Bill Text: TX SB486 | 2021-2022 | 87th Legislature | Introduced

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Bill Title: Relating to provider reimbursements and enrollee cost-sharing payments for services provided under a managed care plan by certain out-of-network providers.

Sponsorship: Partisan Bill (Republican 1)

Status: (Introduced - Dead) 2021-03-09 - Referred to Business & Commerce [SB486 Detail]

Download: Texas-2021-SB486-Introduced.html

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87R4874 SMT-F
By: Schwertner S.B. No. 486

A BILL TO BE ENTITLED
AN ACT
relating to provider reimbursements and enrollee cost-sharing
payments for services provided under a managed care plan by certain
out-of-network providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 533, Government Code, is
amended by adding Section 533.01316 to read as follows:
Sec. 533.01316. REIMBURSEMENT FOR CERTAIN OUT-OF-NETWORK
SERVICES. (a) This section applies only to a Medicaid service
provided to a recipient by a provider who, on the date the recipient
was initially enrolled or was reenrolled for a subsequent
enrollment period in a managed care plan offered by a Medicaid
managed care organization, was included in the organization's
provider network directory but is no longer in the provider network
on the date the service is provided to the recipient.
(b) Except as provided by Subsection (c), the commission
shall require a Medicaid managed care organization to reimburse a
provider of a service to which this section applies at the
organization's in-network reimbursement rate if the service is
provided to the recipient during the enrollment period that began
on the date described by Subsection (a).
(c) Subsection (b) does not apply if the provider is no
longer in the Medicaid managed care organization's provider network
on the date the service is provided because:
(1) the provider's license to provide health care
services is expired, suspended, or revoked; or
(2) the provider unilaterally terminated
participation in the network for a reason other than the
organization's default or breach of the contract between the
provider and the organization.
SECTION 2. Subchapter K, Chapter 1451, Insurance Code, is
amended by adding Section 1451.506 to read as follows:
Sec. 1451.506. PAYMENT OR REIMBURSEMENT FOR CERTAIN
OUT-OF-NETWORK HEALTH CARE SERVICES. (a) If a provider is included
in a health benefit plan issuer's provider directory on the date an
enrollee enrolls in the plan, the issuer shall, until the
expiration of the health benefit plan contract year or other
contract period during which the enrollee enrolled:
(1) pay or reimburse the provider the in-network rate
for services provided to the enrollee; and
(2) ensure that the enrollee is not responsible for a
cost-sharing amount that is higher than the amount the enrollee
would have been required to pay if the service had been provided by
an in-network provider.
(b) This section does not apply if the provider is no longer
in the health benefit plan issuer's provider network on the date the
service is provided because:
(1) the provider's license to provide health care
services is expired, suspended, or revoked; or
(2) the provider unilaterally terminated
participation in the network for a reason other than the issuer's
default or breach of the contract between the provider and the
issuer.
SECTION 3. (a) The Health and Human Services Commission
shall, in a contract between the commission and a managed care
organization under Chapter 533, Government Code, that is entered
into or renewed on or after the effective date of this Act, require
that the managed care organization comply with Section 533.01316,
Government Code, as added by this Act.
(b) The Health and Human Services Commission shall seek to
amend contracts entered into with managed care organizations under
Chapter 533, Government Code, before the effective date of this Act
to require those managed care organizations to comply with Section
533.01316, Government Code, as added by this Act. To the extent of
a conflict between that section and a provision of a contract with a
managed care organization entered into before the effective date of
this Act, the contract provision prevails.
SECTION 4. Section 1451.506, Insurance Code, as added by
this Act, applies only to a health benefit plan that is delivered,
issued for delivery, or renewed on or after January 1, 2022. A
health benefit plan 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 5. If before implementing any provision of this Act
a state agency determines that a waiver or authorization from a
federal agency is necessary for implementation of that provision,
the agency affected by the provision shall request the waiver or
authorization and may delay implementing that provision until the
waiver or authorization is granted.
SECTION 6. This Act takes effect September 1, 2021.