Signed by Governor Greg Abbott

Vote Smart's Synopsis:

Vote to pass a bill that authorizes an arbitration process for insurers to stop "surprise billings".

Highlights:

• Authorizes the attorney general to bring a civil action against any individual or entity that has intentionally and repeatedly violated a law that prohibits the individual or entity from billing an insured, participant, or enrollee in an amount that is larger than an applicable copayment, coinsurance, and deductible under the insured, participant’s, or enrollee’s managed care plan, or that imposes a requirement related to that prohibition (Sec. 1.01).

• Authorizes an appropriate regulatory agency to take disciplinary action against a physician, practitioner, facility, or provider if they violate a law that prohibits the physician, practitioner, facility, or provider from billing an insured, participant, or enrollee in an amount that is larger than an applicable copayment, coinsurance, and deductible under their managed care plan, or that imposes a requirement related to that prohibition (Sec. 1.01).

• Authorizes the department to take disciplinary action against a health benefit plan issuer or administrator if they violate a law that requires the issuer or administrator to give notice of a balance billing prohibition or make a related disclosure (Sec. 1.01).

• Requires a health maintenance organization to provide written notice of an explanation of the enrollee’s benefits to the enrollee and the physician or provider who is connected with a health care service or supply given by a non-network physician or provider (Sec. 1.02).

• Prohibits a non-network physician or provider or a person asserting a claim as an agent on their behalf, from billing an enrollee in an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee’s health care plan for emergency care or a supply related to that care (Sec. 1.03).

• Prohibits a non-network facility-based provider or a person asserting a claim as an agent on their behalf, from billing an enrollee in an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee’s health care plan for a covered health care service performed for, or a covered supply related to a service provided to the enrollee by the non-network physician or provider who is a facility-based provider (Sec. 1.04).

• Prohibits a non-network diagnostic imaging provider or laboratory service provider or a person asserting a claim as an agent on their behalf, from billing an enrollee in an amount greater than an applicable copayment, coinsurance, and deductible under the enrollee’s health care plan for a covered health care service performed by or a covered supply related to that service provided to an enrollee by a non-network diagnostic imaging provider or laboratory service provider (Sec. 1.04).

• Requires the issuer of an exclusive provider benefit plan to reimburse any out-of-network provider that has provided emergency care to an enrollee of the plan (Sec. 1.06).

• Requires an insurer to provide written notice of an explanation of the insured’s benefits to the enrollee and the physician or health care provider who is connected with a health care service or supply given by an out-of-network provider (Sec. 1.07).

• Prohibits an out-of-network provider or a person asserting a claim as an agent on their behalf, from billing an insured in an amount greater than an applicable copayment, coinsurance, and deductible under the insured’s preferred provider benefit plan for emergency care or a supply related to that care (Sec. 1.08).

• Prohibits an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent on their behalf, from billing an insured in an amount greater than an applicable copayment, coinsurance, and deductible under the insured’s preferred provider benefit plan for a covered health care service performed for, or a covered supply related to a service provided to the insured by an out-of-network provider who is a facility-based provider (Sec. 1.09).

• Prohibits an out-of-network provider who is a diagnostic imaging provider or laboratory service provider or a person asserting a claim as an agent on their behalf, from billing an insured in an amount greater than an applicable copayment, coinsurance, and deductible under the insured’s preferred provider benefit plan for a covered health care service performed by or a covered supply related to that service provided to an insured by an out-of-network provider who is a diagnostic imaging provider or laboratory service provider (Sec. 1.09).

• Requires the administrator of a managed care plan provided under the group benefits program, the group program, or other program, to provide written notice of an explanation of the participant’s or enrollee’s benefits to the participant or enrollee and the physician or health care provider who is connected with a health care service or supply given by an out-of-network provider (Sec. 1.11, 1.14, & 1.17).

• Prohibits an out-of-network provider or a person asserting a claim as an agent on their behalf, from billing a participant or enrollee in an amount greater than an applicable copayment, coinsurance, and deductible under the participant’s or enrollee’s managed care plan for emergency care or a supply related to that care (Sec. 1.12, 1.15, & 1.18).

• Prohibits an out-of-network provider who is a facility-based provider or a person asserting a claim as an agent on their behalf, from billing a participant or enrollee in an amount greater than an applicable copayment, coinsurance, and deductible under the participant’s or enrollee’s managed care plan for a covered health care service performed for, or a covered supply related to a service provided to the participant or enrollee by an out-of-network provider who is a facility-based provider (Sec. 1.12, 1.15, & 1.18).

• Prohibits an out-of-network provider who is a diagnostic imaging provider or laboratory service provider or a person asserting a claim as an agent on their behalf, from billing a participant or enrollee in an amount greater than an applicable copayment, coinsurance, and deductible under the participant’s or enrollee’s managed care plan for a covered health care service performed for, or a covered supply related to a service provided to the participant or enrollee by an out-of-network provider who is a diagnostic imaging provider or laboratory service provider (Sec. 1.12, 1.15, & 1.18).

• Requires the commissioner to choose an organization to maintain a benchmarking database that will contain information needed to calculate for each geogzip area the 80th percentile of billed charges of all physicians or health care providers who are not facilities, and the 50th percentile of rates paid to participating providers who are not facilities (Sec. 2.03).

• Requires the commissioner to establish and administer a mediation program and an arbitration program to resolve disputes over out-of-network provider charges, including the establishment of a portal on the department’s website through which a request for mediation or arbitration can be submitted (Sec. 2.05 & 2.15).

• Authorizes either party to an unresolved mediation after the 45th day following the mediator’s report submission, to file a civil action to determine the amount due to an out-of-network provider (Sec. 2.13).

• Authorizes a party dissatisfied with an arbitrator’s decision after the 45th day following the arbitrator’s decision, to file an action to determine the payment due to an out-of-network provider (Sec. 2.15). 

• Requires the department to conduct a study on the impacts of this bill on consumers and health coverage in Texas, each biennium (Sec. 4.01).

Full Bill Text