Bill Text: TX HB2360 | 2013-2014 | 83rd Legislature | Comm Sub
Bill Title: Relating to the disclosure of health care prices and related information.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Introduced - Dead) 2013-04-26 - Committee report sent to Calendars [HB2360 Detail]
Download: Texas-2013-HB2360-Comm_Sub.html
83R22015 SCL-D | |||
By: Bonnen of Galveston, et al. | H.B. No. 2360 | ||
Substitute the following for H.B. No. 2360: | |||
By: Bonnen of Galveston | C.S.H.B. No. 2360 |
|
||
|
||
relating to the disclosure of health care prices and related | ||
information. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended | ||
by adding Chapter 1470 to read as follows: | ||
CHAPTER 1470. DISCLOSURE OF PAYMENT AND COMPENSATION METHODOLOGY | ||
Sec. 1470.001. DEFINITIONS. In this chapter, unless the | ||
context otherwise requires: | ||
(1) "Edit" means a practice or procedure under which | ||
an adjustment is made regarding procedure codes that results in: | ||
(A) payment for some, but not all, of the health | ||
care procedures performed under a procedure code; | ||
(B) payment made under a different procedure | ||
code; | ||
(C) a reduced payment as a result of services | ||
provided to a patient that are claimed under more than one procedure | ||
code on the same service date; | ||
(D) a reduced payment related to a modifier used | ||
with a procedure code; or | ||
(E) a reduced payment based on multiple units of | ||
the same procedure code billed for a single date of service. | ||
(2) "Health benefit plan issuer" means: | ||
(A) an insurance company, association, | ||
organization, health maintenance organization, or pharmacy benefit | ||
manager that delivers or issues for delivery an individual, group, | ||
blanket, or franchise insurance policy or insurance agreement or an | ||
evidence of coverage that provides health insurance or health care | ||
benefits and includes: | ||
(i) a life, health, or accident insurance | ||
company operating under Chapter 841 or 982; | ||
(ii) a general casualty insurance company | ||
operating under Chapter 861; | ||
(iii) a fraternal benefit society operating | ||
under Chapter 885; | ||
(iv) a mutual life insurance company | ||
operating under Chapter 882; | ||
(v) a local mutual aid association | ||
operating under Chapter 886; | ||
(vi) a statewide mutual assessment company | ||
operating under Chapter 881; | ||
(vii) a mutual assessment company or mutual | ||
assessment life, health, and accident association operating under | ||
Chapter 887; | ||
(viii) a mutual insurance company operating | ||
under Chapter 883 that writes coverage other than life insurance; | ||
(ix) a Lloyd's plan operating under Chapter | ||
941; | ||
(x) a reciprocal exchange operating under | ||
Chapter 942; | ||
(xi) a stipulated premium insurance company | ||
operating under Chapter 884; | ||
(xii) an exchange operating under Chapter | ||
942; | ||
(xiii) a Medicare supplemental policy as | ||
defined by Section 1882(g)(1), Social Security Act (42 U.S.C. | ||
Section 1395ss(g)(1)); | ||
(xiv) a Medicaid managed care program | ||
operated under Chapter 533, Government Code; | ||
(xv) a health maintenance organization | ||
operating under Chapter 843; | ||
(xvi) a multiple employer welfare | ||
arrangement that holds a certificate of authority under Chapter | ||
846; and | ||
(xvii) an approved nonprofit health | ||
corporation that holds a certificate of authority under Chapter | ||
844; | ||
(B) the state Medicaid program operated under | ||
Chapter 32, Human Resources Code, or the state child health plan or | ||
health benefits plan for children under Chapter 62 or 63, Health and | ||
Safety Code; | ||
(C) the Employees Retirement System of Texas or | ||
another entity issuing or administering a basic coverage plan under | ||
Chapter 1551; | ||
(D) the Teacher Retirement System of Texas or | ||
another entity issuing or administering a basic plan under Chapter | ||
1575 or a primary care coverage plan under Chapter 1579; | ||
(E) The Texas A&M University System or The | ||
University of Texas System or another entity issuing or | ||
administering basic coverage under Chapter 1601; and | ||
(F) an entity issuing or administering medical | ||
benefits provided under a workers' compensation insurance policy or | ||
otherwise under Title 5, Labor Code. | ||
(3) "Health care contract" means a contract entered | ||
into or renewed between a health care contractor and a physician or | ||
health care provider for the delivery of health care services to | ||
others. | ||
(4) "Health care contractor" means an individual or | ||
entity that has as a business purpose contracting with physicians | ||
or health care providers for the delivery of health care services. | ||
The term includes a health benefit plan issuer, an administrator | ||
regulated under Chapter 4151, and a pharmacy benefit manager that | ||
administers or manages prescription drug benefits. | ||
(5) "Health care provider" means an individual or | ||
entity that furnishes goods or services under a license, | ||
certificate, registration, or other authority issued by this state | ||
to diagnose, prevent, alleviate, or cure a human illness or injury. | ||
The term does not include a physician, hospital, or other health | ||
care facility. | ||
(6) "Physician" means: | ||
(A) an individual licensed to engage in the | ||
practice of medicine in this state; or | ||
(B) an entity organized under Subchapter B, | ||
Chapter 162, Occupations Code. | ||
(7) "Procedure code" means an alphanumeric code used | ||
to identify a specific health procedure performed by a health care | ||
provider. The term includes: | ||
(A) the American Medical Association's Current | ||
Procedural Terminology code, also known as the "CPT code"; | ||
(B) the Centers for Medicare and Medicaid | ||
Services Health Care Common Procedure Coding System; and | ||
(C) other analogous codes published by national | ||
organizations and recognized by the commissioner. | ||
Sec. 1470.002. DEFINITION OF MATERIAL CHANGE. For purposes | ||
of this chapter, "material change" means a change to a contract that | ||
decreases the health care provider's or physician's payment or | ||
compensation. | ||
Sec. 1470.003. APPLICABILITY OF CHAPTER. (a) Except as | ||
otherwise provided by Subsection (c), this chapter applies only to | ||
contracts between a health care contractor and: | ||
(1) a physician; or | ||
(2) a health care provider who has filed a form | ||
described by Section 118.002, Occupations Code, with the | ||
commissioner. | ||
(b) This chapter does not apply to an employment contract or | ||
arrangement between health care providers or physicians. | ||
(c) Notwithstanding Subsection (a), this chapter applies to | ||
contracts for health care services between a medical group and | ||
other medical groups. | ||
Sec. 1470.004. RULEMAKING AUTHORITY. The commissioner may | ||
adopt reasonable rules as necessary to implement the purposes and | ||
provisions of this chapter. | ||
Sec. 1470.005. DISCLOSURE TO THIRD PARTY. A health care | ||
contract may not preclude the use of the contract or disclosure of | ||
the contract to a third party to enforce this chapter or other state | ||
or federal law. The third party is bound by any applicable | ||
confidentiality requirements, including those stated in the | ||
contract. | ||
Sec. 1470.006. REQUIRED DISCLOSURE OF PAYMENT AND | ||
COMPENSATION TERMS. (a) Each health care contract must include a | ||
disclosure form that states, in plain language, payment and | ||
compensation terms. The form must include information sufficient | ||
for a health care provider or physician to determine the | ||
compensation or payment for the provider's or physician's services. | ||
(b) The disclosure form under Subsection (a) must include: | ||
(1) the manner of payment, such as fee-for-service, | ||
capitation, or risk sharing; | ||
(2) the methodology used to compute any fee schedule, | ||
such as the use of a relative value unit system and conversion | ||
factor, percentage of Medicare payment system, or percentage of | ||
billed charges; | ||
(3) the fee schedule for procedure codes reasonably | ||
expected to be billed by the health care provider or physician for | ||
services provided under the contract and, on request, the fee | ||
schedule for other procedure codes used by, or that may be used by, | ||
the health care provider or physician; and | ||
(4) the effect of edits, if any, on payment or | ||
compensation. | ||
(c) As applicable, the methodology disclosure under | ||
Subsection (b)(2) must include: | ||
(1) the name of any relative value system used; | ||
(2) the version, edition, or publication date of that | ||
system; | ||
(3) any applicable conversion or geographic factors; | ||
and | ||
(4) the date by which compensation or fee schedules | ||
may be changed by the methodology, if allowed under the contract. | ||
(d) The fee schedule described by Subsection (b)(3) must | ||
include, as applicable, service or procedure codes and the | ||
associated payment or compensation for each code. The fee schedule | ||
may be provided electronically. | ||
(e) A health care contractor shall provide the fee schedule | ||
described by Subsection (b)(3) to an affected health care provider | ||
or physician when a material change related to payment or | ||
compensation occurs. Additionally, a health care provider or | ||
physician may request that a written fee schedule be provided up to | ||
twice annually, and the health care contractor must provide the | ||
written fee schedule promptly. | ||
(f) A health care contractor may satisfy the requirement | ||
under Subsection (b)(4) regarding the effect of edits by providing | ||
a clearly understandable, readily available mechanism that allows a | ||
health care provider or physician to determine the effect of an | ||
edit on payment or compensation before a service is provided or a | ||
claim is submitted. | ||
Sec. 1470.007. ENFORCEMENT. (a) The commissioner shall | ||
adopt rules as necessary to enforce the provisions of this chapter. | ||
(b) A violation of Section 1470.006 is a deceptive act or | ||
practice in insurance under Subchapter B, Chapter 541. | ||
SECTION 2. Subtitle A, Title 3, Occupations Code, is | ||
amended by adding Chapter 118 to read as follows: | ||
CHAPTER 118. DISCLOSURE OF HEALTH CARE PRICES | ||
Sec. 118.001. DEFINITIONS. In this chapter: | ||
(1) "Consumer" means an individual who seeks or | ||
acquires health care goods, including drugs or devices, or services | ||
from a health care provider or physician. | ||
(2) "Health care contractor" has the meaning assigned | ||
by Section 1470.001, Insurance Code. | ||
(3) "Health care good" or "health care service" means | ||
a good or service, as applicable, to diagnose, prevent, alleviate, | ||
cure, or heal a health condition, sickness, or injury that is | ||
provided to a consumer by a physician or health care provider. | ||
(4) "Health care provider" means a person who | ||
furnishes goods or services under a license, certificate, | ||
registration, or other authority issued by this state to diagnose, | ||
prevent, alleviate, or cure a human illness or injury. The term | ||
does not include a physician, hospital, or other health care | ||
facility. | ||
Sec. 118.002. APPLICABILITY. (a) This chapter applies | ||
only to: | ||
(1) a physician; and | ||
(2) a health care provider who elects to comply with | ||
this chapter and files a form evidencing that election with the | ||
commissioner of insurance. | ||
(b) The commissioner of insurance shall adopt a form to be | ||
used to comply with Subsection (a). | ||
Sec. 118.003. DISCLOSURE OF HEALTH CARE PRICES. (a) A | ||
health care provider who elects to comply with this chapter and a | ||
physician must disclose to a consumer before the commencement of a | ||
health care service or the transfer of a health care good, including | ||
a drug or device, the price of the service or good. | ||
(b) The disclosure may be made through the health care | ||
provider's or physician's Internet website or in writing given to | ||
the consumer before the commencement of the health care service or | ||
the transfer of the health care good. If the disclosure was given | ||
through the provider's or physician's Internet website, the | ||
provider or physician shall inform the consumer in writing, before | ||
the commencement of the service or transfer of the good, that health | ||
care prices are disclosed on the website. | ||
Sec. 118.004. FAILURE TO DISCLOSE. (a) A health care | ||
provider or physician who fails to disclose the information as | ||
described by this section cannot recover a fee, a deductible, a | ||
copayment, or any other payment or obligation from the consumer | ||
related to a health care service or good for which the provider or | ||
physician did not disclose the price. | ||
(b) Notwithstanding Subsection (a), a health care provider | ||
or physician may recover the amount of a payment or other obligation | ||
owed to the provider or physician from a consumer if the cause of | ||
the failure to disclose was a health care contractor's failure to | ||
disclose information under Section 1470.005, Insurance Code. | ||
SECTION 3. (a) Chapter 1470, Insurance Code, as added by | ||
this Act, applies only to a health care contract that is entered | ||
into or renewed on or after January 1, 2014. A health care contract | ||
entered into before January 1, 2014, 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. | ||
(b) Chapter 118, Occupations Code, as added by this Act, | ||
applies only to a health care service that is commenced or a health | ||
care good that is transferred on or after the effective date of this | ||
Act. A health care service that is commenced or a health care good | ||
that is transferred before the effective date of this Act is | ||
governed by the law in effect immediately before the effective date | ||
of this Act, and that law is continued in effect for that purpose. | ||
SECTION 4. This Act takes effect September 1, 2013. |