85R3341 SMT-F     By: Frullo H.B. No. 1566       A BILL TO BE ENTITLED   AN ACT   relating to mediation of the settlement of certain out-of-network   health benefit claims involving balance billing.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 1467.001, Insurance Code, is amended by   amending Subdivisions (1), (3), (4), (5), and (7) and adding   Subdivisions (2-a), (3-a), and (4-a) to read as follows:                (1)  "Administrator" means:                      (A)  an administering firm for a health benefit   plan providing coverage under Chapter 1551, 1575, or 1579; and                      (B)  if applicable, the claims administrator for   the health benefit plan.                (2-a)  "Emergency care provider" means a physician,   health care practitioner, facility, or other health care provider   who provides and bills an enrollee, administrator, or health   benefit plan for emergency care.                (3)  "Enrollee" means an individual who is eligible to   receive benefits through a preferred provider benefit plan or a   health benefit plan under Chapter 1551, 1575, or 1579.                (3-a)  "Facility" has the meaning assigned by Section   324.001, Health and Safety Code.                (4)  "Facility-based provider [physician]" means a   physician, health care practitioner, or other health care provider   [radiologist, an anesthesiologist, a pathologist, an emergency   department physician, a neonatologist, or an assistant surgeon:                      [(A)     to whom the facility has granted clinical   privileges; and                      [(B)]  who provides health care or medical    services to patients of a [the] facility [under those clinical   privileges].                (4-a)  "Health care practitioner" means an individual   who is licensed to provide health care services.                (5)  "Mediation" means a process in which an impartial   mediator facilitates and promotes agreement between the insurer   offering a preferred provider benefit plan or the administrator and   a facility-based provider or emergency care provider [physician] or   the provider's [physician's] representative to settle a health   benefit claim of an enrollee.                (7)  "Party" means an insurer offering a preferred   provider benefit plan, an administrator, or a facility-based   provider or emergency care provider [physician] or the provider's   [physician's] representative who participates in a mediation   conducted under this chapter.  The enrollee is also considered a   party to the mediation.          SECTION 2.  Section 1467.002, Insurance Code, is amended to   read as follows:          Sec. 1467.002.  APPLICABILITY OF CHAPTER. This chapter   applies to:                (1)  a preferred provider benefit plan offered by an   insurer under Chapter 1301; and                (2)  an administrator of a health benefit plan, other   than a health maintenance organization plan, under Chapter 1551,   1575, or 1579.          SECTION 3.  Section 1467.003, Insurance Code, is amended to   read as follows:          Sec. 1467.003.  RULES. The commissioner, the Texas Medical   Board, any other appropriate regulatory agency, and the chief   administrative law judge shall adopt rules as necessary to   implement their respective powers and duties under this chapter.          SECTION 4.  Section 1467.005, Insurance Code, is amended to   read as follows:          Sec. 1467.005.  REFORM. This chapter may not be construed to   prohibit:                (1)  an insurer offering a preferred provider benefit   plan or administrator from, at any time, offering a reformed claim   settlement; or                (2)  a facility-based provider or emergency care   provider [physician] from, at any time, offering a reformed charge   for health care or medical services.          SECTION 5.  Section 1467.051, Insurance Code, is amended to   read as follows:          Sec. 1467.051.  AVAILABILITY OF MANDATORY MEDIATION;   EXCEPTION.  (a)  An enrollee may request mediation of a settlement   of an out-of-network health benefit claim if:                (1)  the amount for which the enrollee is responsible   to a facility-based provider or emergency care provider   [physician], after copayments, deductibles, and coinsurance,   including the amount unpaid by the administrator or insurer, is   greater than $500; and                (2)  the health benefit claim is for:                      (A)  emergency care; or                      (B)  a health care or medical service or supply   provided by a facility-based provider [physician] in a facility   [hospital] that is a preferred provider or that has a contract with   the administrator.          (b)  Except as provided by Subsections (c) and (d), if an   enrollee requests mediation under this subchapter, the   facility-based provider or emergency care provider, [physician] or   the provider's [physician's] representative, and the insurer or the   administrator, as appropriate, shall participate in the mediation.          (c)  Except in the case of an emergency and if requested by   the enrollee, a facility-based provider [physician] shall, before   providing a health care or medical service or supply, provide a   complete disclosure to an enrollee that:                (1)  explains that the facility-based provider   [physician] does not have a contract with the enrollee's health   benefit plan;                (2)  discloses projected amounts for which the enrollee   may be responsible; and                (3)  discloses the circumstances under which the   enrollee would be responsible for those amounts.          (d)  A facility-based provider [physician] who makes a   disclosure under Subsection (c) and obtains the enrollee's written   acknowledgment of that disclosure may not be required to mediate a   billed charge under this subchapter if the amount billed is less   than or equal to the maximum amount projected in the disclosure.          (e)  A bill sent to an enrollee by a facility-based provider   or emergency care provider for an out-of-network health benefit   claim eligible for mediation under this chapter must contain, in   not less than 10-point boldface type, a conspicuous, plain-language   explanation of the mediation process available under this chapter,   including information on how to request mediation and a statement   substantially similar to the following: "This statement is a   balance bill for out-of-network services that may be eligible for   mediation. You may obtain more information at   www.tdi.texas.gov/consumer/cpmmediation.html."          SECTION 6.  Section 1467.052(c), Insurance Code, is amended   to read as follows:          (c)  A person may not act as mediator for a claim settlement   dispute if the person has been employed by, consulted for, or   otherwise had a business relationship with an insurer offering the   preferred provider benefit plan or a physician, health care   practitioner, or other health care provider during the three years   immediately preceding the request for mediation.          SECTION 7.  Section 1467.053(d), Insurance Code, is amended   to read as follows:          (d)  The mediator's fees shall be split evenly and paid by   the insurer or administrator and the facility-based provider or   emergency care provider [physician].          SECTION 8.  Sections 1467.054(b), (c), (d), and (e),   Insurance Code, are amended to read as follows:          (b)  A request for mandatory mediation must be provided to   the department on a form prescribed by the commissioner and must   include:                (1)  the name of the enrollee requesting mediation;                (2)  a brief description of the claim to be mediated;                (3)  contact information, including a telephone   number, for the requesting enrollee and the enrollee's counsel, if   the enrollee retains counsel;                (4)  the name of the facility-based provider or   emergency care provider [physician] and name of the insurer or   administrator; and                (5)  any other information the commissioner may require   by rule.          (c)  On receipt of a request for mediation, the department   shall notify the facility-based provider or emergency care provider   [physician] and insurer or administrator of the request.          (d)  In an effort to settle the claim before mediation, all   parties must participate in an informal settlement teleconference   not later than the 30th day after the date on which the enrollee   submits a request for mediation under this section unless otherwise   agreed by all parties. The facility-based provider or emergency   care provider and the insurer or administrator are equally   responsible for scheduling the informal settlement teleconference.          (e)  A dispute to be mediated under this chapter that does   not settle as a result of a teleconference conducted under   Subsection (d) must be conducted in the county in which the health   care or medical services were rendered.          SECTION 9.  Sections 1467.055(d), (g), (h), and (i),   Insurance Code, are amended to read as follows:          (d)  If the enrollee is participating in the mediation in   person, at the beginning of the mediation the mediator shall inform   the enrollee that if the enrollee is not satisfied with the mediated   agreement, the enrollee may file a complaint with:                (1)  the Texas Medical Board or other appropriate   regulatory agency against the facility-based provider or emergency   care provider [physician] for improper billing; and                (2)  the department for unfair claim settlement   practices.          (g)  Except at the request of an enrollee or as otherwise   agreed by all parties, a mediation shall be held not later than the   180th day after the date of the request for mediation.          (h)  On receipt of notice from the department that an   enrollee has made a request for mediation that meets the   requirements of this chapter, the facility-based provider or   emergency care provider [physician] may not pursue any collection   effort against the enrollee who has requested mediation for amounts   other than copayments, deductibles, and coinsurance before the   earlier of:                (1)  the date the mediation is completed; or                (2)  the date the request to mediate is withdrawn.          (i)  A health care or medical service provided by a   facility-based provider or emergency care provider [physician] may   not be summarily disallowed.  This subsection does not require an   insurer or administrator to pay for an uncovered service.          SECTION 10.  Sections 1467.056(a), (b), and (d), Insurance   Code, are amended to read as follows:          (a)  In a mediation under this chapter, the parties shall:                (1)  evaluate whether:                      (A)  the amount charged by the facility-based   provider or emergency care provider [physician] for the health care   or medical service or supply is excessive; and                      (B)  the amount paid by the insurer or   administrator represents the usual and customary rate for the   health care or medical service or supply or is unreasonably low; and                (2)  as a result of the amounts described by   Subdivision (1), determine the amount, after copayments,   deductibles, and coinsurance are applied, for which an enrollee is   responsible to the facility-based provider or emergency care   provider [physician].          (b)  The facility-based provider or emergency care provider   [physician] may present information regarding the amount charged   for the health care or medical service or supply. The insurer or   administrator may present information regarding the amount paid by   the insurer or administrator.          (d)  The goal of the mediation is to reach an agreement among   the enrollee, the facility-based provider or emergency care   provider [physician], and the insurer or administrator, as   applicable, as to the amount paid by the insurer or administrator to   the facility-based provider or emergency care provider   [physician], the amount charged by the facility-based provider or   emergency care provider [physician], and the amount paid to the   facility-based provider or emergency care provider [physician] by   the enrollee.          SECTION 11.  Section 1467.057(a), Insurance Code, is amended   to read as follows:          (a)  The mediator of an unsuccessful mediation under this   chapter shall report the outcome of the mediation to the   department, the Texas Medical Board or other appropriate regulatory   agency, and the chief administrative law judge.          SECTION 12.  Section 1467.058, Insurance Code, is amended to   read as follows:          Sec. 1467.058.  CONTINUATION OF MEDIATION. After a referral   is made under Section 1467.057, the facility-based provider or   emergency care provider [physician] and the insurer or   administrator may elect to continue the mediation to further   determine their responsibilities. Continuation of mediation under   this section does not affect the amount of the billed charge to the   enrollee.          SECTION 13.  Section 1467.059, Insurance Code, is amended to   read as follows:          Sec. 1467.059.  MEDIATION AGREEMENT. The mediator shall   prepare a confidential mediation agreement and order that states:                (1)  the total amount for which the enrollee will be   responsible to the facility-based provider or emergency care   provider [physician], after copayments, deductibles, and   coinsurance; and                (2)  any agreement reached by the parties under Section   1467.058.          SECTION 14.  Section 1467.060, Insurance Code, is amended to   read as follows:          Sec. 1467.060.  REPORT OF MEDIATOR. The mediator shall   report to the commissioner and the Texas Medical Board or other   appropriate regulatory agency:                (1)  the names of the parties to the mediation; and                (2)  whether the parties reached an agreement or the   mediator made a referral under Section 1467.057.          SECTION 15.  Section 1467.101(c), Insurance Code, is amended   to read as follows:          (c)  A mediator shall report bad faith mediation to the   commissioner or the Texas Medical Board or other regulatory agency,   as appropriate, following the conclusion of the mediation.          SECTION 16.  Section 1467.151, Insurance Code, is amended to   read as follows:          Sec. 1467.151.  CONSUMER PROTECTION; RULES.  (a)  The   commissioner and the Texas Medical Board or other regulatory   agency, as appropriate, shall adopt rules regulating the   investigation and review of a complaint filed that relates to the   settlement of an out-of-network health benefit claim that is   subject to this chapter.  The rules adopted under this section   must:                (1)  distinguish among complaints for out-of-network   coverage or payment and give priority to investigating allegations   of delayed health care or medical care;                (2)  develop a form for filing a complaint and   establish an outreach effort to inform enrollees of the   availability of the claims dispute resolution process under this   chapter;                (3)  ensure that a complaint is not dismissed without   appropriate consideration;                (4)  ensure that enrollees are informed of the   availability of mandatory mediation; and                (5)  require the administrator to include a notice of   the claims dispute resolution process available under this chapter   with the explanation of benefits sent to an enrollee.          (b)  The department and the Texas Medical Board or other   appropriate regulatory agency shall maintain information:                (1)  on each complaint filed that concerns a claim or   mediation subject to this chapter; and                (2)  related to a claim that is the basis of an enrollee   complaint, including:                      (A)  the type of services that gave rise to the   dispute;                      (B)  the type and specialty, if any, of the   facility-based provider or emergency care provider [physician] who   provided the out-of-network service;                      (C)  the county and metropolitan area in which the   health care or medical service or supply was provided;                      (D)  whether the health care or medical service or   supply was for emergency care; and                      (E)  any other information about:                            (i)  the insurer or administrator that the   commissioner by rule requires; or                            (ii)  the facility-based provider or   emergency care provider [physician] that the Texas Medical Board or   other appropriate regulatory agency by rule requires.          (c)  The information collected and maintained by the   department and the Texas Medical Board and other appropriate   regulatory agencies under Subsection (b)(2) is public information   as defined by Section 552.002, Government Code, and may not include   personally identifiable information or health care or medical   information.          (d)  A facility-based provider or emergency care provider   [physician] who fails to provide a disclosure under Section   1467.051 is not subject to discipline by the Texas Medical Board or   other appropriate regulatory agency for that failure and a cause of   action is not created by a failure to disclose as required by   Section 1467.051.          SECTION 17.  The changes in law made by this Act apply only   to a claim for health care or medical services provided on or after   January 1, 2018. A claim for health care or medical services   provided before January 1, 2018, is governed by the law in effect   immediately before the effective date of this Act, and that law is   continued in effect for that purpose.          SECTION 18.  This Act takes effect September 1, 2017.