Bill Text: TX HB1742 | 2019-2020 | 86th Legislature | Enrolled


Bill Title: Relating to the mediation of the settlement of certain health benefit claims involving balance billing by out-of-network laboratories.

Spectrum: Bipartisan Bill

Status: (Vetoed) 2019-06-15 - Vetoed by the Governor [HB1742 Detail]

Download: Texas-2019-HB1742-Enrolled.html
 
 
  H.B. No. 1742
 
 
 
 
AN ACT
  relating to the mediation of the settlement of certain health
  benefit claims involving balance billing by out-of-network
  laboratories.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1467.001, Insurance Code, is amended by
  amending Subdivisions (4), (5), and (7) and adding Subdivisions
  (4-b) and (4-c) to read as follows:
               (4)  "Facility-based provider" means a physician,
  health care practitioner, or other health care provider who
  provides health care [or medical] services to patients of a
  facility.
               (4-b)  "Health care services" has the meaning assigned
  by Section 562.002.
               (4-c) "Laboratory" means an accredited facility in
  which a specimen taken from a human body is interpreted and
  pathological diagnoses are made.
               (5)  "Mediation" means a process in which an impartial
  mediator facilitates and promotes agreement between the insurer
  offering a preferred provider benefit plan or the administrator and
  a laboratory, facility-based provider, or emergency care provider
  or the laboratory's or provider's representative to settle a health
  benefit claim of an enrollee.
               (7)  "Party" means an insurer offering a preferred
  provider benefit plan, an administrator, or a laboratory,
  facility-based provider, or emergency care provider or the
  laboratory's or provider's representative who participates in a
  mediation conducted under this chapter.  The enrollee is also
  considered a party to the mediation.
         SECTION 2.  Section 1467.005, Insurance Code, is amended to
  read as follows:
         Sec. 1467.005.  REFORM.  This chapter may not be construed
  to prohibit:
               (1)  an insurer offering a preferred provider benefit
  plan or administrator from, at any time, offering a reformed claim
  settlement; or
               (2)  a laboratory, facility-based provider, or
  emergency care provider from, at any time, offering a reformed
  charge for health care [or medical] services [or supplies].
         SECTION 3.  Section 1467.051, Insurance Code, is amended to
  read as follows:
         Sec. 1467.051.  AVAILABILITY OF MANDATORY MEDIATION;
  EXCEPTION. (a)  An enrollee may request mediation of a settlement
  of an out-of-network health benefit claim if:
               (1)  the amount for which the enrollee is responsible
  to a laboratory, facility-based provider, or emergency care
  provider, after copayments, deductibles, and coinsurance,
  including the amount unpaid by the administrator or insurer, is
  greater than $500; and
               (2)  the health benefit claim is for:
                     (A)  emergency care; [or]
                     (B)  a health care [or medical] service [or
  supply] provided by a facility-based provider in a facility that is
  a preferred provider or that has a contract with the administrator;
  or
                     (C)  a laboratory service, if:
                           (i)  the specimen evaluated by the
  laboratory is collected:
                                 (a)  at the office of a health care
  practitioner who is a preferred provider or has a contract with the
  administrator; or
                                 (b)  at a facility that is a preferred
  provider or that has a contract with the administrator; and
                           (ii)  the laboratory is an out-of-network
  laboratory.
         (b)  Except as provided by Subsections (c) and (d), if an
  enrollee requests mediation under this subchapter, the laboratory,
  facility-based provider, or emergency care provider, or the
  laboratory's or provider's representative, and the insurer or the
  administrator, as appropriate, shall participate in the mediation.
         (c)  Except in the case of an emergency and if requested by
  the enrollee, a laboratory or facility-based provider shall, before
  providing a health care [or medical] service [or supply], provide a
  complete disclosure to an enrollee that:
               (1)  explains that the laboratory or facility-based
  provider does not have a contract with the enrollee's health
  benefit plan;
               (2)  discloses projected amounts for which the enrollee
  may be responsible; and
               (3)  discloses the circumstances under which the
  enrollee would be responsible for those amounts.
         (d)  A laboratory or facility-based provider who makes a
  disclosure under Subsection (c) and obtains the enrollee's written
  acknowledgment of that disclosure may not be required to mediate a
  billed charge under this subchapter if the amount billed is less
  than or equal to the maximum amount projected in the disclosure.
         SECTION 4.  Section 1467.0511, Insurance Code, is amended to
  read as follows:
         Sec. 1467.0511.  NOTICE AND INFORMATION PROVIDED TO
  ENROLLEE. (a)  A bill sent to an enrollee by a laboratory,
  facility-based provider, or emergency care provider or an
  explanation of benefits sent to an enrollee by an insurer or
  administrator for an out-of-network health benefit claim eligible
  for mediation under this chapter must contain, in not less than
  10-point boldface type, a conspicuous, plain-language explanation
  of the mediation process available under this chapter, including
  information on how to request mediation and a statement that is
  substantially similar to the following:
         "You may be able to reduce some of your out-of-pocket costs
  for an out-of-network medical or health care claim that is eligible
  for mediation by contacting the Texas Department of Insurance at
  (website) and (phone number)."
         (b)  If an enrollee contacts an insurer, administrator,
  laboratory, facility-based provider, or emergency care provider
  about a bill that may be eligible for mediation under this chapter,
  the insurer, administrator, laboratory, facility-based provider,
  or emergency care provider is encouraged to:
               (1)  inform the enrollee about mediation under this
  chapter; and
               (2)  provide the enrollee with the department's
  toll-free telephone number and Internet website address.
         SECTION 5.  Section 1467.052(c), Insurance Code, is amended
  to read as follows:
         (c)  A person may not act as mediator for a claim settlement
  dispute if the person has been employed by, consulted for, or
  otherwise had a business relationship with an insurer offering the
  preferred provider benefit plan or a physician, laboratory, health
  care practitioner, or other health care provider during the three
  years immediately preceding the request for mediation.
         SECTION 6.  Section 1467.053(d), Insurance Code, is amended
  to read as follows:
         (d)  The mediator's fees shall be split evenly and paid by
  the insurer or administrator and the laboratory, facility-based
  provider, or emergency care provider.
         SECTION 7.  Sections 1467.054(b), (c), and (e), Insurance
  Code, are amended to read as follows:
         (b)  A request for mandatory mediation must be provided to
  the department on a form prescribed by the commissioner and must
  include:
               (1)  the name of the enrollee requesting mediation;
               (2)  a brief description of the claim to be mediated;
               (3)  contact information, including a telephone
  number, for the requesting enrollee and the enrollee's counsel, if
  the enrollee retains counsel;
               (4)  the name of the laboratory, facility-based
  provider, or emergency care provider and name of the insurer or
  administrator; and
               (5)  any other information the commissioner may require
  by rule.
         (c)  On receipt of a request for mediation, the department
  shall notify the laboratory, facility-based provider, or emergency
  care provider and insurer or administrator of the request.
         (e)  A dispute to be mediated under this chapter that does
  not settle as a result of a teleconference conducted under
  Subsection (d) must be conducted in the county in which the health
  care [or medical] services were rendered.
         SECTION 8.  Sections 1467.055(d), (h), and (i), Insurance
  Code, are amended to read as follows:
         (d)  If the enrollee is participating in the mediation in
  person, at the beginning of the mediation the mediator shall inform
  the enrollee that if the enrollee is not satisfied with the mediated
  agreement, the enrollee may file a complaint with:
               (1)  the Texas Medical Board or other appropriate
  regulatory agency against the laboratory, facility-based provider,
  or emergency care provider for improper billing; and
               (2)  the department for unfair claim settlement
  practices.
         (h)  On receipt of notice from the department that an
  enrollee has made a request for mediation that meets the
  requirements of this chapter, the laboratory, facility-based
  provider, or emergency care provider may not pursue any collection
  effort against the enrollee who has requested mediation for amounts
  other than copayments, deductibles, and coinsurance before the
  earlier of:
               (1)  the date the mediation is completed; or
               (2)  the date the request to mediate is withdrawn.
         (i)  A health care [or medical] service [or supply] provided
  by a laboratory, facility-based provider, or emergency care
  provider may not be summarily disallowed.  This subsection does not
  require an insurer or administrator to pay for an uncovered service
  [or supply].
         SECTION 9.  Sections 1467.056(a), (b), and (d), Insurance
  Code, are amended to read as follows:
         (a)  In a mediation under this chapter, the parties shall:
               (1)  evaluate whether:
                     (A)  the amount charged by the laboratory,
  facility-based provider, or emergency care provider for the health
  care [or medical] service [or supply] is excessive; and
                     (B)  the amount paid by the insurer or
  administrator represents the usual and customary rate for the
  health care [or medical] service [or supply] or is unreasonably
  low; and
               (2)  as a result of the amounts described by
  Subdivision (1), determine the amount, after copayments,
  deductibles, and coinsurance are applied, for which an enrollee is
  responsible to the laboratory, facility-based provider, or
  emergency care provider.
         (b)  The laboratory, facility-based provider, or emergency
  care provider may present information regarding the amount charged
  for the health care [or medical] service [or supply].  The insurer
  or administrator may present information regarding the amount paid
  by the insurer or administrator.
         (d)  The goal of the mediation is to reach an agreement among
  the enrollee, the laboratory, facility-based provider, or
  emergency care provider, and the insurer or administrator, as
  applicable, as to the amount paid by the insurer or administrator to
  the laboratory, facility-based provider, or emergency care
  provider, the amount charged by the laboratory, facility-based
  provider, or emergency care provider, and the amount paid to the
  laboratory, facility-based provider, or emergency care provider by
  the enrollee.
         SECTION 10.  Section 1467.058, Insurance Code, is amended to
  read as follows:
         Sec. 1467.058.  CONTINUATION OF MEDIATION.  After a
  referral is made under Section 1467.057, the laboratory,
  facility-based provider, or emergency care provider and the insurer
  or administrator may elect to continue the mediation to further
  determine their responsibilities.  Continuation of mediation under
  this section does not affect the amount of the billed charge to the
  enrollee.
         SECTION 11.  Section 1467.059, Insurance Code, is amended to
  read as follows:
         Sec. 1467.059.  MEDIATION AGREEMENT.  The mediator shall
  prepare a confidential mediation agreement and order that states:
               (1)  the total amount for which the enrollee will be
  responsible to the laboratory, facility-based provider, or
  emergency care provider, after copayments, deductibles, and
  coinsurance; and
               (2)  any agreement reached by the parties under Section
  1467.058.
         SECTION 12.  Sections 1467.151(a), (b), and (d), Insurance
  Code, are amended to read as follows:
         (a)  The commissioner and the Texas Medical Board or other
  regulatory agency, as appropriate, shall adopt rules regulating the
  investigation and review of a complaint filed that relates to the
  settlement of an out-of-network health benefit claim that is
  subject to this chapter.  The rules adopted under this section
  must:
               (1)  distinguish among complaints for out-of-network
  coverage or payment and give priority to investigating allegations
  of delayed health care services [or medical care];
               (2)  develop a form for filing a complaint and
  establish an outreach effort to inform enrollees of the
  availability of the claims dispute resolution process under this
  chapter;
               (3)  ensure that a complaint is not dismissed without
  appropriate consideration;
               (4)  ensure that enrollees are informed of the
  availability of mandatory mediation; and
               (5)  require the administrator to include a notice of
  the claims dispute resolution process available under this chapter
  with the explanation of benefits sent to an enrollee.
         (b)  The department and the Texas Medical Board or other
  appropriate regulatory agency shall maintain information:
               (1)  on each complaint filed that concerns a claim or
  mediation subject to this chapter; and
               (2)  related to a claim that is the basis of an enrollee
  complaint, including:
                     (A)  the type of services that gave rise to the
  dispute;
                     (B)  the type and specialty, if any, of the
  laboratory, facility-based provider, or emergency care provider
  who provided the out-of-network service;
                     (C)  the county and metropolitan area in which the
  health care [or medical] service [or supply] was provided;
                     (D)  whether the health care [or medical] service
  [or supply] was for emergency care; and
                     (E)  any other information about:
                           (i)  the insurer or administrator that the
  commissioner by rule requires; or
                           (ii)  the laboratory, facility-based
  provider, or emergency care provider that the Texas Medical Board
  or other appropriate regulatory agency by rule requires.
         (d)  A laboratory, facility-based provider, or emergency
  care provider who fails to provide a disclosure under Section
  1467.051 or 1467.0511 is not subject to discipline by the Texas
  Medical Board or other appropriate regulatory agency for that
  failure and a cause of action is not created by a failure to
  disclose as required by Section 1467.051 or 1467.0511.
         SECTION 13.  The changes in law made by this Act apply only
  to a claim for health care services provided on or after September
  1, 2019. A claim for health care services provided before September
  1, 2019, 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 14.  This Act takes effect only if none of the
  following bills proposed by the 86th Legislature, Regular Session,
  2019, or similar legislation of the 86th Legislature, Regular
  Session, 2019, are enacted and become law:
               (1)  H.B. 2967, relating to prohibited balance billing
  and an independent dispute resolution program for out-of-network
  coverage under certain managed care plans;
               (2)  H.B. 3933, relating to consumer protections
  against billing and limitations on information reported by consumer
  reporting agencies;
               (3)  S.B. 1264, relating to consumer protections
  against certain medical and health care billing by certain
  out-of-network providers; or
               (4)  S.B. 1591, relating to prohibited balance billing
  and an independent dispute resolution program for out-of-network
  coverage under certain managed care plans.
         SECTION 15.  This Act takes effect September 1, 2019.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 1742 was passed by the House on April
  26, 2019, by the following vote:  Yeas 139, Nays 0, 2 present, not
  voting; and that the House concurred in Senate amendments to H.B.
  No. 1742 on May 24, 2019, by the following vote:  Yeas 142, Nays 0,
  2 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 1742 was passed by the Senate, with
  amendments, on May 22, 2019, by the following vote:  Yeas 31, Nays
  0.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor       
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