Bill Text: TX HB2090 | 2021-2022 | 87th Legislature | Enrolled
Bill Title: 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.
Spectrum: Moderate Partisan Bill (Republican 9-2)
Status: (Passed) 2021-06-07 - Effective on 9/1/21 [HB2090 Detail]
Download: Texas-2021-HB2090-Enrolled.html
H.B. No. 2090 |
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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 |