Bill Text: TX HB1436 | 2021-2022 | 87th Legislature | Introduced

Texas House Bill 1436 (Prior Session Legislation)

Introduced

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.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2021-03-05 - Referred to Human Services [HB1436 Detail]

Download: Texas-2021-HB1436-Introduced.html

	87R4874 SMT-F

	By: Lucio III	H.B. No. 1436



	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.