Bill Text: TX SB358 | 2023-2024 | 88th Legislature | Introduced

Texas Senate Bill 358 (Prior Session Legislation)

Introduced

Bill Title: Relating to establishment of a shared savings program for certain managed care plans.

Sponsorship: Partisan Bill (Republican 1)

Status: (Introduced - Dead) 2023-02-15 - Referred to Health & Human Services [SB358 Detail]

Download: Texas-2023-SB358-Introduced.html

	88R2849 SCL-D

	By: Kolkhorst	S.B. No. 358



	A BILL TO BE ENTITLED
	AN ACT
	relating to establishment of a shared savings program for certain
	managed care plans.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
	SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
	by adding Chapter 1276 to read as follows:
	CHAPTER 1276. SHARED SAVINGS PROGRAM
	SUBCHAPTER A. GENERAL PROVISIONS
	Sec. 1276.001. DEFINITIONS. In this chapter:
	(1) "Health care provider" means a health care
	practitioner or health care facility that provides health care
	services or supplies under a license, certificate, registration, or
	similar authorization issued by this state.
	(2) "Managed care plan" means a health benefit plan
	under which health care services or supplies are provided to
	enrollees through contracts with health care providers and that
	requires enrollees to use contracting providers or that provides a
	different level of coverage for enrollees who use contracting
	providers.
	(3) "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.
	(4) "Program" means the shared savings program
	established under this chapter.
	Sec. 1276.002. APPLICABILITY OF CHAPTER. (a) This chapter
	applies only with respect to nonemergency health care services or
	supplies covered under a managed care plan.
	(b) This chapter applies only to the following health
	benefit plans:
	(1) a health benefit plan provided by a health
	maintenance organization operating under Chapter 843;
	(2) a preferred provider benefit plan provided under
	Chapter 1301; or
	(3) a basic coverage plan provided under Chapter 1551.
	(c) Notwithstanding any other law, this chapter applies to
	an administrator of a health benefit plan described by this
	section.
	Sec. 1276.003. RULES. The commissioner may adopt rules
	necessary to implement this chapter.
	SUBCHAPTER B. PROGRAM REQUIREMENTS
	Sec. 1276.051. PROGRAM REQUIRED. (a) A health benefit plan
	issuer or administrator to which this chapter applies shall
	establish a shared savings program in accordance with this chapter.
	(b) A health benefit plan issuer or administrator shall
	provide written notice to its enrollees of the program.
	Sec. 1276.052. AVERAGE CONTRACTED RATE DISCLOSURE. (a) As
	part of the program, a health benefit plan issuer or administrator
	shall establish and operate a toll-free telephone number and
	publicly accessible Internet website for a plan enrollee to request
	that the plan disclose to the enrollee the average contracted rate
	paid under the plan to a health care provider in the plan's provider
	network for a particular health care service or supply in the
	preceding 12 months.
	(b) A health benefit plan issuer or administrator shall
	disclose to the enrollee the amount requested by the enrollee under
	Subsection (a).
	Sec. 1276.053. HEALTH CARE PROVIDER ESTIMATE. An
	out-of-network provider shall, on an enrollee's request, provide
	the enrollee a written estimate of the final charge for a proposed
	health care service or supply that is eligible for the enrollee's
	program. The estimate must include all costs associated with the
	service or supply and reflect the enrollee's final out-of-pocket
	cost associated with the proposed service or supply.
	Sec. 1276.054. SHARED SAVINGS PAYMENT. (a) Except as
	provided by Subsection (b), if an enrollee who requests a
	disclosure under Section 1276.052 elects and receives a health care
	service or supply the actual cost of which is less than the amount
	disclosed under Section 1276.052, the health benefit plan issuer or
	administrator shall pay to the enrollee 50 percent of the
	difference between the amount disclosed under Section 1276.052 and
	the actual cost, minus any applicable deductible, copayment, or
	coinsurance.
	(b) A health benefit plan issuer is not required to pay an
	enrollee under Subsection (a) if the difference described by that
	subsection is less than $50.
	(c) A health benefit plan issuer or administrator shall pay
	an enrollee under Subsection (a) not later than the 30th day after
	the date on which the enrollee submits a program claim.
	Sec. 1276.055. DEDUCTIBLES UNDER PROGRAM. (a) This section
	applies only to a health care service or supply for which an
	enrollee received:
	(1) a disclosure under Section 1276.052; and
	(2) an estimate under Section 1276.053 that is at
	least $50 less than the amount provided under the disclosure.
	(b) A health benefit plan issuer or administrator shall
	apply the same deductible to a health care service or supply to
	which this section applies as would be applied to a network service
	or supply.
	Sec. 1276.056. LIABILITY FOR UNFORESEEN CHARGE OVER
	ESTIMATE. If the final charge for the health care service or supply
	described by Section 1276.055(a) is greater than the estimate
	provided under Section 1276.053 due to unforeseen circumstances,
	the enrollee's health benefit plan issuer or administrator shall
	pay 95 percent of the difference up to the allowed amount for the
	service or supply and the enrollee is responsible for the remaining
	difference.
	SECTION 2. Chapter 1276, 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.
	SECTION 3. This Act takes effect September 1, 2023.