Bill Text: TX HB3947 | 2021-2022 | 87th Legislature | Introduced
Bill Title: Relating to health care cost transparency by health benefit plan issuers.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2021-03-24 - Referred to Insurance [HB3947 Detail]
Download: Texas-2021-HB3947-Introduced.html
| 87R6281 SCL-D | ||
| By: Muñoz, Jr. | H.B. No. 3947 | |
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| relating to health care cost transparency by health benefit plan | ||
| issuers. | ||
| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
| SECTION 1. The heading to Subtitle J, Title 8, Insurance | ||
| Code, is amended to read as follows: | ||
| SUBTITLE J. HEALTH INFORMATION TECHNOLOGY AND TRANSPARENCY | ||
| SECTION 2. Subtitle J, Title 8, Insurance Code, is amended | ||
| by adding Chapter 1663 to read as follows: | ||
| CHAPTER 1663. HEALTH CARE COST TRANSPARENCY | ||
| SUBCHAPTER A. GENERAL PROVISIONS | ||
| Sec. 1663.001. DEFINITIONS. In this chapter: | ||
| (1) "Allowed amount" means the amount paid by a health | ||
| benefit plan issuer to a participating provider for a covered | ||
| service under a contract between the issuer and provider. | ||
| (2) "Enrollee" means an individual who is eligible to | ||
| receive benefits for health care services through a health benefit | ||
| plan. | ||
| (3) "Health benefit plan" means: | ||
| (A) an individual, group, blanket, or franchise | ||
| insurance policy, a certificate issued under an individual or group | ||
| policy, or a group hospital service contract that provides benefits | ||
| for health care services; or | ||
| (B) a group subscriber contract or group or | ||
| individual evidence of coverage issued by a health maintenance | ||
| organization that provides benefits for health care services. | ||
| (4) "Health benefit plan issuer" means a health | ||
| maintenance organization operating under Chapter 843, a preferred | ||
| provider organization operating under Chapter 1301, an approved | ||
| nonprofit health corporation that holds a certificate of authority | ||
| under Chapter 844, and any other entity that issues a health benefit | ||
| plan, including: | ||
| (A) an insurance company; | ||
| (B) a group hospital service corporation | ||
| operating under Chapter 842; | ||
| (C) a fraternal benefit society operating under | ||
| Chapter 885; or | ||
| (D) a stipulated premium company operating under | ||
| Chapter 884. | ||
| (5) "Health care provider" means a physician, | ||
| hospital, pharmacy, pharmacist, laboratory, or other person or | ||
| organization that furnishes health care services and that is | ||
| licensed or otherwise authorized to practice in this state. | ||
| (6) "Health care service" means a service for the | ||
| diagnosis, prevention, treatment, cure, or relief of a health | ||
| condition, illness, injury, or disease. | ||
| (7) "Managed care plan" means a health benefit plan | ||
| under which health care services are provided to enrollees through | ||
| contracts with health care providers and that requires enrollees to | ||
| use participating providers or that provides a different level of | ||
| coverage for enrollees who use participating providers. | ||
| (8) "Out-of-network provider," with respect to a | ||
| managed care plan, means a health care provider who is not a | ||
| participating provider of the plan. | ||
| (9) "Participating provider" means a health care | ||
| provider who has contracted with a health benefit plan issuer to | ||
| provide health care services to enrollees. | ||
| Sec. 1663.002. 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) health benefits provided by or through a church | ||
| benefits board under Subchapter I, Chapter 22, Business | ||
| Organizations Code; | ||
| (8) the state Medicaid program, including the Medicaid | ||
| managed care program operated under Chapter 533, Government Code; | ||
| (9) the child health plan program under Chapter 62, | ||
| Health and Safety Code; | ||
| (10) a regional or local health care program operated | ||
| under Section 75.104, Health and Safety Code; | ||
| (11) a self-funded health benefit plan sponsored by a | ||
| professional employer organization under Chapter 91, Labor Code; | ||
| (12) county employee group health benefits provided | ||
| under Chapter 157, Local Government Code; and | ||
| (13) health and accident coverage provided by a risk | ||
| pool created under Chapter 172, Local Government Code. | ||
| Sec. 1663.003. RULES. The commissioner may adopt rules to | ||
| implement this chapter. | ||
| SUBCHAPTER B. TRANSPARENCY TOOLS | ||
| Sec. 1663.051. AVAILABILITY OF PRICE AND QUALITY | ||
| INFORMATION. (a) A health benefit plan issuer shall provide on its | ||
| publicly available Internet website an interactive mechanism that, | ||
| for a health care service classified by the Current Procedural | ||
| Terminology code associated with the service, allows an enrollee | ||
| to: | ||
| (1) request and obtain from the issuer: | ||
| (A) information on the payments made by the | ||
| issuer to participating providers under the enrollee's health | ||
| benefit plan; and | ||
| (B) the payment methodology for and an estimate | ||
| of the dollar amount the issuer will pay for a health care service | ||
| provided by a health care provider who is not a participating | ||
| provider, including an out-of-network provider; | ||
| (2) compare allowed amounts among participating | ||
| providers; and | ||
| (3) estimate the enrollee's out-of-pocket costs under | ||
| the enrollee's health benefit plan. | ||
| (b) The interactive mechanism must: | ||
| (1) have a brief description of each Current | ||
| Procedural Terminology code that allows an enrollee to find the | ||
| appropriate code for a particular health care service; | ||
| (2) allow an enrollee to receive the requested | ||
| information before the enrollee receives the health care service or | ||
| an associated supply for which the enrollee requested information; | ||
| and | ||
| (3) provide the information to the enrollee using | ||
| plain language. | ||
| (c) A health benefit plan issuer shall update the | ||
| interactive mechanism for a health benefit plan with each payment | ||
| made by the issuer with respect to the plan. | ||
| (d) A health benefit plan issuer may contract with a third | ||
| party to provide the interactive mechanism. | ||
| Sec. 1663.052. ESTIMATE REQUIREMENTS. To satisfy the | ||
| requirement under Section 1663.051(a)(3), a health benefit plan | ||
| issuer shall provide a good-faith estimate of the amount the | ||
| enrollee will be responsible to pay for a health care service based | ||
| on the information available to the issuer at the time the estimate | ||
| is requested. | ||
| Sec. 1663.053. NOTICE TO ENROLLEES. A health benefit plan | ||
| issuer shall inform an enrollee requesting an estimate under | ||
| Section 1663.051(a)(3) that the actual amount of the charges and | ||
| the amount the enrollee is responsible to pay for the service may | ||
| vary based upon unforeseen services that arise from the proposed | ||
| service. | ||
| SECTION 3. Chapter 1663, 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. A health benefit | ||
| plan that is delivered, issued for delivery, or renewed before | ||
| January 1, 2022, 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 4. This Act takes effect September 1, 2021. | ||
