subsection (a).
         (c)  A health benefit plan issuer shall grant a request that
  complies with Subsection (a) and rules adopted under this chapter.
         Sec. 1275.0153.  NOTICE TO ENROLLEES. A health benefit plan
  issuer shall provide written notice to enrollees on the issuer's
  Internet website and in the enrollees' health benefit plan
  materials of the enrollees' rights to make an election under
  Section 1275.0151 and a request under Section 1275.0152 and the
  process for making the election and request.
         SECTION 2.  Chapter 1275, Insurance Code, as added by this
  Act, applies only to a health benefit plan delivered, issued for
  delivery, or renewed on or after January 1, 2020. A health benefit
  plan that is delivered, issued for delivery, or renewed before
  January 1, 2020, 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, 2019.