Bill Text: TX SB358 | 2023-2024 | 88th Legislature | Introduced


Bill Title: Relating to establishment of a shared savings program for certain managed care plans.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2023-02-15 - Referred to Health & Human Services [SB358 Detail]

Download: Texas-2023-SB358-Introduced.html
  88R2849 SCL-D
 
  By: Kolkhorst S.B. No. 358
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to establishment of a shared savings program for certain
  managed care plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Subtitle C, Title 8, Insurance Code, is amended
  by adding Chapter 1276 to read as follows:
  CHAPTER 1276. SHARED SAVINGS PROGRAM
  SUBCHAPTER A. GENERAL PROVISIONS
         Sec. 1276.001.  DEFINITIONS. In this chapter:
               (1)  "Health care provider" means a health care
  practitioner or health care facility that provides health care
  services or supplies under a license, certificate, registration, or
  similar authorization issued by this state.
               (2)  "Managed care plan" means a health benefit plan
  under which health care services or supplies are provided to
  enrollees through contracts with health care providers and that
  requires enrollees to use contracting providers or that provides a
  different level of coverage for enrollees who use contracting
  providers.
               (3)  "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.
               (4)  "Program" means the shared savings program
  established under this chapter.
         Sec. 1276.002.  APPLICABILITY OF CHAPTER. (a) This chapter
  applies only with respect to nonemergency health care services or
  supplies covered under a managed care plan.
         (b)  This chapter applies only to the following health
  benefit plans:
               (1)  a health benefit plan provided by a health
  maintenance organization operating under Chapter 843;
               (2)  a preferred provider benefit plan provided under
  Chapter 1301; or
               (3)  a basic coverage plan provided under Chapter 1551.
         (c)  Notwithstanding any other law, this chapter applies to
  an administrator of a health benefit plan described by this
  section.
         Sec. 1276.003.  RULES. The commissioner may adopt rules
  necessary to implement this chapter.
  SUBCHAPTER B. PROGRAM REQUIREMENTS
         Sec. 1276.051.  PROGRAM REQUIRED. (a) A health benefit plan
  issuer or administrator to which this chapter applies shall
  establish a shared savings program in accordance with this chapter.
         (b)  A health benefit plan issuer or administrator shall
  provide written notice to its enrollees of the program.
         Sec. 1276.052.  AVERAGE CONTRACTED RATE DISCLOSURE. (a) As
  part of the program, a health benefit plan issuer or administrator
  shall establish and operate a toll-free telephone number and
  publicly accessible Internet website for a plan enrollee to request
  that the plan disclose to the enrollee the average contracted rate
  paid under the plan to a health care provider in the plan's provider
  network for a particular health care service or supply in the
  preceding 12 months.
         (b)  A health benefit plan issuer or administrator shall
  disclose to the enrollee the amount requested by the enrollee under
  Subsection (a).
         Sec. 1276.053.  HEALTH CARE PROVIDER ESTIMATE. An
  out-of-network provider shall, on an enrollee's request, provide
  the enrollee a written estimate of the final charge for a proposed
  health care service or supply that is eligible for the enrollee's
  program. The estimate must include all costs associated with the
  service or supply and reflect the enrollee's final out-of-pocket
  cost associated with the proposed service or supply.
         Sec. 1276.054.  SHARED SAVINGS PAYMENT. (a) Except as
  provided by Subsection (b), if an enrollee who requests a
  disclosure under Section 1276.052 elects and receives a health care
  service or supply the actual cost of which is less than the amount
  disclosed under Section 1276.052, the health benefit plan issuer or
  administrator shall pay to the enrollee 50 percent of the
  difference between the amount disclosed under Section 1276.052 and
  the actual cost, minus any applicable deductible, copayment, or
  coinsurance.
         (b)  A health benefit plan issuer is not required to pay an
  enrollee under Subsection (a) if the difference described by that
  subsection is less than $50.
         (c)  A health benefit plan issuer or administrator shall pay
  an enrollee under Subsection (a) not later than the 30th day after
  the date on which the enrollee submits a program claim.
         Sec. 1276.055.  DEDUCTIBLES UNDER PROGRAM. (a) This section
  applies only to a health care service or supply for which an
  enrollee received:
               (1)  a disclosure under Section 1276.052; and 
               (2)  an estimate under Section 1276.053 that is at
  least $50 less than the amount provided under the disclosure.
         (b)  A health benefit plan issuer or administrator shall
  apply the same deductible to a health care service or supply to
  which this section applies as would be applied to a network service
  or supply. 
         Sec. 1276.056.  LIABILITY FOR UNFORESEEN CHARGE OVER
  ESTIMATE. If the final charge for the health care service or supply
  described by Section 1276.055(a) is greater than the estimate
  provided under Section 1276.053 due to unforeseen circumstances,
  the enrollee's health benefit plan issuer or administrator shall
  pay 95 percent of the difference up to the allowed amount for the
  service or supply and the enrollee is responsible for the remaining
  difference.
         SECTION 2.  Chapter 1276, 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.
         SECTION 3.  This Act takes effect September 1, 2023.
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