Bill Text: TX HB1742 | 2019-2020 | 86th Legislature | Introduced
NOTE: There are more recent revisions of this legislation. Read Latest Draft
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-Introduced.html
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-Introduced.html
86R9268 SMT-D | ||
By: Smithee | H.B. No. 1742 |
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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 [ |
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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 [ |
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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; [ |
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(B) a health care [ |
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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 by an in-network physician, health care | ||
practitioner, or health care provider; | ||
(ii) the laboratory is an out-of-network | ||
laboratory; and | ||
(iii) the enrollee did not have a | ||
reasonable opportunity to inquire about the laboratory's network | ||
status. | ||
(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 [ |
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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 laboratory, 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 [ |
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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 [ |
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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 | ||
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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 [ |
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(B) the amount paid by the insurer or | ||
administrator represents the usual and customary rate for the | ||
health care [ |
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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 [ |
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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 [ |
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(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 [ |
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(D) whether the health care [ |
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(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 January 1, | ||
2020. A claim for health care services provided before January 1, | ||
2020, is governed by the law as it existed immediately before the | ||
effective date of this Act, and that law is continued in effect for | ||
that purpose. | ||
SECTION 14. This Act takes effect September 1, 2019. |