Bill Text: TX HB3727 | 2015-2016 | 84th Legislature | Introduced
Bill Title: Relating to the provision of health care payment information and related information for health care services, supplies, and procedures; authorizing enforcement and penalties.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2015-03-19 - Referred to Insurance [HB3727 Detail]
Download: Texas-2015-HB3727-Introduced.html
By: Bonnen of Galveston | H.B. No. 3727 |
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relating to the provision of health care payment information and | ||
related information for health care services, supplies, and | ||
procedures; authorizing enforcement and penalties. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended | ||
by adding Chapter 1470 to read as follows: | ||
CHAPTER 1470. DISCLOSURE OF PAYMENT AND COMPENSATION | ||
METHODOLOGY | ||
Sec. 1470.001. DEFINITIONS. In this chapter, unless the | ||
context otherwise requires: | ||
(1) "Edit" means a practice or procedure under which | ||
an adjustme | ||
nt is made regarding procedure codes that results in: | ||
(A) payment for some, but not all, of the health | ||
care procedures performed under a procedure code; | ||
(B) payment made under a different procedure | ||
code; | ||
(C) a reduced payment as a result of services | ||
provided to a patient that are claimed under more than one procedure | ||
code on the same service date; | ||
(D) a reduced payment related to a modifier used | ||
with a procedure code; or | ||
(E) a reduced payment based on multiple units of | ||
the same procedure code billed for a single date of service. | ||
(2) "Health benefit plan issuer" means: | ||
(A) an insurance company, association, | ||
organization, group hospital service corporation, health | ||
maintenance organization, or pharmacy benefit manager that | ||
delivers or issues for delivery an individual, group, blanket, or | ||
franchise insurance policy or insurance agreement, a group hospital | ||
service contract, or an evidence of coverage that provides health | ||
insurance or health care benefits and includes: | ||
(i) a life, health, or accident insurance | ||
company operating under Chapter 841 or 982; | ||
(ii) a general casualty insurance company | ||
operating under Chapter 861; | ||
(iii) a fraternal benefit society operating | ||
under Chapter 885; | ||
(iv) a mutual life insurance company | ||
operating under Chapter 882; | ||
(v) a local mutual aid association | ||
operating under Chapter 886; | ||
(vi) a statewide mutual assessment company | ||
operating under Chapter 881; | ||
(vii) a mutual assessment company or mutual | ||
assessment life, health, and accident association operating under | ||
Chapter 887; | ||
(viii) a mutual insurance company operating | ||
under Chapter 883 that writes coverage other than life insurance; | ||
(ix) a Lloyd's plan operating under Chapter | ||
941; | ||
(x) a reciprocal exchange operating under | ||
Chapter 942; | ||
(xi) a stipulated premium insurance company | ||
operating under Chapter 884; | ||
(xii) an exchange operating under Chapter | ||
942; | ||
(xiii) a Medicare supplemental policy as | ||
defined by Section 1882(g)(1), Social Security Act (42 U.S.C. | ||
Section 1395ss(g)(1); | ||
(xiv) a Medicaid managed care program | ||
operated under Chapter 533, Government Code; | ||
(xv) a health maintenance organization | ||
operating under Chapter 843; | ||
(xvi) a multiple employer welfare | ||
arrangement that holds a certificate of authority under Chapter | ||
846; and | ||
(xvii) an approved nonprofit health | ||
corporation that holds a certificate of authority under Chapter | ||
844; | ||
(B) the state Medicaid program operated under | ||
Chapter 32, Human Resources Code, or the state child health plan or | ||
health benefits plan for children under Chapter 62 or 63, Health and | ||
Safety Code; | ||
(C) the Employees Retirement System of Texas or | ||
another entity issuing or administering a basic coverage plan under | ||
Chapter 1551; | ||
(D) the Teacher Retirement System of Texas or | ||
another entity issuing or administering a basic plan under Chapter | ||
1575 or a primary care coverage plan under Chapter 1579; | ||
(E) The Texas A&M University System or The | ||
University of Texas System or another entity issuing or | ||
administering basic coverage under Chapter 1601; and | ||
(F) an entity issuing or administering medical | ||
benefits provided under a workers' compensation insurance policy or | ||
otherwise under Title 5, Labor Code. | ||
(3) "Health care contract" means a contract entered | ||
into or renewed between a health care contractor and a physician or | ||
health care provider for the delivery of health care services to | ||
others. | ||
(4) "Health care contractor" means an individual or | ||
entity that has as a business purpose contracting with physicians | ||
or health care providers for the delivery of health care services. | ||
The term includes a health benefit plan issuer, an administrator | ||
regulated under Chapter 4151, and a pharmacy benefit manager that | ||
administers or manages prescription drug benefits. | ||
(5) "Health care provider" means an individual or | ||
entity that furnishes goods or services under a license, | ||
certificate, registration, or other authority issued by this state | ||
to diagnose, prevent, alleviate, or cure a human illness or injury. | ||
The term includes a physician or a hospital or other health care | ||
facility. | ||
(6) "Physician" means: | ||
(A) an individual licensed to engage in the | ||
practice of medicine in this state; or | ||
(B) an entity organized under Subchapter B, | ||
Chapter 162, Occupations Code. | ||
(7) "Procedure code" means an alphanumeric code used | ||
to identify a specific health procedure performed by a health care | ||
provider. The term includes: | ||
(A) the American Medical Association's Current | ||
Procedural Terminology code, also known as the "CPT code"; | ||
(B) the Centers for Medicare and Medicaid | ||
Services Health Care Common Procedure Coding System; and | ||
(C) other analogous codes published by national | ||
organizations and recognized by the commissioner. | ||
Sec. 1470.002. DEFINITION OF MATERIAL CHANGE. For purposes | ||
of this chapter, "material change" means a change to a contract that | ||
decreases the health care provider's payment or compensation. | ||
Sec. 1470.003. APPLICABILITY OF CHAPTER. This chapter does | ||
not apply to an employment contract or arrangement between health | ||
care providers. | ||
Sec. 1470.004. RULEMAKING AUTHORITY. The commissioner may | ||
adopt reasonable rules as necessary to implement the purposes and | ||
provisions of this chapter. | ||
Sec. 1470.005. REQUIRED DISCLOSURE OF PAYMENT AND | ||
COMPENSATION TERMS. (a) Each health care contract must include a | ||
disclosure form that states, in plain language, payment and | ||
compensation terms for the provision of health care services, | ||
supplies or procedures. The form must include information | ||
sufficient for a health care provider to determine the compensation | ||
or payment for the provider's services. | ||
(b) The disclosure form under Subsection (a) must include: | ||
(1) the manner of payment, such as fee-for-service, | ||
capitation, or risk sharing; | ||
(2) the methodology used to compute any fee schedule, | ||
such as the use of a relative value unit system and conversion | ||
factor, percentage of Medicare payment system, or percentage of | ||
billed charges; | ||
(3) the fee schedule for procedure codes reasonably | ||
expected to be billed by the health care provider for services | ||
provided under the contract and, on request, the fee schedule for | ||
other procedure codes used by, or that may be used by, the health | ||
care provider; and | ||
(4) the effect of edits, if any, on payment or | ||
compensation. | ||
(c) As applicable, the methodology disclosure under | ||
Subsection (b)(2) must include: | ||
(1) the name of any relative value system used; | ||
(2) the version, edition, or publication date of that | ||
system; | ||
(3) any applicable conversion or geographic factors; | ||
and | ||
(4) the date by which compensation or fee schedules | ||
may be changed by the methodology, if allowed under the contract. | ||
(d) The fee schedule described by Subsection (b)(3) must | ||
include, as applicable, service or procedure codes and the | ||
associated payment or compensation for each code. The fee schedule | ||
may be provided electronically. | ||
(e) A health care contractor shall provide the fee schedule | ||
described by Subsection (b)(3) to an affected health care provider | ||
when a material change related to payment or compensation occurs. | ||
Additionally, a health care provider may request that a written fee | ||
schedule be provided up to twice annually, and the health care | ||
contractor must provide the written fee schedule within 10 business | ||
days. | ||
(f) A health care contractor may satisfy the requirement | ||
under Subsection (b)(4) regarding the effect of edits by providing | ||
a clearly understandable, readily available mechanism that allows a | ||
health care provider to determine the effect of an edit on payment | ||
or compensation before a service is provided or a claim is | ||
submitted. | ||
Sec. 1470.006. ENFORCEMENT. (a) The commissioner shall | ||
adopt rules as necessary to enforce the provisions of this chapter, | ||
including the imposition of administrative penalties. | ||
(b) A violation of Section 1470.005 is a deceptive act or | ||
practice in insurance under Subchapter B, Chapter 541. | ||
SECTION 2. Chapter 1470, Insurance Code, as added by this | ||
Act, applies only to a health care contract that is entered into or | ||
renewed on or after January 1, 2016. A health care contract entered | ||
into before January 1, 2014, 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 3. This Act takes effect September 1, 2015. |