85R12718 LED-F     By: Cook H.B. No. 4178       A BILL TO BE ENTITLED   AN ACT   relating to disclosure of certain health care costs and shared   savings between certain health benefit plans and state employees.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Chapter 1551, Insurance Code, is amended by   adding Subchapters K and L to read as follows:   SUBCHAPTER K. HEALTH CARE PRICE DISCLOSURES          Sec. 1551.501.  DEFINITIONS. In this subchapter:                (1)  "Administrator" means an administering firm for a   health benefit plan provided as basic coverage under this chapter.                (2)  "Enrollee" means a participant enrolled in a   health benefit plan provided as basic coverage under this chapter.                (3)  "Facility" means a hospital, outpatient clinic,   birthing center, ambulatory surgical center, or other licensed   facility providing health care services. The term does not include   an emergency clinic, a freestanding emergency medical care   facility, or other facility providing only emergency care.                (4)  "Practitioner" means an individual who is licensed   to provide and provides medical or other health care services.          Sec. 1551.502.  PROVIDER PRICE DISCLOSURE OR ESTIMATE. (a)     On the request of an enrollee and before providing a nonemergency   health care service offered to the enrollee by the facility or   practitioner, a facility or practitioner shall provide a price   disclosure described by Subsection (b) or an estimate described by   Subsection (c), as applicable, not later than the second business   day after the date on which the enrollee requests the disclosure or   estimate.          (b)  Except as provided by Subsection (c), a facility or   practitioner required to provide a price disclosure under   Subsection (a) shall disclose to the enrollee the amount, including   facility fees, that:                (1)  the enrollee's health benefit plan will reimburse   the facility or practitioner for the service, if the facility or   practitioner is participating in the enrollee's health benefit plan   provider network; or                (2)  the facility or practitioner will charge for the   service, if the facility or practitioner is not participating in   the enrollee's health benefit plan provider network.           (c)  If a facility or practitioner is unable to quote a   specific amount under Subsection (b) because of the facility's or   practitioner's inability to predict the specific service the   enrollee will need, the facility or practitioner shall provide an   estimate of the amount required to be disclosed, including facility   fees.          (d)  A facility or practitioner that provides an estimate   described by Subsection (c) shall:                (1)  disclose the incomplete nature of the estimate;   and                 (2)  inform the enrollee that the facility or   practitioner may be able to provide an updated estimate after the   facility or practitioner obtains additional information.           Sec. 1551.503.  EFFECT OF OTHER LAW. A facility that   provides an estimate under Section 324.101(d) is not relieved of   the obligation to provide a price disclosure or estimate under   Section 1551.502.          Sec. 1551.504.  HEALTH CARE SERVICE INFORMATION. On   request, a facility or practitioner participating in the enrollee's   health benefit plan provider network shall provide an enrollee with   sufficient information about a proposed nonemergency health care   service to enable the enrollee to obtain a cost estimate to   determine the amount for which the enrollee will be personally   liable by using the enrollee's health benefit plan's toll-free   telephone number or Internet website or a third-party service.  The   facility or practitioner shall provide the information to the   enrollee based on the information that is available to the facility   or practitioner at the time of the request.  The facility or   practitioner may assist the enrollee in using the telephone number,   website, or third-party service.          Sec. 1551.505.  HEALTH BENEFIT PLAN ESTIMATE OF CHARGES.     (a)  The administrator for an enrollee's health benefit plan shall,   on the request of the enrollee, provide a good faith estimate of   payments that will be made for any medically necessary, covered    health care service from a network provider and shall also specify   any deductibles, copayments, coinsurance, or other amounts for   which the enrollee is responsible, based on the information   available to the administrator at the time the estimate was   requested.  The estimate must be provided not later than the second   business day after the date on which the estimate was requested.     The administrator must advise the enrollee that the actual payment   and charges for the services may vary based upon the enrollee's   actual medical condition and other factors associated with   performance of medical services, including any factors unknown to   or unforeseeable by the administrator or provider at the time the   estimate was requested.          (b)  An administrator may require an enrollee to pay any   deductibles, copayments, coinsurance, or other amounts disclosed   in the enrollee's coverage documents for an unforeseen health care   service that arises out of the provision of the proposed health care   service.   SUBCHAPTER L. SHARED SAVINGS INCENTIVE PROGRAM          Sec. 1551.551.  DEFINITIONS. In this subchapter:                (1)  "Administrator" means an administering firm for a   health benefit plan provided as basic coverage under this chapter.                (2)  "Enrollee" means a participant enrolled in a   health benefit plan provided as basic coverage under this chapter.                (3)  "Program" means the shared savings incentive   program established under this subchapter.                (4)  "Shoppable health care service" means a health   care service covered by an enrollee's health benefit plan for which   the plan provides an incentive under the program. The term   includes:                      (A)  physical and occupational therapy services;                      (B)  obstetrical and gynecological services;                      (C)  radiology and imaging services;                      (D)  laboratory services;                      (E)  infusion therapy;                      (F)  inpatient and outpatient surgical   procedures;                      (G)  outpatient nonsurgical diagnostic tests or   procedures; and                      (H)  any other health care service designated as a   shoppable health care service by the commissioner for purposes of   this subchapter.          Sec. 1551.552.  APPLICABILITY. This subchapter applies to a   health benefit plan provided as basic coverage under this chapter.          Sec. 1551.553.  RULES.  The commissioner may adopt rules to   implement this subchapter.          Sec. 1551.554.  SHARED SAVINGS INCENTIVE PROGRAM. An   administrator shall develop and implement a shared savings   incentive program through which a health benefit plan provides an   incentive in accordance with this subchapter to an enrollee for   electing to receive a shoppable health care service at a lower cost   than the average cost for that service paid by the health benefit   plan.          Sec. 1551.555.  DEPARTMENT REVIEW OF PROGRAM.  Before   offering the program, an administrator shall file a description of   the program with the department in the form and manner prescribed by   the commissioner.  The department shall review the description to   determine whether the program complies with this subchapter and   rules adopted under this subchapter.  A description of a shared   savings incentive program and any supporting documentation filed   under this section are confidential until the department has   reviewed and approved a program.          Sec. 1551.556.  NOTICE TO PARTICIPANTS. Annually and at   enrollment or renewal of a health benefit plan, the board of   trustees or administrator shall provide written notice to   participants and enrollees about the availability of the program.          Sec. 1551.557.  PRICE DISCLOSURE TELEPHONE NUMBER AND   WEBSITE. (a) An administrator shall establish and operate a   toll-free telephone number and an interactive mechanism on the   publicly accessible Internet website for the health benefit plan   that an enrollee may use to:                (1)  request and obtain from the administrator or a   designated third party the average amount paid under the health   benefit plan to providers in the health benefit plan provider   network for a particular health care service; and                (2)  compare the cost of a shoppable health care   service among network providers.          (b)  An administrator may contract with a third party to   operate the telephone number or interactive mechanism described by   Subsection (a).          Sec. 1551.558.  AVERAGE COST DETERMINATION. (a) Except as   provided by Subsection (b), for purposes of this subchapter an   administrator shall determine the average amount paid under a   health benefit plan to providers in the health benefit plan   provider network for a particular health care service using amounts   paid within a reasonable period of not more than one year.          (b)  The commissioner may approve an alternative method for   determining the average cost amount described by Subsection (a).          Sec. 1551.559.  INCENTIVE PAYMENTS. (a) An administrator   must calculate an incentive under this section as a percentage of   the difference in price, as a flat dollar amount, or by some other   reasonable method approved by the commissioner. The administrator   must provide the incentive as a cash payment to the enrollee.          (b)  Except as provided by Subsection (c), if an enrollee   elects to receive a shoppable health care service the total cost of   which is less than the average cost amount determined for the   service under Section 1551.558, the administrator shall pay to the   enrollee an incentive payment that is at least 50 percent of the   health benefit plan's saved cost.          (c)  An administrator is not required to pay an enrollee   under Subsection (b) if the health benefit plan's saved cost is $50   or less.          (d)  If an enrollee elects to receive a shoppable health care   service from a provider outside the enrollee's health benefit plan   provider network the total cost of which is less than the average   cost amount determined for the service under Section 1551.558, the   administrator, in addition to paying any incentive payment due   under Subsection (b):                (1)  may hold the enrollee responsible only for any   deductible, copayment, or coinsurance that would be due if the   service were provided by a provider in the health benefit plan   provider network; and                (2)  shall apply the amount paid for the service toward   the enrollee's cost-sharing maximums, as if the service were   provided by a provider in the health benefit plan provider network.          (e)  An incentive payment made in accordance with this   section is not an administrative expense of the administrator for   purposes of rate development or rate filing.          Sec. 1551.560.  SHARED SAVINGS REPORTING. (a) Not later   than February 1 of each year, an administrator shall submit to the   commissioner and the board of trustees a report for the preceding   calendar year stating:                (1)  the total number of incentive payments made under   Section 1551.559;                (2)  the total amount of those incentive payments;                (3)  the average amount of those incentive payments by   category of health care service;                (4)  the total number and percentage of the health   benefit plan's enrollees who received an incentive payment;                (5)  the number of shoppable health care services by   category for which incentive payments were made and the average   cost amount for those services; and                (6)  the total savings achieved by the health benefit   plan for each category of health care service for which an incentive   payment was made.          (b)  Not later than April 1 of each year, the department   shall submit a report aggregating the information submitted by each   health benefit plan administrator under this section to the   governor, the lieutenant governor, the speaker of the house of   representatives, and each legislative committee with jurisdiction   over health insurance matters.          SECTION 2.  Section 324.101, Health and Safety Code, is   amended by adding Subsection (d-1) to read as follows:          (d-1)  A facility that provides a price disclosure or   estimate under Section 1551.502, Insurance Code, is not relieved of   the obligation to provide an estimate under Subsection (d).          SECTION 3.  (a) Subchapter K, Chapter 1551, Insurance Code,   as added by this Act, applies only to a service provided by a   facility or practitioner during a plan year beginning on or after   January 1, 2018. A service provided during a plan year beginning   before January 1, 2018, 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.          (b)  Subchapter L, Chapter 1551, Insurance Code, as added by   this Act, applies only to a health benefit plan for a plan year   beginning on or after January 1, 2018. A health benefit plan for a   plan year beginning before January 1, 2018, 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 4.  This Act takes effect September 1, 2017.