S.B. No. 1731

	AN ACT
	relating to consumer access to health care information and consumer
	protection for services provided by or through health benefit
	plans, hospitals, ambulatory surgical centers, birthing centers,
	and other health care facilities, and funding for health care
	information services; providing penalties.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1.  Subtitle G, Title 4, Health and Safety Code, is
	amended by adding Chapter 324 to read as follows:
	CHAPTER 324. CONSUMER ACCESS TO HEALTH CARE INFORMATION
	SUBCHAPTER A. GENERAL PROVISIONS
	Sec. 324.001.  DEFINITIONS. In this chapter:
	(1)  "Average charge" means the mathematical average of
	facility charges for an inpatient admission or outpatient surgical
	procedure.  The term does not include charges for a particular
	inpatient admission or outpatient surgical procedure that exceed
	the average by more than two standard deviations.
	(2)  "Billed charge" means the amount a facility
	charges for an inpatient admission, outpatient surgical procedure,
	or health care service or supply.
	(3)  "Costs" means the fixed and variable expenses
	incurred by a facility in the provision of a health care service.
	(4)  "Consumer" means any person who is considering
	receiving, is receiving, or has received a health care service or
	supply as a patient from a facility. The term includes the personal
	representative of the patient.
	(5)  "Department" means the Department of State Health
	Services.
	(6)  "Executive commissioner" means the executive
	commissioner of the Health and Human Services Commission.
	(7)  "Facility" means:
	(A)  an ambulatory surgical center licensed under
	Chapter 243;
	(B)  a birthing center licensed under Chapter 244;
	or
	(C)  a hospital licensed under Chapter 241.
	Sec. 324.002.  RULES. The executive commissioner shall
	adopt and enforce rules to further the purposes of this chapter.
	[Sections 324.003-324.050 reserved for expansion]
	SUBCHAPTER B. CONSUMER GUIDE TO HEALTH CARE
	Sec. 324.051.  DEPARTMENT WEBSITE.  (a)  The department
	shall make available on the department's Internet website a
	consumer guide to health care. The department shall include
	information in the guide concerning facility pricing practices and
	the correlation between a facility's average charge for an
	inpatient admission or outpatient surgical procedure and the
	actual, billed charge for the admission or procedure, including
	notice that the average charge for a particular inpatient admission
	or outpatient surgical procedure will vary from the actual, billed
	charge for the admission or procedure based on:
	(1)  the person's medical condition;
	(2)  any unknown medical conditions of the person;
	(3)  the person's diagnosis and recommended treatment
	protocols ordered by the physician providing care to the person;
	and
	(4)  other factors associated with the inpatient
	admission or outpatient surgical procedure.
	(b)  The department shall include information in the guide to
	advise consumers that:
	(1)  the average charge for an inpatient admission or
	outpatient surgical procedure may vary between facilities
	depending on a facility's cost structure, the range and frequency
	of the services provided, intensity of care, and payor mix;
	(2)  the average charge by a facility for an inpatient
	admission or outpatient surgical procedure will vary from the
	facility's costs or the amount that the facility may be reimbursed
	by a health benefit plan for the admission or surgical procedure;
	(3)  the consumer may be personally liable for payment
	for an inpatient admission, outpatient surgical procedure, or
	health care service or supply depending on the consumer's health
	benefit plan coverage;
	(4)  the consumer should contact the consumer's health
	benefit plan for accurate information regarding the plan structure,
	benefit coverage, deductibles, copayments, coinsurance, and other
	plan provisions that may impact the consumer's liability for
	payment for an inpatient admission, outpatient surgical procedure,
	or health care service or supply; and
	(5)  the consumer, if uninsured, may be eligible for a
	discount on facility charges based on a sliding fee scale or a
	written charity care policy established by the facility.
	(c)  The department shall include on the consumer guide to
	health care website:
	(1)  an Internet link for consumers to access quality
	of care data, including:
	(A)  the Texas Health Care Information Collection
	website;
	(B)  the Hospital Compare website within the
	United States Department of Health and Human Services website;
	(C)  the Joint Commission on Accreditation of
	Healthcare Organizations website; and
	(D)  the Texas Hospital Association's Texas
	PricePoint website; and
	(2)  a disclaimer noting the websites that are not
	provided by this state or an agency of this state.
	(d)  The department may accept gifts and grants to fund the
	consumer guide to health care.  On the department's Internet
	website, the department may not identify, recognize, or acknowledge
	in any format the donors or grantors to the consumer guide to health
	care.
	[Sections 324.052-324.100 reserved for expansion]
	SUBCHAPTER C.  BILLING OF FACILITY SERVICES AND SUPPLIES
	Sec. 324.101.  FACILITY POLICIES. (a)  Each facility shall
	develop, implement, and enforce written policies for the billing of
	facility health care services and supplies. The policies must
	address:
	(1)  any discounting of facility charges to an
	uninsured consumer, subject to Chapter 552, Insurance Code;
	(2)  any discounting of facility charges provided to a
	financially or medically indigent consumer who qualifies for
	indigent services based on a sliding fee scale or a written charity
	care policy established by the facility and the documented income
	and other resources of the consumer;
	(3)  the providing of an itemized statement required by
	Subsection (e);
	(4)  whether interest will be applied to any billed
	service not covered by a third-party payor and the rate of any
	interest charged;
	(5)  the procedure for handling complaints; and
	(6)  the providing of a conspicuous written disclosure
	to a consumer at the time the consumer is first admitted to the
	facility or first receives services at the facility that:
	(A)  provides confirmation whether the facility
	is a participating provider under the consumer's third-party payor
	coverage on the date services are to be rendered based on the
	information received from the consumer at the time the confirmation
	is provided; and
	(B)  informs the consumer that a physician or
	other health care provider who may provide services to the consumer
	while in the facility may not be a participating provider with the
	same third-party payors as the facility.
	(b)  For services provided in an emergency department of a
	hospital or as a result of an emergent direct admission, the
	hospital shall provide the written disclosure required by
	Subsection (a)(6) before discharging the patient from the emergency
	department or hospital, as appropriate.
	(c)  Each facility shall post in the general waiting area and
	in the waiting areas of any off-site or on-site registration,
	admission, or business office a clear and conspicuous notice of the
	availability of the policies required by Subsection (a).
	(d)  The facility shall provide an estimate of the facility's
	charges for any elective inpatient admission or nonemergency
	outpatient surgical procedure or other service on request and
	before the scheduling of the admission or procedure or service. The
	estimate must be provided not later than the 10th business day after
	the date on which the estimate is requested. The facility must
	advise the consumer that:
	(1)  the request for an estimate of charges may result
	in a delay in the scheduling and provision of the inpatient
	admission, outpatient surgical procedure, or other service;
	(2)  the actual charges for an inpatient admission,
	outpatient surgical procedure, or other service will vary based on
	the person's medical condition and other factors associated with
	performance of the procedure or service;
	(3)  the actual charges for an inpatient admission,
	outpatient surgical procedure, or other service may differ from the
	amount to be paid by the consumer or the consumer's third-party
	payor;
	(4)  the consumer may be personally liable for payment
	for the inpatient admission, outpatient surgical procedure, or
	other service depending on the consumer's health benefit plan
	coverage; and
	(5)  the consumer should contact the consumer's health
	benefit plan for accurate information regarding the plan structure,
	benefit coverage, deductibles, copayments, coinsurance, and other
	plan provisions that may impact the consumer's liability for
	payment for the inpatient admission, outpatient surgical
	procedure, or other service.
	(e)  A facility shall provide to the consumer at the
	consumer's request an itemized statement 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.
	(f)  A facility shall provide an itemized statement of billed
	services to a third-party payor who is actually or potentially
	responsible for paying all or part of the billed services provided
	to a patient and who has received a claim for payment of those
	services. To be entitled to receive a statement, the third-party
	payor must request the statement from the facility and must have
	received a claim for payment. The request must be made not later
	than one year after the date on which the payor received the claim
	for payment. The facility shall provide the statement to the payor
	not later than the 30th day after the date on which the payor
	requests the statement. If a third-party payor receives a claim for
	payment of part but not all of the billed services, the third-party
	payor may request an itemized statement of only the billed services
	for which payment is claimed or to which any deduction or copayment
	applies.
	(g)  A facility in violation of this section is subject to
	enforcement action by the appropriate licensing agency.
	(h)  If a consumer or a third-party payor requests more than
	two copies of the statement, the facility may charge a reasonable
	fee for the third and subsequent copies provided. The fee may not
	exceed the sum of:
	(1)  a basic retrieval or processing fee, which must
	include the fee for providing the first 10 pages of the copies and
	which may not exceed $30;
	(2)  a charge for each page of:
	(A)  $1 for the 11th through the 60th page of the
	provided copies;
	(B)  50 cents for the 61st through the 400th page
	of the provided copies; and
	(C)  25 cents for any remaining pages of the
	provided copies; and
	(3)  the actual cost of mailing, shipping, or otherwise
	delivering the provided copies.
	(i)  If a consumer overpays a facility, the facility must
	refund the amount of the overpayment not later than the 30th day
	after the date the facility determines that an overpayment has been
	made. This subsection does not apply to an overpayment subject to
	Section 1301.132 or 843.350, Insurance Code.
	Sec. 324.102.  COMPLAINT PROCESS. A facility shall
	establish and implement a procedure for handling consumer
	complaints, and must make a good faith effort to resolve the
	complaint in an informal manner based on its complaint procedures.
	If the complaint cannot be resolved informally, the facility shall
	advise the consumer that a complaint may be filed with the
	department and shall provide the consumer with the mailing address
	and telephone number of the department.
	Sec. 324.103.  CONSUMER WAIVER PROHIBITED. The provisions
	of this chapter may not be waived, voided, or nullified by a
	contract or an agreement between a facility and a consumer.
	SECTION 2.  Subdivision (10), Section 108.002, Health and
	Safety Code, is amended to read as follows:
	(10)  "Health care facility" means:
	(A)  a hospital;
	(B)  an ambulatory surgical center licensed under
	Chapter 243;
	(C)  a chemical dependency treatment facility
	licensed under Chapter 464;
	(D)  a renal dialysis facility;
	(E)  a birthing center;
	(F)  a rural health clinic; [or]
	(G)  a federally qualified health center as
	defined by 42 U.S.C. Section 1396d(l)(2)(B); or
	(H)  a free-standing imaging center.
	SECTION 3.  Subsection (k), Section 108.009, Health and
	Safety Code, is amended to read as follows:
	(k)  The council shall collect health care data elements
	relating to payer type, the racial and ethnic background of
	patients, and the use of health care services by consumers.  The
	council shall prioritize data collection efforts on inpatient and
	outpatient surgical and radiological procedures from hospitals,
	ambulatory surgical centers, and free-standing radiology centers.
	SECTION 4.  Section 241.025, Health and Safety Code, is
	amended by adding Subsection (e) to read as follows:
	(e)  Notwithstanding Subsection (d), to the extent that
	money received from the fees collected under this chapter exceeds
	the costs to the department to conduct the activity for which the
	fee is imposed, the department may use the money to administer
	Chapter 324 and similar laws that require the department to provide
	information related to hospital care to the public. The department
	may not consider the costs of administering Chapter 324 or similar
	laws in adopting a fee imposed under this section.
	SECTION 5.  Subsection (h), Section 311.002, Health and
	Safety Code, is amended to read as follows:
	(h)  In this section, "hospital" includes:
	(1)  [a hospital licensed under Chapter 241;
	[(2)]  a treatment facility licensed under Chapter 464;
	and
	(2) [(3)]  a mental health facility licensed under
	Chapter 577.
	SECTION 6.  Chapter 101, Occupations Code, is amended by
	adding Subchapter H, transferring Section 101.202 to Subchapter H
	redesignated as Section 101.351 and further amending that section,
	and adding Section 101.352 to read as follows:
	SUBCHAPTER H.  BILLING
	Sec. 101.351 [101.202].  FAILURE TO PROVIDE BILLING
	INFORMATION. On the written request of a patient, a health care
	professional shall provide, in plain language, a written
	explanation of the charges for professional services previously
	made on a bill or statement for the patient.  This section does not
	apply to a physician subject to Section 101.352.
	Sec. 101.352.  BILLING POLICIES AND INFORMATION;
	PHYSICIANS.  (a)  A physician shall develop, implement, and enforce
	written policies for the billing of health care services and
	supplies. The policies must address:
	(1)  any discounting of charges for health care
	services or supplies provided to an uninsured patient that is not
	covered by a patient's third-party payor, subject to Chapter 552,
	Insurance Code;
	(2)  any discounting of charges for health care
	services or supplies provided to an indigent patient who qualifies
	for services or supplies based on a sliding fee scale or a written
	charity care policy established by the physician;
	(3)  whether interest will be applied to any billed
	health care service or supply not covered by a third-party payor and
	the rate of any interest charged; and
	(4)  the procedure for handling complaints relating to
	billed charges for health care services or supplies.
	(b)  Each physician who maintains a waiting area shall post a
	clear and conspicuous notice of the availability of the policies
	required by Subsection (a) in the waiting area and in any
	registration, admission, or business office in which patients are
	reasonably expected to seek service.
	(c)  On the request of a patient who is seeking services that
	are to be provided on an out-of-network basis or who does not have
	coverage under a government program, health insurance policy, or
	health maintenance organization evidence of coverage, a physician
	shall provide an estimate of the charges for any health care
	services or supplies. The estimate must be provided not later than
	the 10th business day after the date of the request. A physician
	must advise the consumer that:
	(1)  the request for an estimate of charges may result
	in a delay in the scheduling and provision of the services;
	(2)  the actual charges for the services or supplies
	will vary based on the patient's medical condition and other
	factors associated with performance of the services;
	(3)  the actual charges for the services or supplies
	may differ from the amount to be paid by the patient or the
	patient's third-party payor; and
	(4)  the patient may be personally liable for payment
	for the services or supplies depending on the patient's health
	benefit plan coverage.
	(d)  For services provided in an emergency department of a
	hospital or as a result of an emergent direct admission, the
	physician shall provide the estimate of charges required by
	Subsection (c) not later than the 10th business day after the
	request or before discharging the patient from the emergency
	department or hospital, whichever is later, as appropriate.
	(e)  A physician shall provide a patient with an itemized
	statement of the charges for professional services or supplies not
	later than the 10th business day after the date on which the
	statement is requested if the patient requests the statement not
	later than the first anniversary of the date on which the health
	care services or supplies were provided.
	(f)  If a patient requests more than two copies of the
	statement, a physician may charge a reasonable fee for the third and
	subsequent copies provided. The Texas Medical Board shall by rule
	set the permissible fee a physician may charge for copying,
	processing, and delivering a copy of the statement.
	(g)  On the request of a patient, a physician shall provide,
	in plain language, a written explanation of the charges for
	services or supplies previously made on a bill or statement for the
	patient.
	(h)  If a patient overpays a physician, the physician must
	refund the amount of the overpayment not later than the 30th day
	after the date the physician determines that an overpayment has
	been made. This subsection does not apply to an overpayment subject
	to Section 1301.132 or 843.350, Insurance Code.
	(i)  In this section, "physician" means a person licensed to
	practice in this state.
	SECTION 7.  Section 154.002, Occupations Code, is amended by
	adding Subsection (c) to read as follows:
	(c)  The board shall make available on the board's Internet
	website a consumer guide to health care. The board shall include
	information in the guide concerning the billing and reimbursement
	of health care services provided by physicians, including
	information that advises consumers that:
	(1)  the charge for a health care service or supply will
	vary based on:
	(A)  the person's medical condition;
	(B)  any unknown medical conditions of the person;
	(C)  the person's diagnosis and recommended
	treatment protocols; and
	(D)  other factors associated with performance of
	the health care service;
	(2)  the charge for a health care service or supply may
	differ from the amount to be paid by the consumer or the consumer's
	third-party payor;
	(3)  the consumer may be personally liable for payment
	for the health care service or supply depending on the consumer's
	health benefit plan coverage; and
	(4)  the consumer should contact the consumer's health
	benefit plan for accurate information regarding the plan structure,
	benefit coverage, deductibles, copayments, coinsurance, and other
	plan provisions that may impact the consumer's liability for
	payment for the health care services or supplies.
	SECTION 8.  Chapter 38, Insurance Code, is amended by adding
	Subchapter H to read as follows:
	SUBCHAPTER H.  HEALTH CARE REIMBURSEMENT RATE INFORMATION
	Sec. 38.351.  PURPOSE OF SUBCHAPTER.  The purpose of this
	subchapter is to authorize the department to:
	(1)  collect data concerning health benefit plan
	reimbursement rates in a uniform format; and
	(2)  disseminate, on an aggregate basis for
	geographical regions in this state, information concerning health
	care reimbursement rates derived from the data.
	Sec. 38.352.  DEFINITION.  In this subchapter, "group health
	benefit plan" means a preferred provider benefit plan as defined by
	Section 1301.001 or an evidence of coverage for a health care plan
	that provides basic health care services as defined by Section
	843.002.
	Sec. 38.353.  APPLICABILITY OF SUBCHAPTER. (a)  This
	subchapter applies to the issuer of a group health benefit plan,
	including:
	(1)  an insurance company;
	(2)  a group hospital service corporation;
	(3)  a fraternal benefit society;
	(4)  a stipulated premium company;
	(5)  a reciprocal or interinsurance exchange; or
	(6)  a health maintenance organization.
	(b)  Notwithstanding any provision in Chapter 1551, 1575,
	1579, or 1601 or any other law, and except as provided by Subsection
	(e), this subchapter applies to:
	(1)  a basic coverage plan under Chapter 1551;
	(2)  a basic plan under Chapter 1575;
	(3)  a primary care coverage plan under Chapter 1579;
	and
	(4)  basic coverage under Chapter 1601.
	(c)  Except as provided by Subsection (d), this subchapter
	applies to a small employer health benefit plan provided under
	Chapter 1501.
	(d)  This subchapter does not apply to:
	(1)  standard health benefit plans provided under
	Chapter 1507;
	(2)  children's health benefit plans provided under
	Chapter 1502;
	(3)  health care benefits provided under a workers'
	compensation insurance policy;
	(4)  Medicaid managed care programs operated under
	Chapter 533, Government Code;
	(5)  Medicaid programs operated under Chapter 32, Human
	Resources Code; or
	(6)  the state child health plan operated under Chapter
	62 or 63, Health and Safety Code.
	(e)  The commissioner by rule may exclude a type of health
	benefit plan from the requirements of this subchapter if the
	commissioner finds that data collected in relation to the health
	benefit plan would not be relevant to accomplishing the purposes of
	this subchapter.
	Sec. 38.354.  RULES.  The commissioner may adopt rules as
	provided by Subchapter A, Chapter 36, to implement this subchapter.
	Sec. 38.355.  DATA CALL; STANDARDIZED FORMAT.  (a)  Each
	health benefit plan issuer shall submit to the department, at the
	time and in the form and manner required by the department,
	aggregate reimbursement rates by region paid by the health benefit
	plan issuer for health care services identified by the department.
	(b)  The department shall require that data submitted under
	this section be submitted in a standardized format, established by
	rule, to permit comparison of health care reimbursement rates.  To
	the extent feasible, the department shall develop the data
	submission requirements in a manner that allows collection of
	reimbursement rates as a dollar amount and not by comparison to
	other standard reimbursement rates, such as Medicare reimbursement
	rates.
	(c)  The department shall specify the period for which
	reimbursement rates must be filed under this section.
	(d)  The department may contract with a private third party
	to obtain the data under this subchapter. If the department
	contracts with a third party, the department may determine the
	aggregate data to be collected and published under Section 38.357
	if consistent with the purposes of this subchapter described in
	Section 38.351. The department shall prohibit the third party
	contractor from selling, leasing, or publishing the data obtained
	by the contractor under this subchapter.
	Sec. 38.356.  CONFIDENTIALITY OF DATA.  Except as provided
	by Section 38.357, data collected under this subchapter is
	confidential and not subject to disclosure under Chapter 552,
	Government Code.
	Sec. 38.357.  PUBLICATION OF AGGREGATE HEALTH CARE
	REIMBURSEMENT RATE INFORMATION.  The department shall provide to
	the Department of State Health Services for publication, for
	identified regions of this state, aggregate health care
	reimbursement rate information derived from the data collected
	under this subchapter.  The published information may not reveal
	the name of any health care provider or health benefit plan issuer.
	The department may make the aggregate health care reimbursement
	rate information available through the department's Internet
	website.
	Sec. 38.358.  PENALTIES.  A health benefit plan issuer that
	fails to submit data as required in accordance with this subchapter
	is subject to an administrative penalty under Chapter 84.  For
	purposes of penalty assessment, each day the health benefit plan
	issuer fails to submit the data as required is a separate violation.
	SECTION 9.  Section 843.155, Insurance Code, is amended by
	amending Subsection (b) and adding Subsection (d) to read as
	follows:
	(b)  The report shall:
	(1)  be verified by at least two principal officers;
	(2)  be in a form prescribed by the commissioner; and
	(3)  include:
	(A)  a financial statement of the health
	maintenance organization, including its balance sheet and receipts
	and disbursements for the preceding calendar year, certified by an
	independent public accountant;
	(B)  the number of individuals enrolled during the
	preceding calendar year, the number of enrollees as of the end of
	that year, and the number of enrollments terminated during that
	year;
	(C)  a statement of:
	(i)  an evaluation of enrollee satisfaction;
	(ii)  an evaluation of quality of care;
	(iii)  coverage areas;
	(iv)  accreditation status;
	(v)  premium costs;
	(vi)  plan costs;
	(vii)  premium increases;
	(viii)  the range of benefits provided;
	(ix)  copayments and deductibles;
	(x)  the accuracy and speed of claims
	payment by the organization;
	(xi)  the credentials of physicians of the
	organization; and
	(xii)  the number of providers;
	(D)  updated financial projections for the next
	calendar year of the type described in Section 843.078(e), until
	the health maintenance organization has had a net income for 12
	consecutive months; and
	(E) [(D)]  other information relating to the
	performance of the health maintenance organization as necessary to
	enable the commissioner to perform the commissioner's duties under
	this chapter and Chapter 20A.
	(d)  The annual report filed by the health maintenance
	organization shall be made publicly available on the department's
	Internet website in a user-friendly format that allows consumers to
	make direct comparisons of the financial and other data reported by
	health maintenance organizations under this section.
	SECTION 10.  Subchapter A, Chapter 1301, Insurance Code, is
	amended by adding Section 1301.009 to read as follows:
	Sec. 1301.009.  ANNUAL REPORT.  (a)  Not later than March 1
	of each year, an insurer shall file with the commissioner a report
	relating to the preferred provider benefit plan offered under this
	chapter and covering the preceding calendar year.
	(b)  The report shall:
	(1)  be verified by at least two principal officers;
	(2)  be in a form prescribed by the commissioner; and
	(3)  include:
	(A)  a financial statement of the insurer,
	including its balance sheet and receipts and disbursements for the
	preceding calendar year, certified by an independent public
	accountant;
	(B)  the number of individuals enrolled during the
	preceding calendar year, the number of enrollees as of the end of
	that year, and the number of enrollments terminated during that
	year; and
	(C)  a statement of:
	(i)  an evaluation of enrollee satisfaction;
	(ii)  an evaluation of quality of care;
	(iii)  coverage areas;
	(iv)  accreditation status;
	(v)  premium costs;
	(vi)  plan costs;
	(vii)  premium increases;
	(viii)  the range of benefits provided;
	(ix)  copayments and deductibles;
	(x)  the accuracy and speed of claims
	payment by the insurer for the plan;
	(xi)  the credentials of physicians who are
	preferred providers; and
	(xii)  the number of preferred providers.
	(c)  The annual report filed by the insurer shall be made
	publicly available on the department's website in a user-friendly
	format that allows consumers to make direct comparisons of the
	financial and other data reported by insurers under this section.
	(d)  An insurer providing group coverage of $10 million or
	less in premiums or individual coverage of $2 million or less in
	premiums is not required to report the data required under
	Subsection (b)(3)(C).
	SECTION 11.  Subtitle F, Title 8, Insurance Code, is amended
	by adding Chapter 1456 to read as follows:
	CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS
	Sec. 1456.001.  DEFINITIONS. In this chapter:
	(1)  "Balance billing" means the practice of charging
	an enrollee in a health benefit plan that uses a provider network to
	recover from the enrollee the balance of a non-network health care
	provider's fee for service received by the enrollee from the health
	care provider that is not fully reimbursed by the enrollee's health
	benefit plan.
	(2)  "Enrollee" means an individual who is eligible to
	receive health care services through a health benefit plan.
	(3)  "Facility-based physician" means a radiologist,
	an anesthesiologist, a pathologist, an emergency department
	physician, or a neonatologist:
	(A)  to whom the facility has granted clinical
	privileges; and
	(B)  who provides services to patients of the
	facility under those clinical privileges.
	(4)  "Health care facility" means a hospital, emergency
	clinic, outpatient clinic, birthing center, ambulatory surgical
	center, or other facility providing health care services.
	(5)  "Health care practitioner" means an individual who
	is licensed to provide and provides health care services.
	(6)  "Provider network" means a health benefit plan
	under which health care services are provided to enrollees through
	contracts with health care providers and that requires those
	enrollees to use health care providers participating in the plan
	and procedures covered by the plan. The term includes a network
	operated by:
	(A)  a health maintenance organization;
	(B)  a preferred provider benefit plan issuer; or
	(C)  another entity that issues a health benefit
	plan, including an insurance company.
	Sec. 1456.002.  APPLICABILITY OF CHAPTER.  (a)  This chapter
	applies to any health benefit plan that:
	(1)  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 that is offered by:
	(A)  an insurance company;
	(B)  a group hospital service corporation
	operating under Chapter 842;
	(C)  a fraternal benefit society operating under
	Chapter 885;
	(D)  a stipulated premium company operating under
	Chapter 884;
	(E)  a health maintenance organization operating
	under Chapter 843;
	(F)  a multiple employer welfare arrangement that
	holds a certificate of authority under Chapter 846;
	(G)  an approved nonprofit health corporation
	that holds a certificate of authority under Chapter 844; or
	(H)  an entity not authorized under this code or
	another insurance law of this state that contracts directly for
	health care services on a risk-sharing basis, including a
	capitation basis; or
	(2)  provides health and accident coverage through a
	risk pool created under Chapter 172, Local Government Code,
	notwithstanding Section 172.014, Local Government Code, or any
	other law.
	(b)  This chapter applies to a person to whom a health
	benefit plan contracts to:
	(1)  process or pay claims;
	(2)  obtain the services of physicians or other
	providers to provide health care services to enrollees; or
	(3)  issue verifications or preauthorizations.
	(c)  This chapter does not apply to:
	(1)  Medicaid managed care programs operated under
	Chapter 533, Government Code;
	(2)  Medicaid programs operated under Chapter 32, Human
	Resources Code; or
	(3)  the state child health plan operated under Chapter
	62 or 63, Health and Safety Code.
	Sec. 1456.003.  REQUIRED DISCLOSURE:  HEALTH BENEFIT PLAN.
	(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)  a health care practitioner described by
	Subdivision (1) may balance bill the enrollee for amounts not paid
	by the health benefit plan.
	(b)  The health benefit plan shall provide the disclosure in
	writing to each enrollee:
	(1)  in any materials sent to the enrollee in
	conjunction with issuance or renewal of the plan's insurance policy
	or evidence of coverage;
	(2)  in an explanation of payment summary provided to
	the enrollee or in any other analogous document that describes the
	enrollee's benefits under the plan; and
	(3)  conspicuously displayed, on any health benefit
	plan website that an enrollee is reasonably expected to access.
	(c)  A health benefit plan must clearly identify any health
	care facilities within the provider network in which facility-based
	physicians do not participate in the health benefit plan's provider
	network. Health care facilities identified under this subsection
	must be identified in a separate and conspicuous manner in any
	provider network directory or website directory.
	(d)  Along with any explanation of benefits sent to an
	enrollee that contains a remark code indicating a payment made to a
	non-network physician has been paid at the health benefit plan's
	allowable or usual and customary amount, a health benefit plan must
	also include the number for the department's consumer protection
	division for complaints regarding payment.
	Sec. 1456.004.  REQUIRED DISCLOSURE:  FACILITY-BASED
	PHYSICIANS. (a)  If a facility-based physician bills a patient who
	is covered by a health benefit plan described in Section 1456.002
	that does not have a contract with the facility-based physician,
	the facility-based physician shall send a billing statement that:
	(1)  contains an itemized listing of the services and
	supplies provided along with the dates the services and supplies
	were provided;
	(2)  contains a conspicuous, plain-language
	explanation that:
	(A)  the facility-based physician is not within
	the health plan provider network; and
	(B)  the health benefit plan has paid a rate, as
	determined by the health benefit plan, which is below the
	facility-based physician billed amount;
	(3)  contains a telephone number to call to discuss the
	statement, provide an explanation of any acronyms, abbreviations,
	and numbers used on the statement, or discuss any payment issues;
	(4)  contains a statement that the patient may call to
	discuss alternative payment arrangements;
	(5)  contains a notice that the patient may file
	complaints with the Texas Medical Board and includes the Texas
	Medical Board mailing address and complaint telephone number; and
	(6)  for billing statements that total an amount
	greater than $200, over any applicable copayments or deductibles,
	states, in plain language, that if the patient finalizes a payment
	plan agreement within 45 days of receiving the first billing
	statement and substantially complies with the agreement, the
	facility-based physician may not furnish adverse information to a
	consumer reporting agency regarding an amount owed by the patient
	for the receipt of medical treatment.
	(b)  A patient may be considered by the facility-based
	physician to be out of substantial compliance with the payment plan
	agreement if payments are not made in compliance with the agreement
	for a period of 90 days.
	Sec. 1456.005.  DISCIPLINARY ACTION AND ADMINISTRATIVE
	PENALTY. (a)  The commissioner may take disciplinary action
	against a licensee that violates this chapter, in accordance with
	Chapter 84.
	(b)  A violation of this chapter by a facility-based
	physician is grounds for disciplinary action and imposition of an
	administrative penalty by the Texas Medical Board.
	(c)  The Texas Medical Board shall:
	(1)  notify a facility-based physician of a finding by
	the Texas Medical Board that the facility-based physician is
	violating or has violated this chapter or a rule adopted under this
	chapter; and
	(2)  provide the facility-based physician with an
	opportunity to correct the violation without penalty or reprimand.
	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 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. 1456.0065.  STUDY OF NETWORK ADEQUACY AND CONTRACTS OF
	HEALTH PLANS. (a)  In this section:
	(1)  "Commissioner" means the commissioner of
	insurance.
	(2)  "Health benefit plan" means an insurance policy or
	a contract or evidence of coverage issued by a health maintenance
	organization or an employer or employee sponsored health plan.
	(b)  The commissioner shall appoint an advisory committee to
	study facility-based provider network adequacy of health benefit
	plans.
	(c)  The advisory committee shall be composed of:
	(1)  one or more physician representatives;
	(2)  one or more hospital representatives;
	(3)  one or more health benefit plan representatives,
	to equal the total number of physician and hospital
	representatives; and
	(4)  one representative each from associations
	representing physicians, hospitals, and health benefit plans.
	(d)  The advisory committee periodically and not later than
	December 1, 2008, shall advise the following of its findings:
	(1)  the governor;
	(2)  the lieutenant governor;
	(3)  the speaker of the house of representatives;
	(4)  the commissioner; and
	(5)  the chairs of the standing committees of the
	senate and house of representatives that have primary jurisdiction
	over health benefit plans.
	(e)  Members of the advisory committee serve without
	compensation.
	(f)  The advisory committee is abolished and this section
	expires January 1, 2009.
	Sec. 1456.007.  HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. A
	health benefit plan that must comply with this chapter under
	Section 1456.002 shall, on the request of an enrollee, provide 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. 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 will vary based upon the enrollee's actual medical
	condition and other factors associated with performance of medical
	services; and
	(2)  the enrollee may be personally liable for the
	payment of services or supplies based upon the enrollee's health
	benefit plan coverage.
	SECTION 12.  Section 843.201, Insurance Code, is amended by
	adding Subsection (d) to read as follows:
	(d)  A health maintenance organization shall provide to an
	enrollee on request information on:
	(1)  whether a physician or other health care provider
	is a participating provider in the health maintenance
	organization's network;
	(2)  whether proposed health care services are covered
	by the health plan; and
	(3)  what the enrollee's personal responsibility will
	be for payment of applicable copayment or deductible amounts.
	SECTION 13.  Subchapter F, Chapter 843, Insurance Code, is
	amended by adding Section 843.211 to read as follows:
	Sec. 843.211.  APPLICABILITY OF SUBCHAPTER TO ENTITIES
	CONTRACTING WITH HEALTH MAINTENANCE ORGANIZATION.  This subchapter
	applies to a person to whom a health maintenance organization
	contracts to:
	(1)  process or pay claims;
	(2)  obtain the services of physicians or other
	providers to provide health care services to enrollees; or
	(3)  issue verifications or preauthorizations.
	SECTION 14.  Section 1301.158, Insurance Code, is amended by
	adding Subsection (d) to read as follows:
	(d)  An insurer shall provide to an insured on request
	information on:
	(1)  whether a physician or other health care provider
	is a participating provider in the insurer's preferred provider
	network;
	(2)  whether proposed health care services are covered
	by the health insurance policy;
	(3)  what the insured's personal responsibility will be
	for payment of applicable copayment or deductible amounts; and
	(4)  coinsurance amounts owed based on the provider's
	contracted rate for in-network services or the insurer's usual and
	customary reimbursement rate for out-of-network services.
	SECTION 15.  Subchapter D, Chapter 1301, Insurance Code, is
	amended by adding Section 1301.163 to read as follows:
	Sec. 1301.163.  APPLICABILITY OF SUBCHAPTER TO ENTITIES
	CONTRACTING WITH INSURER.  This subchapter applies to a person to
	whom an insurer contracts to:
	(1)  process or pay claims;
	(2)  obtain the services of physicians or other
	providers to provide health care services to enrollees; or
	(3)  issue verifications or preauthorizations.
	SECTION 16.  Section 1506.007, Insurance Code, is amended by
	adding Subsections (a-1) and (a-2) to read as follows:
	(a-1)  A health benefit plan issuer, employer, or other
	person who is required to provide notice to an individual of the
	individual's ability to continue coverage in accordance with Title
	X, Consolidated Omnibus Budget Reconciliation Act of 1985 (29
	U.S.C. Section 1161 et seq.) (COBRA), shall, at the time that that
	notice is required, also provide notice to the individual of the
	availability of coverage under the pool.
	(a-2)  A health benefit plan issuer who is providing coverage
	to an individual in accordance with Title X, Consolidated Omnibus
	Budget Reconciliation Act of 1985 (29 U.S.C. Section 1161 et seq.)
	(COBRA), shall, not later than the 45th day before the date that
	coverage expires, notify the individual of the availability of
	coverage under the pool.
	SECTION 17.  This Act applies to an insurance policy,
	certificate, or contract or an evidence of coverage delivered,
	issued for delivery, or renewed on or after the effective date of
	this Act. A policy, certificate, or contract or evidence of
	coverage delivered, issued for delivery, or renewed before the
	effective date of this Act 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 18.  Except as provided by Section 19 of this Act,
	the Department of State Health Services, Texas Medical Board, and
	Texas Department of Insurance shall adopt rules as necessary to
	implement this Act not later than May 1, 2008.
	SECTION 19.  Not later than December 31, 2007, the
	commissioner of insurance shall adopt rules as necessary to
	implement Subchapter H, Chapter 38, Insurance Code, as added by
	this Act.  The rules must require that each health benefit plan
	issuer subject to that subchapter make the initial submission of
	data under that subchapter not later than the 60th day after the
	effective date of the rules.
	SECTION 20.  (a)  The commissioner of insurance by rule
	shall require each health benefit plan issuer subject to Chapter
	1456, Insurance Code, as added by this Act, to submit information to
	the Texas Department of Insurance concerning the use of non-network
	providers by health benefit plan enrollees and the payments made to
	those providers.  The information collected must cover a 12-month
	period specified by the commissioner of insurance.  The
	commissioner of insurance shall work with the network adequacy
	study group to develop the data collection and evaluate the
	information collected.
	(b)  A health benefit plan issuer that fails to submit data
	as required in accordance with this section is subject to an
	administrative penalty under Chapter 84, Insurance Code.  For
	purposes of penalty assessment, each day the health benefit plan
	issuer fails to submit the data as required is a separate violation.
	SECTION 21.  This Act takes effect September 1, 2007.
	______________________________	______________________________
	President of the Senate	Speaker of the House
	I hereby certify that S.B. No. 1731 passed the Senate on
	April 30, 2007, by the following vote:  Yeas 31, Nays 0;
	May 25, 2007, Senate refused to concur in House amendments and
	requested appointment of Conference Committee; May 26, 2007, House
	granted request of the Senate; May 27, 2007, Senate adopted
	Conference Committee Report by the following vote:  Yeas 30,
	Nays 0.
	______________________________
	Secretary of the Senate
	I hereby certify that S.B. No. 1731 passed the House, with
	amendments, on May 23, 2007, by the following vote:  Yeas 145,
	Nays 0, three present not voting; May 26, 2007, House granted
	request of the Senate for appointment of Conference Committee;
	May 27, 2007, House adopted Conference Committee Report by the
	following vote:  Yeas 144, Nays 0, two present not voting.
	______________________________
	Chief Clerk of the House
	Approved:
	______________________________
	Date
	______________________________
	Governor