Bill Text: TX HB2525 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to participation in the health care market by enrollees of certain governmental managed care plans.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2019-04-18 - Left pending in committee [HB2525 Detail]
Download: Texas-2019-HB2525-Introduced.html
86R9507 SCL-F | ||
By: Burrows | H.B. No. 2525 |
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relating to participation in the health care market by enrollees of | ||
certain governmental managed care plans. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subtitle H, Title 8, Insurance Code, is amended | ||
by adding Chapter 1580 to read as follows: | ||
CHAPTER 1580. HEALTH CARE MARKET PARTICIPATION FOR CERTAIN | ||
GOVERNMENTAL MANAGED CARE PLANS | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
Sec. 1580.0001. DEFINITIONS. In this chapter: | ||
(1) "Enrollee" means an individual who is eligible to | ||
receive benefits for health care services through a health benefit | ||
plan. | ||
(2) "Health benefit plan" means a plan to which this | ||
chapter applies under Section 1580.0002. | ||
(3) "Health care provider" means a physician, | ||
hospital, pharmacy, pharmacist, laboratory, or other person or | ||
organization that furnishes health care services and that is | ||
licensed or otherwise authorized to practice in this state. | ||
(4) "Health care service" means a service for the | ||
diagnosis, prevention, treatment, cure, or relief of a health | ||
condition, illness, injury, or disease. | ||
(5) "Managed care plan" means a health benefit plan | ||
under which health care services are provided to enrollees through | ||
contracts with health care providers and that requires enrollees to | ||
use participating providers or that provides a different level of | ||
coverage for enrollees who use participating providers. | ||
(6) "Participating provider" means a health care | ||
provider who has contracted with a health benefit plan issuer or | ||
administrator to provide health care services to enrollees. | ||
Sec. 1580.0002. APPLICABILITY OF CHAPTER. (a) This | ||
chapter applies only with respect to nonemergency health care | ||
services covered under a managed care plan. | ||
(b) Notwithstanding any provision in Chapter 1551, 1575, or | ||
1579 or any other law, this chapter applies only to: | ||
(1) a basic coverage plan under Chapter 1551; | ||
(2) a basic plan under Chapter 1575; and | ||
(3) a health coverage plan under Chapter 1579. | ||
(c) Notwithstanding any other law, this chapter applies to | ||
an independent administrator, manager, or third-party | ||
administrator of a health benefit plan described by this section. | ||
Sec. 1580.0003. RULES. The board of trustees of the | ||
Employees Retirement System of Texas or Teacher Retirement System | ||
of Texas, as applicable, may adopt rules to implement this chapter. | ||
SUBCHAPTER B. TRANSPARENCY TOOLS | ||
Sec. 1580.0051. AVAILABILITY OF PRICE AND QUALITY | ||
INFORMATION. (a) A health benefit plan issuer or administrator | ||
shall provide by a toll-free telephone number and on its publicly | ||
available Internet website an interactive mechanism that, for a | ||
specific health care service, allows an enrollee to request and | ||
obtain from the issuer or administrator: | ||
(1) information on the payments made by the issuer or | ||
administrator to participating providers under the enrollee's | ||
health benefit plan sufficient for the enrollee to compare costs | ||
for that service among participating providers, including costs for | ||
that service among participating providers after an enrollee has | ||
exceeded the enrollee's deductible; | ||
(2) quality data on participating providers to the | ||
extent that data is available; and | ||
(3) an estimate of the enrollee's out-of-pocket costs | ||
under the enrollee's health benefit plan. | ||
(b) A health benefit plan issuer or administrator may | ||
contract with a third-party vendor to satisfy the requirements of | ||
this section. | ||
Sec. 1580.0052. NOTICE TO ENROLLEES. A health benefit plan | ||
issuer or administrator shall inform an enrollee requesting an | ||
estimate under Section 1580.0051 that any out-of-pocket amount | ||
provided is only an estimate and that the actual amount of the cost | ||
and the amount the enrollee is responsible to pay for the service | ||
may vary based upon unforeseen issues that arise in connection with | ||
the proposed service. | ||
Sec. 1580.0053. EFFECT OF SUBCHAPTER. This subchapter does | ||
not prohibit a health benefit plan issuer or administrator from | ||
imposing deductibles, copayments, or coinsurance under the health | ||
benefit plan for a health care service that was not included in the | ||
original estimate provided under Section 1580.0051. | ||
SUBCHAPTER C. SHARED SAVINGS INCENTIVE PROGRAM | ||
Sec. 1580.0101. ESTABLISHMENT OF INCENTIVE PROGRAM. A | ||
health benefit plan issuer or administrator shall establish a | ||
shared savings incentive program for all enrollees of the health | ||
benefit plan. The program must provide an incentive paid in | ||
accordance with this subchapter to an enrollee who elects to | ||
receive a health care service from a participating provider who | ||
provides a high-quality service at a reasonable cost, as determined | ||
by the Employees Retirement System of Texas or the Teacher | ||
Retirement System of Texas, as applicable. | ||
Sec. 1580.0102. NOTICE TO ENROLLEES. The health benefit | ||
plan issuer or administrator shall annually provide written notice | ||
to enrollees about the program. | ||
Sec. 1580.0103. INCENTIVE PAYMENTS. A health benefit plan | ||
issuer or administrator may pay a program incentive in the form and | ||
manner approved by the Employees Retirement System of Texas or | ||
Teacher Retirement System of Texas, as applicable. | ||
SECTION 2. Chapter 1580, Insurance Code, as added by this | ||
Act, applies only to a health benefit plan for a plan year that | ||
begins after the first open enrollment period that occurs on or | ||
after January 1, 2020. | ||
SECTION 3. This Act takes effect September 1, 2019. |