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A BILL TO BE ENTITLED
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AN ACT
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relating to payment of out-of-network ambulatory surgery benefits |
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by certain health benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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by adding Chapter 1458 to read as follows: |
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CHAPTER 1458. PAYMENT OF OUT-OF-NETWORK BENEFITS FOR AMBULATORY |
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SURGERY AND PROCEDURES |
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Sec. 1458.001. DEFINITIONS. In this chapter: |
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(1) "Ambulatory surgery or procedure" means a surgery |
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or procedure provided in accordance with the medical standard of |
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care to an ambulatory patient in an ambulatory surgical center or |
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hospital outpatient department in this state. |
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(2) "Ambulatory surgical center" means a facility |
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licensed under Chapter 243, Health and Safety Code. |
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(3) "Fair market value" means the marketplace value |
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within a geozip area for the facility services for an ambulatory |
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surgery or procedure based on payment information, excluding |
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payments discounted under a governmental or nongovernmental health |
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benefit plan. |
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(4) "Geozip area" means an area that includes all zip |
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codes with the identical first three digits. |
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(5) "Hospital" includes a public or private |
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institution licensed under Chapter 241 or 577, Health and Safety |
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Code. |
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(6) "Managed care plan" means a health benefit plan |
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under which health care services are provided to enrollees through |
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contracts with health care providers and that requires or provides |
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incentives for those enrollees to use health care providers |
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participating in the plan and procedures covered by the plan. The |
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term includes a health benefit plan issued by: |
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(A) a health maintenance organization; |
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(B) a preferred provider benefit plan issuer; |
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(C) an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844; or |
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(D) any other entity that issues a health benefit |
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plan, including: |
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(i) an insurance company; |
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(ii) a group hospital service corporation |
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operating under Chapter 842; |
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(iii) a fraternal benefit society operating |
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under Chapter 885; |
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(iv) a stipulated premium company operating |
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under Chapter 884; or |
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(v) a multiple employer welfare arrangement |
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that holds a certificate of authority under Chapter 846. |
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(7) "Out-of-network provider," with respect to a |
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managed care plan, means a provider who is not a preferred or |
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participating provider of the plan. |
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(8) "Usual and customary charge" with respect to an |
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ambulatory surgery or procedure facility fee means the fair market |
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value of the facility fee for the ambulatory surgery or procedure |
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within the geozip area in which the surgery or procedure is |
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performed. |
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Sec. 1458.002. PAYMENT OF USUAL AND CUSTOMARY CHARGE |
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REQUIRED. A managed care plan that provides a benefit for an |
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ambulatory surgery or procedure provided by an ambulatory surgical |
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center or hospital that is an out-of-network provider with respect |
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to the plan must pay a benefit for the facility fee for the surgery |
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or procedure that is computed based on the usual and customary |
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charge with respect to the facility fee. |
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SECTION 2. Chapter 1458, Insurance Code, as added by this |
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Act, applies only to a health benefit plan delivered, issued for |
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delivery, or renewed on or after January 1, 2014. A health benefit |
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plan delivered, issued for delivery, or renewed before January 1, |
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2014, is governed by the law in effect immediately before the |
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effective date of this Act, and that law is continued in effect for |
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that purpose. |
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SECTION 3. This Act takes effect September 1, 2013. |