Bill Text: TX SB1935 | 2017-2018 | 85th Legislature | Introduced
Bill Title: Relating to disclosure of certain health care costs and shared savings between certain health benefit plans and state employees.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2017-03-27 - Referred to State Affairs [SB1935 Detail]
Download: Texas-2017-SB1935-Introduced.html
By: Hughes | S.B. No. 1935 | |
|
||
|
||
relating to disclosure of certain health care costs and shared | ||
savings between certain health benefit plans and state employees. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Chapter 1551, Insurance Code, is amended by | ||
adding Subchapters K and L to read as follows: | ||
SUBCHAPTER K. HEALTH CARE PRICE DISCLOSURES | ||
Sec. 1551.501. DEFINITIONS. In this subchapter: | ||
(1) "Administrator" means an administering firm for a | ||
health benefit plan provided as basic coverage under this chapter. | ||
(2) "Enrollee" means a participant enrolled in a | ||
health benefit plan provided as basic coverage under this chapter. | ||
(3) "Facility" means a hospital, outpatient clinic, | ||
birthing center, ambulatory surgical center, or other licensed | ||
facility providing health care services. The term does not include | ||
an emergency clinic, a freestanding emergency medical care | ||
facility, or other facility providing only emergency care. | ||
(4) "Practitioner" means an individual who is licensed | ||
to provide and provides medical or other health care services. | ||
Sec. 1551.502. PROVIDER PRICE DISCLOSURE OR ESTIMATE. | ||
(a) On the request of an enrollee and before providing a | ||
nonemergency health care service offered to the enrollee by the | ||
facility or practitioner, a facility or practitioner shall provide | ||
a price disclosure described by Subsection (b) or an estimate | ||
described by Subsection (c), as applicable, not later than the | ||
second business day after the date on which the enrollee requests | ||
the disclosure or estimate. | ||
(b) Except as provided by Subsection (c), a facility or | ||
practitioner required to provide a price disclosure under | ||
Subsection (a) shall disclose to the enrollee the amount, including | ||
facility fees, that: | ||
(1) the enrollee's health benefit plan will reimburse | ||
the facility or practitioner for the service, if the facility or | ||
practitioner is participating in the enrollee's health benefit plan | ||
provider network; or | ||
(2) the facility or practitioner will charge for the | ||
service, if the facility or practitioner is not participating in | ||
the enrollee's health benefit plan provider network. | ||
(c) If a facility or practitioner is unable to quote a | ||
specific amount under Subsection (b) because of the facility's or | ||
practitioner's inability to predict the specific service the | ||
enrollee will need, the facility or practitioner shall provide an | ||
estimate of the amount required to be disclosed, including facility | ||
fees. | ||
(d) A facility or practitioner that provides an estimate | ||
described by Subsection (c) shall: | ||
(1) disclose the incomplete nature of the estimate; | ||
and | ||
(2) inform the enrollee that the facility or | ||
practitioner may be able to provide an updated estimate after the | ||
facility or practitioner obtains additional information. | ||
Sec. 1551.503. EFFECT OF OTHER LAW. A facility that | ||
provides an estimate under Section 324.101(d) is not relieved of | ||
the obligation to provide a price disclosure or estimate under | ||
Section 1551.502. | ||
Sec. 1551.504. HEALTH CARE SERVICE INFORMATION. On | ||
request, a facility or practitioner participating in the enrollee's | ||
health benefit plan provider network shall provide an enrollee with | ||
sufficient information about a proposed nonemergency health care | ||
service to enable the enrollee to obtain a cost estimate to | ||
determine the amount for which the enrollee will be personally | ||
liable by using the enrollee's health benefit plan's toll-free | ||
telephone number or Internet website or a third-party service. The | ||
facility or practitioner shall provide the information to the | ||
enrollee based on the information that is available to the facility | ||
or practitioner at the time of the request. The facility or | ||
practitioner may assist the enrollee in using the telephone number, | ||
website, or third-party service. | ||
Sec. 1551.505. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. | ||
(a) The administrator for an enrollee's health benefit plan shall, | ||
on the request of the enrollee, provide a good faith estimate of | ||
payments that will be made for any medically necessary, covered | ||
health care service from a network provider and shall also specify | ||
any deductibles, copayments, coinsurance, or other amounts for | ||
which the enrollee is responsible, based on the information | ||
available to the administrator at the time the estimate was | ||
requested. The estimate must be provided not later than the second | ||
business day after the date on which the estimate was requested. | ||
The administrator must advise the enrollee that the actual payment | ||
and charges for the services may vary based upon the enrollee's | ||
actual medical condition and other factors associated with | ||
performance of medical services, including any factors unknown to | ||
or unforeseeable by the administrator or provider at the time the | ||
estimate was requested. | ||
(b) An administrator may require an enrollee to pay any | ||
deductibles, copayments, coinsurance, or other amounts disclosed | ||
in the enrollee's coverage documents for an unforeseen health care | ||
service that arises out of the provision of the proposed health care | ||
service. | ||
SUBCHAPTER L. SHARED SAVINGS INCENTIVE PROGRAM | ||
Sec. 1551.551. DEFINITIONS. In this subchapter: | ||
(1) "Administrator" means an administering firm for a | ||
health benefit plan provided as basic coverage under this chapter. | ||
(2) "Enrollee" means a participant enrolled in a | ||
health benefit plan provided as basic coverage under this chapter. | ||
(3) "Program" means the shared savings incentive | ||
program established under this subchapter. | ||
(4) "Shoppable health care service" means a health | ||
care service covered by an enrollee's health benefit plan for which | ||
the plan provides an incentive under the program. The term | ||
includes: | ||
(A) physical and occupational therapy services; | ||
(B) obstetrical and gynecological services; | ||
(C) radiology and imaging services; | ||
(D) laboratory services; | ||
(E) infusion therapy; | ||
(F) inpatient and outpatient surgical | ||
procedures; | ||
(G) outpatient nonsurgical diagnostic tests or | ||
procedures; and | ||
(H) any other health care service designated as a | ||
shoppable health care service by the commissioner for purposes of | ||
this subchapter. | ||
Sec. 1551.552. APPLICABILITY. This subchapter applies to a | ||
health benefit plan provided as basic coverage under this chapter. | ||
Sec. 1551.553. RULES. The commissioner may adopt rules to | ||
implement this subchapter. | ||
Sec. 1551.554. SHARED SAVINGS INCENTIVE PROGRAM. An | ||
administrator shall develop and implement a shared savings | ||
incentive program through which a health benefit plan provides an | ||
incentive in accordance with this subchapter to an enrollee for | ||
electing to receive a shoppable health care service at a lower cost | ||
than the average cost for that service paid by the health benefit | ||
plan. | ||
Sec. 1551.555. DEPARTMENT REVIEW OF PROGRAM. Before | ||
offering the program, an administrator shall file a description of | ||
the program with the department in the form and manner prescribed by | ||
the commissioner. The department shall review the description to | ||
determine whether the program complies with this subchapter and | ||
rules adopted under this subchapter. A description of a shared | ||
savings incentive program and any supporting documentation filed | ||
under this section are confidential until the department has | ||
reviewed and approved a program. | ||
Sec. 1551.556. NOTICE TO PARTICIPANTS. Annually and at | ||
enrollment or renewal of a health benefit plan, the board of | ||
trustees or administrator shall provide written notice to | ||
participants and enrollees about the availability of the program. | ||
Sec. 1551.557. PRICE DISCLOSURE TELEPHONE NUMBER AND | ||
WEBSITE. (a) An administrator shall establish and operate a | ||
toll-free telephone number and an interactive mechanism on the | ||
publicly accessible Internet website for the health benefit plan | ||
that an enrollee may use to: | ||
(1) request and obtain from the administrator or a | ||
designated third party the average amount paid under the health | ||
benefit plan to providers in the health benefit plan provider | ||
network for a particular health care service; and | ||
(2) compare the cost of a shoppable health care | ||
service among network providers. | ||
(b) An administrator may contract with a third party to | ||
operate the telephone number or interactive mechanism described by | ||
Subsection (a). | ||
Sec. 1551.558. AVERAGE COST DETERMINATION. (a) Except as | ||
provided by Subsection (b), for purposes of this subchapter an | ||
administrator shall determine the average amount paid under a | ||
health benefit plan to providers in the health benefit plan | ||
provider network for a particular health care service using amounts | ||
paid within a reasonable period of not more than one year. | ||
(b) The commissioner may approve an alternative method for | ||
determining the average cost amount described by Subsection (a). | ||
Sec. 1551.559. INCENTIVE PAYMENTS. (a) An administrator | ||
must calculate an incentive under this section as a percentage of | ||
the difference in price, as a flat dollar amount, or by some other | ||
reasonable method approved by the commissioner. The administrator | ||
must provide the incentive as a cash payment to the enrollee. | ||
(b) Except as provided by Subsection (c), if an enrollee | ||
elects to receive a shoppable health care service the total cost of | ||
which is less than the average cost amount determined for the | ||
service under Section 1551.558, the administrator shall pay to the | ||
enrollee an incentive payment that is at least 50 percent of the | ||
health benefit plan's saved cost. | ||
(c) An administrator is not required to pay an enrollee | ||
under Subsection (b) if the health benefit plan's saved cost is $50 | ||
or less. | ||
(d) If an enrollee elects to receive a shoppable health care | ||
service from a provider outside the enrollee's health benefit plan | ||
provider network the total cost of which is less than the average | ||
cost amount determined for the service under Section 1551.558, the | ||
administrator, in addition to paying any incentive payment due | ||
under Subsection (b): | ||
(1) may hold the enrollee responsible only for any | ||
deductible, copayment, or coinsurance that would be due if the | ||
service were provided by a provider in the health benefit plan | ||
provider network; and | ||
(2) shall apply the amount paid for the service toward | ||
the enrollee's cost-sharing maximums, as if the service were | ||
provided by a provider in the health benefit plan provider network. | ||
(e) An incentive payment made in accordance with this | ||
section is not an administrative expense of the administrator for | ||
purposes of rate development or rate filing. | ||
Sec. 1551.560. SHARED SAVINGS REPORTING. (a) Not later | ||
than February 1 of each year, an administrator shall submit to the | ||
commissioner and the board of trustees a report for the preceding | ||
calendar year stating: | ||
(1) the total number of incentive payments made under | ||
Section 1551.559; | ||
(2) the total amount of those incentive payments; | ||
(3) the average amount of those incentive payments by | ||
category of health care service; | ||
(4) the total number and percentage of the health | ||
benefit plan's enrollees who received an incentive payment; | ||
(5) the number of shoppable health care services by | ||
category for which incentive payments were made and the average | ||
cost amount for those services; and | ||
(6) the total savings achieved by the health benefit | ||
plan for each category of health care service for which an incentive | ||
payment was made. | ||
(b) Not later than April 1 of each year, the department | ||
shall submit a report aggregating the information submitted by each | ||
health benefit plan administrator under this section to the | ||
governor, the lieutenant governor, the speaker of the house of | ||
representatives, and each legislative committee with jurisdiction | ||
over health insurance matters. | ||
SECTION 2. Section 324.101, Health and Safety Code, is | ||
amended by adding Subsection (d-1) to read as follows: | ||
(d-1) A facility that provides a price disclosure or | ||
estimate under Section 1551.502, Insurance Code, is not relieved of | ||
the obligation to provide an estimate under Subsection (d). | ||
SECTION 3. (a) Subchapter K, Chapter 1551, Insurance Code, | ||
as added by this Act, applies only to a service provided by a | ||
facility or practitioner during a plan year beginning on or after | ||
January 1, 2018. A service provided during a plan year beginning | ||
before January 1, 2018, 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) Subchapter L, Chapter 1551, Insurance Code, as added by | ||
this Act, applies only to a health benefit plan for a plan year | ||
beginning on or after January 1, 2018. A health benefit plan for a | ||
plan year beginning before January 1, 2018, 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, 2017. |