H.B. No. 2090
 
 
 
 
AN ACT
  relating to the establishment of a statewide all payor claims
  database and health care cost disclosures by health benefit plan
  issuers and third-party administrators.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Chapter 38, Insurance Code, is amended by adding
  Subchapter I to read as follows:
  SUBCHAPTER I. TEXAS ALL PAYOR CLAIMS DATABASE
         Sec. 38.401.  PURPOSE OF SUBCHAPTER. The purpose of this
  subchapter is to authorize the department to establish an all payor
  claims database in this state to increase public transparency of
  health care information and improve the quality of health care in
  this state.
         Sec. 38.402.  DEFINITIONS. In this subchapter:
               (1)  "Allowed amount" means the amount of a billed
  charge that a health benefit plan issuer determines to be covered
  for services provided by a non-network provider. The allowed amount
  includes both the insurer's payment and any applicable deductible,
  copayment, or coinsurance amounts for which the insured is
  responsible.
               (2)  "Center" means the Center for Healthcare Data at
  The University of Texas Health Science Center at Houston.
               (3)  "Contracted rate" means the fee or reimbursement
  amount for a network provider's services, treatments, or supplies
  as established by agreement between the provider and health benefit
  plan issuer.
               (4)  "Data" means the specific claims and encounters,
  enrollment, and benefit information submitted to the center under
  this subchapter.
               (5)  "Database" means the Texas All Payor Claims
  Database established under this subchapter.
               (6)  "Geozip" means an area that includes all zip codes
  with identical first three digits.
               (7)  "Payor" means any of the following entities that
  pay, reimburse, or otherwise contract with a health care provider
  for the provision of health care services, supplies, or devices to a
  patient:
                     (A)  an insurance company providing health or
  dental insurance;
                     (B)  the sponsor or administrator of a health or
  dental plan;
                     (C)  a health maintenance organization operating
  under Chapter 843;
                     (D)  the state Medicaid program, including the
  Medicaid managed care program operating under Chapter 533,
  Government Code;
                     (E)  a health benefit plan offered or administered
  by or on behalf of this state or a political subdivision of this
  state or an agency or instrumentality of the state or a political
  subdivision of this state, including:
                           (i)  a basic coverage plan under Chapter
  1551;
                           (ii)  a basic plan under Chapter 1575; and
                           (iii)  a primary care coverage plan under
  Chapter 1579; or
                     (F)  any other entity providing a health insurance
  or health benefit plan subject to regulation by the department.
               (8)  "Protected health information" has the meaning
  assigned by 45 C.F.R. Section 160.103.
               (9)  "Qualified research entity" means:
                     (A)  an organization engaging in public interest
  research for the purpose of analyzing the delivery of health care in
  this state that is exempt from federal income tax under Section
  501(a), Internal Revenue Code of 1986, by being listed as an exempt
  organization in Section 501(c)(3) of that code;
                     (B)  an institution of higher education engaged in
  public interest research related to the delivery of health care in
  this state; or
                     (C)  a health care provider in this state engaging
  in efforts to improve the quality and cost of health care. 
               (10)  "Stakeholder advisory group" means the
  stakeholder advisory group established under Section 38.403.
         Sec. 38.403.  STAKEHOLDER ADVISORY GROUP. (a)  The center
  shall establish a stakeholder advisory group to assist the center
  as provided by this subchapter, including assistance in:
               (1)  establishing and updating the standards,
  requirements, policies, and procedures relating to the collection
  and use of data contained in the database required by Sections
  38.404(e) and (f);
               (2)  evaluating and prioritizing the types of reports
  the center should publish under Section 38.404(e);
               (3)  evaluating data requests from qualified research
  entities under Section 38.404(e)(2); and
               (4)  assisting the center in developing the center's
  recommendations under Section 38.408(3).
         (b)  The advisory group created under this section must be
  composed of:
               (1)  the state Medicaid director or the director's
  designee;
               (2)  a member designated by the Teacher Retirement
  System of Texas;
               (3)  a member designated by the Employees Retirement
  System of Texas; and
               (4)  12 members designated by the center, including:
                     (A)  two members representing the business
  community, with at least one of those members representing small
  businesses that purchase health benefits but are not involved in
  the provision of health care services, supplies, or devices or
  health benefit plans;
                     (B)  two members who represent consumers and who
  are not professionally involved in the purchase, provision,
  administration, or review of health care services, supplies, or
  devices or health benefit plans, with at least one member
  representing the behavioral health community;
                     (C)  two members representing hospitals that are
  licensed in this state;
                     (D)  two members representing health benefit plan
  issuers that are regulated by the department;
                     (E)  two members who are physicians licensed to
  practice medicine in this state, one of whom is a primary care
  physician; and
                     (F)  two members who are not professionally
  involved in the purchase, provision, administration, or review of
  health care services, supplies, or devices or health benefit plans
  and who have expertise in:
                           (i)  health planning;
                           (ii)  health economics;
                           (iii)  provider quality assurance;
                           (iv)  statistics or health data management;
  or
                           (v)  medical privacy laws.
         (c)  A person serving on the stakeholder advisory group must
  disclose any conflict of interest.
         (d)  Members of the stakeholder advisory group serve fixed
  terms as prescribed by commissioner rules adopted under this
  subchapter.
         Sec. 38.404.  ESTABLISHMENT AND ADMINISTRATION OF DATABASE.
  (a) The department shall collaborate with the center under this
  subchapter to aid in the center's establishment of the database.
  The center shall leverage the existing resources and infrastructure
  of the center to establish the database to collect, process,
  analyze, and store data relating to medical, dental,
  pharmaceutical, and other relevant health care claims and
  encounters, enrollment, and benefit information for the purposes of
  increasing transparency of health care costs, utilization, and
  access and improving the affordability, availability, and quality
  of health care in this state, including by improving population
  health in this state.
         (b)  The center shall serve as the administrator of the
  database, design, build, and secure the database infrastructure,
  and determine the accuracy of the data submitted for inclusion in
  the database.
         (c)  In determining the information a payor is required to
  submit to the center under this subchapter, the center must
  consider requiring inclusion of information useful to health policy
  makers, employers, and consumers for purposes of improving health
  care quality and outcomes, improving population health, and
  controlling health care costs. The required information at a
  minimum must include the following information as it relates to all
  health care services, supplies, and devices paid or otherwise
  adjudicated by the payor:
               (1)  the name and National Provider Identifier, as
  described in 45 C.F.R. Section 162.410, of each health care
  provider paid by the payor;
               (2)  the claim line detail that documents the health
  care services, supplies, or devices provided by the health care
  provider;
               (3)  the amount of charges billed by the health care
  provider and the payor's:
                     (A)  allowed amount or contracted rate for the
  health care services, supplies, or devices; and
                     (B)  adjudicated claim amount for the health care
  services, supplies, or devices;
               (4)  the name of the payor, the name of the health
  benefit plan, and the type of health benefit plan, including
  whether health care services, supplies, or devices were provided to
  an individual through:
                     (A)  a Medicaid or Medicare program;
                     (B)  workers' compensation insurance;
                     (C)  a health maintenance organization operating
  under Chapter 843;
                     (D)  a preferred provider benefit plan offered by
  an insurer under Chapter 1301;
                     (E)  a basic coverage plan under Chapter 1551;
                     (F)  a basic plan under Chapter 1575;
                     (G)  a primary care coverage plan under Chapter
  1579; or
                     (H)  a health benefit plan that is subject to the
  Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
  1001 et seq.); and
               (5)  claim level information that allows the center to
  identify the geozip where the health care services, supplies, or
  devices were provided.
         (d)  Each payor shall submit the required data under
  Subsection (c) at a schedule and frequency determined by the center
  and adopted by the commissioner by rule.
         (e)  In the manner and subject to the standards,
  requirements, policies, and procedures relating to the use of data
  contained in the database established by the center in consultation
  with the stakeholder advisory group, the center may use the data
  contained in the database for a noncommercial purpose:
               (1)  to produce statewide, regional, and geozip
  consumer reports available through the public access portal
  described in Section 38.405 that address:
                     (A)  health care costs, quality, utilization,
  outcomes, and disparities;
                     (B)  population health; or
                     (C)  the availability of health care services; and
               (2)  for research and other analysis conducted by the
  center or a qualified research entity to the extent that such use is
  consistent with all applicable federal and state law, including the
  data privacy and security requirements of Section 38.406 and the
  purposes of this subchapter.
         (f)  The center shall establish data collection procedures
  and evaluate and update data collection procedures established
  under this section.  The center shall test the quality of data
  collected by and reported to the center under this section to ensure
  that the data is accurate, reliable, and complete.
         Sec. 38.405.  PUBLIC ACCESS PORTAL. (a) Except as provided
  by this section and Sections 38.404 and 38.406 and in a manner
  consistent with all applicable federal and state law, the center
  shall collect, compile, and analyze data submitted to or stored in
  the database and disseminate the information described in Section
  38.404(e)(1) in a format that allows the public to easily access and
  navigate the information. The information must be accessible
  through an open access Internet portal that may be accessed by the
  public through an Internet website.
         (b)  The portal created under this section must allow the
  public to easily search and retrieve the information disseminated
  under Subsection (a), subject to data privacy and security
  restrictions described in this subchapter and consistent with all
  applicable federal and state law.
         (c)  Any information or data that is accessible through the
  portal created under this section:
               (1)  must be segmented by type of insurance or health
  benefit plan in a manner that does not combine payment rates
  relating to different types of insurance or health benefit plans;
               (2)  must be aggregated by like Current Procedural
  Terminology codes and health care services in a statewide,
  regional, or geozip area; and
               (3)  may not identify a specific patient, health care
  provider, health benefit plan, health benefit plan issuer, or other
  payor.
         (d)  Before making information or data accessible through
  the portal, the center shall remove any data or information that may
  identify a specific patient in accordance with the
  de-identification standards described in 45 C.F.R. Section
  164.514.
         Sec. 38.406.  DATA PRIVACY AND SECURITY. (a) Any
  information that may identify a patient, health care provider,
  health benefit plan, health benefit plan issuer, or other payor is
  confidential and subject to applicable state and federal law
  relating to records privacy and protected health information,
  including Chapter 181, Health and Safety Code, and is not subject to
  disclosure under Chapter 552, Government Code.
         (b)  A qualified research entity with access to data or
  information that is contained in the database but not accessible
  through the portal described in Section 38.405:
               (1)  may use information contained in the database only
  for purposes consistent with the purposes of this subchapter and
  must use the information in accordance with standards,
  requirements, policies, and procedures established by the center in
  consultation with the stakeholder advisory group;
               (2)  may not sell or share any information contained in
  the database; and
               (3)  may not use the information contained in the
  database for a commercial purpose.
         (c)  A qualified research entity with access to information
  that is contained in the database but not accessible through the
  portal must execute an agreement with the center relating to the
  qualified research entity's compliance with the requirements of
  Subsections (a) and (b), including the confidentiality of
  information contained in the database but not accessible through
  the portal.
         (d)  Notwithstanding any provision of this subchapter, the
  department and the center may not disclose an individual's
  protected health information in violation of any state or federal
  law.
         (e)  The center shall include in the database only the
  minimum amount of protected health information identifiers
  necessary to link public and private data sources and the
  geographic and services data to undertake studies.
         (f)  The center shall maintain protected health information
  identifiers collected under this subchapter but excluded from the
  database under Subsection (e) in a separate database. The separate
  database may not be aggregated with any other information and must
  use a proxy or encrypted record identifier for analysis.
         Sec. 38.407.  CERTAIN ENTITIES NOT REQUIRED TO SUBMIT DATA.
  Any sponsor or administrator of a health benefit plan subject to the
  Employee Retirement Income Security Act of 1974 (29 U.S.C. Section
  1001 et seq.) may elect or decline to participate in or submit data
  to the center for inclusion in the database as consistent with
  federal law.
         Sec. 38.408.  REPORT TO LEGISLATURE. Not later than
  September 1 of each even-numbered year, the center shall submit to
  the legislature a written report containing:
               (1)  an analysis of the data submitted to the center for
  use in the database;
               (2)  information regarding the submission of data to
  the center for use in the database and the maintenance, analysis,
  and use of the data;
               (3)  recommendations from the center, in consultation
  with the stakeholder advisory group, to further improve the
  transparency, cost-effectiveness, accessibility, and quality of
  health care in this state; and
               (4)  an analysis of the trends of health care
  affordability, availability, quality, and utilization.
         Sec. 38.409.  RULES. (a) The commissioner, in consultation
  with the center, shall adopt rules:
               (1)  specifying the types of data a payor is required to
  provide to the center under Section 38.404 to determine health
  benefits costs and other reporting metrics, including, if
  necessary, types of data not expressly identified in that section;
               (2)  specifying the schedule, frequency, and manner in
  which a payor must provide data to the center under Section 38.404,
  which must:
                     (A)  require the payor to provide data to the
  center not less frequently than quarterly; and
                     (B)  include provisions relating to data layout,
  data governance, historical data, data submission, use and sharing,
  information security, and privacy protection in data submissions;
  and
               (3)  establishing oversight and enforcement mechanisms
  to ensure that payors submit data to the database in accordance with
  this subchapter.
         (b)  In adopting rules governing methods for data
  submission, the commissioner shall to the maximum extent
  practicable use methods that are reasonable and cost-effective for
  payors.
         SECTION 2.  The heading to Subtitle J, Title 8, Insurance
  Code, is amended to read as follows:
  SUBTITLE J. HEALTH INFORMATION TECHNOLOGY AND AVAILABILITY
         SECTION 3.  Subtitle J, Title 8, Insurance Code, is amended
  by adding Chapter 1662 to read as follows:
  CHAPTER 1662. HEALTH CARE COST TRANSPARENCY
  SUBCHAPTER A. GENERAL PROVISIONS
         Sec. 1662.001.  DEFINITIONS. In this chapter:
               (1)  "Billed charge" means the total charges for a
  health care service or supply billed to a health benefit plan by a
  health care provider.
               (2)  "Billing code" means the code used by a health
  benefit plan issuer or administrator or health care provider to
  identify a health care service or supply for the purposes of
  billing, adjudicating, and paying claims for a covered health care
  service or supply, including the Current Procedural Terminology
  code, the Healthcare Common Procedure Coding System code, the
  Diagnosis-Related Group code, the National Drug Code, or other
  common payer identifier.
               (3)  "Bundled payment arrangement" means a payment
  model under which a health care provider is paid a single payment
  for all covered health care services and supplies provided to an
  enrollee for a specific treatment or procedure.
               (4)  "Copayment assistance" means the financial
  assistance an enrollee receives from a prescription drug or medical
  supply manufacturer toward the purchase of a covered health care
  service or supply.
               (5)  "Cost-sharing information" means information
  related to any expenditure required by or on behalf of an enrollee
  with respect to health care benefits that are relevant to a
  determination of the enrollee's cost-sharing liability for a
  particular covered health care service or supply.
               (6)  "Cost-sharing liability" means the amount an
  enrollee is responsible for paying for a covered health care
  service or supply under the terms of a health benefit plan. The term
  generally includes deductibles, coinsurance, and copayments but
  does not include premiums, balance billing amounts by
  out-of-network providers, or the cost of health care services or
  supplies that are not covered under a health benefit plan.
               (7)  "Covered health care service or supply" means a
  health care service or supply, including a prescription drug, for
  which the costs are payable, wholly or partly, under the terms of a
  health benefit plan.
               (8)  "Derived amount" means the price that a health
  benefit plan assigns to a health care service or supply for the
  purpose of internal accounting, reconciliation with health care
  providers, or submitting data in accordance with state or federal
  regulations.
               (9)  "Enrollee" means an individual, including a
  dependent, entitled to coverage under a health benefit plan. 
               (10)  "Health care service or supply" means any
  encounter, procedure, medical test, supply, prescription drug,
  durable medical equipment, and fee, including a facility fee,
  provided or assessed in connection with the provision of health
  care.
               (11)  "Historical net price" means the retrospective
  average amount a health benefit plan paid for a prescription drug,
  inclusive of any reasonably allocated rebates, discounts,
  chargebacks, and fees and any additional price concessions received
  by the plan or plan issuer or administrator with respect to the
  prescription drug, determined in accordance with Section 1662.106.
               (12)  "Machine-readable file" means a digital
  representation of data in a file that can be imported or read by a
  computer system for further processing without human intervention
  while ensuring no semantic meaning is lost.
               (13)  "National drug code" means the unique 10- or
  11-digit 3-segment number assigned by the United States Food and
  Drug Administration that is a universal product identifier for
  drugs in the United States.
               (14)  "Negotiated rate" means the amount a health
  benefit plan issuer or administrator has contractually agreed to
  pay a network provider, including a network pharmacy or other
  prescription drug dispenser, for covered health care services and
  supplies, whether directly or indirectly, including through a
  third-party administrator or pharmacy benefit manager.
               (15)  "Network provider" means any health care provider
  of a health care service or supply with which a health benefit plan
  issuer or administrator or a third party for the issuer or
  administrator has a contract with the terms on which a relevant
  health care service or supply is provided to an enrollee.
               (16)  "Out-of-network allowed amount" means the
  maximum amount a health benefit plan issuer or administrator will
  pay for a covered health care service or supply provided by an
  out-of-network provider.
               (17)  "Out-of-network provider" means a health care
  provider of any health care service or supply that does not have a
  contract under an enrollee's health benefit plan.
               (18)  "Out-of-pocket limit" means the maximum amount
  that an enrollee is required to pay during a coverage period for the
  enrollee's share of the costs of covered health care services and
  supplies under the enrollee's health benefit plan, including for
  self-only and other than self-only coverage, as applicable.
               (19)  "Prerequisite" means concurrent review, prior
  authorization, or a step-therapy or fail-first protocol related to
  a covered health care service or supply that must be satisfied
  before a health benefit plan issuer or administrator will cover the
  service or supply. The term does not include a medical necessity
  determination generally or another form of medical management
  technique.
               (20)  "Underlying fee schedule rate" means the rate for
  a covered health care service or supply from a particular network
  provider or health care provider that a health benefit plan issuer
  or administrator uses to determine an enrollee's cost-sharing
  liability for the service or supply when that rate is different from
  the negotiated rate or derived amount.
         Sec. 1662.002.  DEFINITION OF ACCUMULATED AMOUNTS. (a) In
  this chapter, "accumulated amounts" means:
               (1)  the amount of financial responsibility an enrollee
  has incurred at the time a request for cost-sharing information is
  made, with respect to a deductible or out-of-pocket limit; and
               (2)  to the extent a health benefit plan imposes a
  cumulative treatment limitation, including a limitation on the
  number of health care supplies, days, units, visits, or hours
  covered in a defined period, on a particular covered health care
  service or supply independent of individual medical necessity
  determinations, the amount that has accrued toward the limit on the
  health care service or supply.
         (b)  For an individual enrolled in coverage other than
  self-only coverage, the term includes the financial responsibility
  the individual has incurred toward meeting the individual's own
  deductible or out-of-pocket limit and the amount of financial
  responsibility that all individuals enrolled in the individual's
  coverage have incurred, in aggregate, toward meeting the plan's
  other than self-only deductible or out-of-pocket limit, as
  applicable.
         (c)  The term includes any expense that counts toward a
  deductible or out-of-pocket limit, including a copayment or
  coinsurance, but excludes any expense that does not count toward a
  deductible or out-of-pocket limit, including a premium payment,
  out-of-pocket expense for out-of-network health care services or
  supplies, or an amount for a health care service or supply not
  covered by the health benefit plan.
         Sec. 1662.003.  APPLICABILITY OF CHAPTER. (a) This chapter
  applies only to a health benefit plan that provides benefits for
  medical or surgical expenses incurred as a result of a health
  condition, accident, or sickness, including an individual, group,
  blanket, or franchise insurance policy or insurance agreement, a
  group hospital service contract, or an individual or group evidence
  of coverage or similar coverage document that is offered by:
               (1)  an insurance company;
               (2)  a group hospital service corporation operating
  under Chapter 842;
               (3)  a health maintenance organization operating under
  Chapter 843;
               (4)  an approved nonprofit health corporation that
  holds a certificate of authority under Chapter 844;
               (5)  a multiple employer welfare arrangement that holds
  a certificate of authority under Chapter 846;
               (6)  a stipulated premium company operating under
  Chapter 884;
               (7)  a fraternal benefit society operating under
  Chapter 885;
               (8)  a Lloyd's plan operating under Chapter 941; or
               (9)  an exchange operating under Chapter 942.
         (b)  Notwithstanding any other law, this chapter applies to:
               (1)  a small employer health benefit plan subject to
  Chapter 1501, including coverage provided through a health group
  cooperative under Subchapter B of that chapter;
               (2)  a standard health benefit plan issued under
  Chapter 1507;
               (3)  a basic coverage plan under Chapter 1551;
               (4)  a basic plan under Chapter 1575;
               (5)  a primary care coverage plan under Chapter 1579;
               (6)  a plan providing basic coverage under Chapter
  1601;
               (7)  a regional or local health care program operated
  under Section 75.104, Health and Safety Code; and
               (8)  a self-funded health benefit plan sponsored by a
  professional employer organization under Chapter 91, Labor Code.
         (c)  This chapter does not apply to a health reimbursement
  arrangement or other account-based health benefit plan or a
  workers' compensation insurance policy.
         Sec. 1662.004.  RULES. The commissioner may adopt rules
  necessary to implement this chapter.
  SUBCHAPTER B. REQUIRED DISCLOSURES TO ENROLLEES
         Sec. 1662.051.  REQUIRED DISCLOSURE TO ENROLLEE ON REQUEST.
  (a) On request of a health benefit plan enrollee, the health benefit
  plan issuer or administrator shall provide to the enrollee a
  disclosure in accordance with this subchapter.
         (b)  A health benefit plan issuer or administrator may allow
  an enrollee to request cost-sharing information for a specific
  preventive or non-preventive health care service or supply by
  including terms such as "preventive," "non-preventive," or
  "diagnostic" when requesting information under Subsection (a).
         Sec. 1662.052.  REQUIRED DISCLOSURE INFORMATION. (a) A
  disclosure provided under this subchapter must have the following
  information that is accurate at the time the disclosure request is
  made, with respect to the requesting enrollee's cost-sharing
  liability for a covered health care service and supply:
               (1)  an estimate of the enrollee's cost-sharing
  liability for the requested service or supply provided by a health
  care provider that is calculated based on the information described
  by Subdivisions (4), (5), and (6);
               (2)  except as provided by Subsection (b), if the
  request relates to a service or supply that is provided within a
  bundled payment arrangement and the arrangement includes a service
  or supply that has a separate cost-sharing liability, an estimate
  of the cost-sharing liability for:
                     (A)  the requested covered service or supply; and
                     (B)  each service or supply in the arrangement
  that has a separate cost-sharing liability;
               (3)  for a requested service or supply that is a
  recommended preventive service under Section 2713, Public Health
  Service Act (42 U.S.C. Section 300gg-13), if the health benefit
  plan issuer or administrator cannot determine whether the request
  is for preventive or non-preventive purposes, the cost-sharing
  liability for non-preventive purposes;
               (4)  accumulated amounts;
               (5)  the network provider rate that is composed of the
  following that are applicable to the health benefit plan's payment
  model:
                     (A)  the negotiated rate, reflected as a dollar
  amount, for a network provider for the requested service or supply
  regardless of whether the issuer or administrator uses the rate to
  calculate the enrollee's cost-sharing liability; and
                     (B)  the underlying fee schedule rate, reflected
  as a dollar amount, for the requested service or supply, to the
  extent that is different from the negotiated rate;
               (6)  the out-of-network allowed amount or any other
  rate that provides a more accurate estimate of an amount a health
  benefit plan issuer or administrator will pay for the requested
  service or supply, reflected as a dollar amount, if the request for
  cost-sharing information is for a covered service or supply
  provided by an out-of-network provider;
               (7)  if an enrollee requests information for a service
  or supply subject to a bundled payment arrangement, a list of the
  services and supplies included in the arrangement;
               (8)  if applicable, notification that coverage of a
  specific service or supply is subject to a prerequisite; and
               (9)  notice that includes the following information in
  plain language:
                     (A)  unless balance billing is prohibited for the
  requested service or supply, a statement that out-of-network
  providers may bill an enrollee for the difference between a
  provider's billed charges and the sum of the amount collected from
  the health benefit plan issuer or administrator and from the
  enrollee in the form of a copayment or coinsurance amount and that
  the cost-sharing information provided for the service or supply
  does not account for that potential additional charge;
                     (B)  a statement that the actual charges to the
  enrollee for the requested service or supply may be different from
  the estimate provided, depending on the actual services or supplies
  the enrollee receives at the point of care;
                     (C)  a statement that the estimate of cost-sharing
  liability for the requested service or supply is not a guarantee
  that benefits will be provided for that service or supply;
                     (D)  a statement disclosing whether the health
  benefit plan counts copayment assistance and other third-party
  payments in the calculation of the enrollee's deductible and
  out-of-pocket maximum;
                     (E)  for a service or supply that is a recommended
  preventive service under Section 2713, Public Health Service Act
  (42 U.S.C. Section 300gg-13), a statement that a service or supply
  provided by a network provider may not be subject to cost sharing if
  it is billed as a preventive service or supply when the health
  benefit plan issuer or administrator cannot determine whether the
  request is for a preventive or non-preventive service or supply;
  and
                     (F)  any additional information, including other
  disclosures, that the health benefit plan issuer or administrator
  determines is appropriate provided that the additional information
  does not conflict with the information required to be provided
  under this section.
         (b)  A health benefit plan issuer or administrator is not
  required to provide an estimate of cost-sharing liability for a
  bundled payment arrangement in which the cost sharing is imposed
  separately for each health care service or supply included in the
  arrangement. If an issuer or administrator provides an estimate for
  multiple health care services or supplies in a situation in which
  the estimate could be relevant to an enrollee, the issuer or
  administrator must disclose information about the relevant
  services or supplies individually as required by Subsection (a).
         (c)  If a health benefit plan issuer or administrator
  reimburses an out-of-network provider with a percentage of the
  billed charge for a covered health care service or supply, the
  out-of-network allowed amount described by Subsection (a) is that
  reimbursed percentage.
         Sec. 1662.053.  METHOD AND FORMAT FOR DISCLOSURE. A health
  benefit plan issuer or administrator shall provide the disclosure
  required under this subchapter through an Internet-based
  self-service tool described by Section 1662.054, a physical copy in
  accordance with Section 1662.055, or another means authorized by
  Section 1662.056.
         Sec. 1662.054.  INTERNET-BASED SELF-SERVICE TOOL. (a) A
  health benefit plan issuer or administrator may develop and
  maintain an Internet-based self-service tool to provide a
  disclosure required under this subchapter.
         (b)  Information provided on the self-service tool must be
  made available in plain language, without a subscription or other
  fee, on an Internet website that provides real-time responses based
  on cost-sharing information that is accurate at the time of the
  request.
         (c)  A health benefit plan issuer or administrator shall
  ensure that the self-service tool allows a user to:
               (1)  search for cost-sharing information for a covered
  health care service or supply by a specific network provider or by
  all network providers by inputting:
                     (A)  a billing code or descriptive term at the
  option of the user;
                     (B)  the name of the network provider if the user
  seeks cost-sharing information with respect to a specific network
  provider; or
                     (C)  other factors used by the issuer or
  administrator that are relevant for determining the applicable
  cost-sharing information, including the location in which the
  service or supply will be sought or provided, the facility name, or
  the dosage;
               (2)  search for an out-of-network allowed amount,
  percentage of billed charges, or other rate that provides a
  reasonably accurate estimate of the amount the issuer or
  administrator will pay for a covered health care service or supply
  provided by an out-of-network provider by inputting:
                     (A)  a billing code or descriptive term at the
  option of the user; or
                     (B)  other factors used by the issuer or
  administrator that are relevant for determining the applicable
  out-of-network allowed amount or other rate, including the location
  in which the covered health care service or supply will be sought or
  provided; and
               (3)  refine and reorder search results based on
  geographic proximity of network providers and the amount of the
  enrollee's estimated cost-sharing liability for the covered health
  care service or supply if the search returns multiple results.
         Sec. 1662.055.  PHYSICAL COPY OF DISCLOSURE. (a) A health
  benefit plan issuer or administrator shall make the disclosure
  required under this subchapter available in a physical form. A
  disclosure under this section must be made available in plain
  language, without a fee, at the request of the enrollee.
         (b)  In providing a disclosure under this section, a health
  benefit plan issuer or administrator may limit the number of health
  care providers with respect to which cost-sharing information for a
  covered health care service or supply is provided to no fewer than
  20 providers per request.
         (c)  A health benefit plan issuer or administrator providing
  a disclosure under this section shall:
               (1)  disclose any applicable provider-per-request
  limit described by Subsection (b) to the enrollee;
               (2)  provide the cost-sharing information in a physical
  form in accordance with the enrollee's request as if the request was
  made using a self-service tool under Section 1662.054; and
               (3)  mail the disclosure not later than two business
  days after the date the enrollee's request is received.
         Sec. 1662.056.  OTHER MEANS OF DISCLOSURE. If an enrollee
  requests the disclosure required by this subchapter by a means
  other than a physical copy or the self-service tool described by
  Section 1662.054, a health benefit plan issuer or administrator may
  provide the disclosure through the requested means if:
               (1)  the enrollee agrees that disclosure through that
  means is sufficient to satisfy the request;
               (2)  the request is fulfilled at least as rapidly as
  required for the physical copy; and
               (3)  the disclosure includes the information required
  for a physical copy under Section 1662.055.
         Sec. 1662.057.  OTHER CONTRACTUAL AGREEMENTS. (a) A health
  benefit plan issuer or administrator may satisfy the requirements
  of this subchapter by entering into a written agreement under which
  another person, including a pharmacy benefit manager or other third
  party, provides the disclosure required under this subchapter.
         (b)  If a health benefit plan issuer or administrator and
  another person enter into an agreement under Subsection (a), the
  issuer or administrator is subject to an enforcement action for
  failure to provide a required disclosure in accordance with this
  subchapter.
         Sec. 1662.058.  COMPLIANCE WITH SUBCHAPTER. (a) A health
  benefit plan issuer or administrator that, acting in good faith and
  with reasonable diligence, makes an error or omission in a
  disclosure required under this subchapter does not fail to comply
  with this subchapter solely because of the error or omission if the
  issuer or administrator corrects the error or omission as soon as
  practicable.
         (b)  A health benefit plan issuer or administrator, acting in
  good faith and with reasonable diligence, does not fail to comply
  with this subchapter solely because the issuer's or administrator's
  Internet website is temporarily inaccessible if the issuer or
  administrator makes the information available as soon as
  practicable.
         (c)  To the extent compliance with this subchapter requires a
  health benefit plan issuer or administrator to obtain information
  from another person, the issuer or administrator does not fail to
  comply with the subchapter because the issuer or administrator
  relies in good faith on information from the other person unless the
  issuer or administrator knows or reasonably should have known that
  the information is incomplete or inaccurate.
  SUBCHAPTER C. REQUIRED PUBLIC DISCLOSURES
         Sec. 1662.101.  APPLICABILITY OF SUBCHAPTER.  This
  subchapter applies only to a health benefit plan for which federal
  reporting requirements under 26 C.F.R. Part 54, 29 C.F.R. Part
  2590, and 45 C.F.R. Parts 147 and 158 do not apply.
         Sec. 1662.102.  PUBLICATION REQUIRED. A health benefit plan
  issuer or administrator shall publish on an Internet website the
  information required under Section 1662.103 in three
  machine-readable files in accordance with this subchapter.
         Sec. 1662.103.  REQUIRED INFORMATION. (a) A health benefit
  plan issuer or administrator shall publish the following
  information:
               (1)  a network rate machine-readable file that includes
  the following information for all covered health care services and
  supplies, except for prescription drugs that are subject to a
  fee-for-service reimbursement arrangement:
                     (A)  for each coverage option offered by a health
  benefit plan issuer or administered by a health benefit plan
  administrator, the option's name and:
                           (i)  the option's 14-digit health insurance
  oversight system identifier;
                           (ii)  if the 14-digit identifier is not
  available, the option's 5-digit health insurance oversight system
  identifier; or
                           (iii)  if the 14- and 5-digit identifiers
  are not available, the employer identification number associated
  with the option;
                     (B)  a billing code, which must be the national
  drug code for a prescription drug, and a plain-language description
  for each billing code for each covered service or supply under each
  coverage option offered by the issuer or administered by the
  administrator; and
                     (C)  all applicable rates, including negotiated
  rates, underlying fee schedules, or derived amounts, provided in
  accordance with Section 1662.104;
               (2)  an out-of-network allowed amount machine-readable
  file, including:
                     (A)  for each coverage option offered by a health
  benefit plan issuer or administered by a health benefit plan
  administrator, the option's name and:
                           (i)  the option's 14-digit health insurance
  oversight system identifier;
                           (ii)  if the 14-digit identifier is not
  available, the option's 5-digit health insurance oversight system
  identifier; or
                           (iii)  if the 14- and 5-digit identifiers
  are not available, the employer identification number associated
  with the option;
                     (B)  a billing code, which must be the national
  drug code for a prescription drug, and a plain-language description
  for each billing code for each covered service or supply under each
  coverage option offered by the issuer or administered by the
  administrator; and
                     (C)  except as provided by Subsection (b), unique
  out-of-network billed charges and allowed amounts provided in
  accordance with Section 1662.105 for covered health care services
  or supplies provided by out-of-network providers during the 90-day
  period that begins on the 180th day before the date the
  machine-readable file is published; and
               (3)  a prescription drug machine-readable file that
  includes:
                     (A)  for each coverage option offered by a health
  benefit plan issuer or administered by a health benefit plan
  administrator, the option's name and:
                           (i)  the option's 14-digit health insurance
  oversight system identifier;
                           (ii)  if the 14-digit identifier is not
  available, the option's 5-digit health insurance oversight system
  identifier; or
                           (iii)  if the 14- and 5-digit identifiers
  are not available, the employer identification number associated
  with the option;
                     (B)  the national drug code and the proprietary
  and nonproprietary name assigned to the national drug code by the
  United States Food and Drug Administration for each covered
  prescription drug provided under each coverage option offered by
  the issuer or administered by the administrator;
                     (C)  the negotiated rates, which must be:
                           (i)  reflected as a dollar amount with
  respect to each national drug code that is provided by a network
  provider, including a network pharmacy or other prescription drug
  dispenser;
                           (ii)  associated with the national provider
  identifier, tax identification number, and place of service code
  for each network provider, including each network pharmacy or other
  prescription drug dispenser; and
                           (iii)  associated with the last date of the
  contract term for each provider-specific negotiated rate that
  applies to each national drug code; and
                     (D)  except as provided by Subsection (b),
  historical net prices, which must be:
                           (i)  reflected as a dollar amount with
  respect to each national drug code that is provided by a network
  provider, including a network pharmacy or other prescription drug
  dispenser;
                           (ii)  associated with the national provider
  identifier, tax identification number, and place of service code
  for each network provider, including each network pharmacy or other
  prescription drug dispenser; and
                           (iii)  associated with the 90-day period
  that begins on the 180th day before the date the machine-readable
  file is published for each provider-specific historical net price
  calculated in accordance with Section 1662.106 that applies to each
  national drug code.
         (b)  A health benefit plan issuer or administrator shall omit
  information described by Subsection (a)(2)(C) or (a)(3)(D) in
  relation to a particular health care service or supply if
  compliance with that subsection would require the issuer to report
  payment information in connection with fewer than 20 different
  claims for payments under a single health benefit plan.
         (c)  This section does not require the disclosure of
  information that would violate any applicable health information
  privacy law.
         Sec. 1662.104.  NETWORK RATE DISCLOSURES. (a) If a health
  benefit plan issuer or administrator does not use negotiated rates
  for health care provider reimbursement, the issuer or administrator
  shall disclose for purposes of Section 1662.103(a)(1)(C) derived
  amounts to the extent those amounts are already calculated in the
  normal course of business.
         (b)  If a health benefit plan issuer or administrator uses
  underlying fee schedule rates for calculating cost sharing, the
  issuer or administrator shall disclose for purposes of Section
  1662.103(a)(1)(C) the underlying fee schedule rates in addition to
  the negotiated rate or derived amount.
         (c)  The applicable rates, including for both individual
  health care services and supplies and services and supplies in a
  bundled payment arrangement, that a health benefit plan issuer or
  administrator must provide under Section 1662.103(a)(1)(C) must
  be:
               (1)  except as provided by Subdivision (2), reflected
  as dollar amounts with respect to each covered health care service
  or supply that is provided by a network provider;
               (2)  the base negotiated rate applicable to the service
  or supply before an adjustment for enrollee characteristics if the
  rate is a negotiated rate subject to change based on enrollee
  characteristics;
               (3)  associated with the national provider identifier,
  tax identification number, and place of service code for each
  network provider;
               (4)  associated with the last date of the contract term
  or expiration date for each health care provider-specific
  applicable rate that applies to each covered service or supply; and
               (5)  indicated with a notation where a reimbursement
  arrangement other than a standard fee-for-service model, including
  capitation or a bundled payment arrangement, applies.
         Sec. 1662.105.  OUT-OF-NETWORK ALLOWED AMOUNTS. (a) An
  out-of-network allowed amount provided under Section
  1662.103(a)(2)(C) must be:
               (1)  reflected as a dollar amount with respect to each
  covered health care service or supply that is provided by an
  out-of-network provider; and
               (2)  associated with the national provider identifier,
  tax identification number, and place of service code for each
  out-of-network provider.
         (b)  This subchapter does not prohibit a health benefit plan
  issuer or administrator from satisfying the disclosure
  requirements described by Section 1662.103(a)(2)(C) by disclosing
  out-of-network allowed amounts made available by, or otherwise
  obtained from, an issuer, a health care provider, or other party
  with which the issuer or administrator has entered into a written
  agreement to provide the information if the minimum claim threshold
  described by Section 1662.103(b) is independently met for each
  health care service or supply and for each plan included in an
  aggregated allowed amount file.
         (c)  If a health benefit plan issuer or administrator enters
  into an agreement under Subsection (b), the health benefit plan
  issuers, health care providers, or other persons with which the
  issuer or administrator has contracted may aggregate
  out-of-network allowed amounts for more than one plan.
         (d)  This subchapter does not prohibit a third party from
  hosting an allowed amount file on its Internet website or a health
  benefit plan issuer or administrator from contracting with a third
  party to post the file. If the issuer or administrator does not host
  the file separately on its Internet website, the issuer or
  administrator shall provide a link on its Internet website to the
  location where the file is made publicly available.
         Sec. 1662.106.  HISTORICAL NET PRICE. (a) For purposes of
  determining the historical net price for a prescription drug, the
  allocation of price concessions is determined by the dollar value
  for non-product specific and product-specific rebates, discounts,
  chargebacks, fees, and other price concessions to the extent that
  the total amount of any such price concession is known to the health
  benefit plan issuer or administrator at the time of publication of
  the historical net price under Section 1662.103(a)(3)(D).
         (b)  To the extent that the total amount of any non-product
  specific and product-specific rebates, discounts, chargebacks,
  fees, or other price concessions is not known to a health benefit
  plan issuer or administrator at the time of publication of the
  historical net price under Section 1662.103(a)(3)(D), the issuer or
  administrator shall allocate those price concessions by using a
  good faith, reasonable estimate of the average price concessions
  based on the price concessions received over a period before the
  current reporting period and of equal duration to the current
  reporting period.
         Sec. 1662.107.  REQUIRED METHOD AND FORMAT FOR DISCLOSURE.
  The machine-readable files described by Section 1662.103 must be
  available in a form and manner prescribed by department rule. The
  files must be available and accessible to any person free of charge
  and without conditions, including establishment of a user account,
  password, or other credentials, or submission of personally
  identifiable information to access the file.
         Sec. 1662.108.  FILE UPDATES. A health benefit plan issuer
  or administrator shall update the machine-readable files described
  by Section 1662.103 and the information described by this
  subchapter monthly. The issuer or administrator must clearly
  indicate in the files the date that the files were most recently
  updated.
         Sec. 1662.109.  OTHER CONTRACTUAL AGREEMENTS. (a) A health
  benefit plan issuer or administrator may satisfy the requirements
  of this subchapter by entering into a written agreement under which
  another person, including a third-party administrator or health
  care claims clearinghouse, provides the disclosure required under
  this subchapter in compliance with this subchapter.
         (b)  If a health benefit plan issuer or administrator and
  another person enter into an agreement under Subsection (a), the
  issuer or administrator is subject to an enforcement action for
  failure to provide a required disclosure in accordance with this
  subchapter.
         Sec. 1662.110.  COMPLIANCE WITH SUBCHAPTER. (a) A health
  benefit plan issuer or administrator that, acting in good faith and
  with reasonable diligence, makes an error or omission in a
  disclosure required under this subchapter does not fail to comply
  with this subchapter solely because of the error or omission if the
  issuer or administrator corrects the error or omission as soon as
  practicable.
         (b)  A health benefit plan issuer or administrator, acting in
  good faith and with reasonable diligence, does not fail to comply
  with this subchapter solely because the issuer's or administrator's
  Internet website is temporarily inaccessible if the issuer or
  administrator makes the information available as soon as
  practicable. 
         (c)  To the extent compliance with this subchapter requires a
  health benefit plan issuer or administrator to obtain information
  from another person, the issuer or administrator does not fail to
  comply with the subchapter because the issuer or administrator
  relies in good faith on information from the other person unless the
  issuer or administrator knows or reasonably should have known that
  the information is incomplete or inaccurate.
         SECTION 4.  (a)  Not later than January 1, 2022, the Center
  for Healthcare Data at The University of Texas Health Science
  Center at Houston shall establish the stakeholder advisory group in
  accordance with Section 38.403, Insurance Code, as added by this
  Act.
         (b)  Not later than June 1, 2022, the Texas Department of
  Insurance shall adopt rules, and the Center for Healthcare Data at
  The University of Texas Health Science Center at Houston shall
  adopt, in consultation with the stakeholder advisory group,
  standards, requirements, policies, and procedures, necessary to
  implement Subchapter I, Chapter 38, Insurance Code, as added by
  this Act.
         SECTION 5.  As soon as practicable after the effective date
  of this Act, the Center for Healthcare Data at The University of
  Texas Health Science Center at Houston shall actively seek
  financial support from the federal grant program for development of
  state all payer claims databases established under the Consolidated
  Appropriations Act, 2021 (Pub. L. No. 116-260) and from any other
  available source of financial support provided by the federal
  government for purposes of implementing Subchapter I, Chapter 38,
  Insurance Code, as added by this Act.
         SECTION 6.  If before implementing any provision of
  Subchapter I, Chapter 38, Insurance Code, as added by this Act, the
  commissioner of insurance determines that a waiver or authorization
  from a federal agency is necessary for implementation of that
  provision, the commissioner shall request the waiver or
  authorization and may delay implementing that provision until the
  waiver or authorization is granted.
         SECTION 7.  (a)  Subchapter B, Chapter 1662, 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,
  2024, or for a plan year that begins on or after that date.
         (b)  Subchapter C, Chapter 1662, 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, 2022, or for a plan
  year that begins on or after that date.
         SECTION 8.  This Act takes effect September 1, 2021.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 2090 was passed by the House on April
  15, 2021, by the following vote:  Yeas 144, Nays 0, 1 present, not
  voting; and that the House concurred in Senate amendments to H.B.
  No. 2090 on May 24, 2021, by the following vote:  Yeas 145, Nays 1,
  1 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 2090 was passed by the Senate, with
  amendments, on May 19, 2021, by the following vote:  Yeas 31, Nays
  0.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor