shared savings program for nonemergency care in HMOs and PPOs

The text as introduced · 834 words

89R8002 SCL-D

By: Kolkhorst
S.B. No. 884

A BILL TO BE ENTITLED

AN ACT

relating to establishment of a shared savings program for certain

managed care plans.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle C, Title 8, Insurance Code, is amended

by adding Chapter 1276 to read as follows:

CHAPTER 1276. SHARED SAVINGS PROGRAM

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 1276.001. DEFINITIONS. In this chapter:

(1) "Health care provider" means a health care

practitioner or health care facility that provides health care

services or supplies under a license, certificate, registration, or

similar authorization issued by this state.

(2) "Managed care plan" means a health benefit plan

under which health care services or supplies are provided to

enrollees through contracts with health care providers and that

requires enrollees to use contracting providers or that provides a

different level of coverage for enrollees who use contracting

providers.

(3) "Out-of-network provider" means a health care

provider of any health care service or supply that does not have a

contract under an enrollee's health benefit plan.

(4) "Program" means the shared savings program

established under this chapter.

Sec. 1276.002. APPLICABILITY OF CHAPTER. (a) This chapter

applies only to nonemergency health care services or supplies

covered under a managed care plan.

(b) This chapter applies only to the following health

benefit plans:

(1) a health benefit plan provided by a health

maintenance organization operating under Chapter 843;

(2) a preferred provider benefit plan provided under

Chapter 1301; or

(3) a basic coverage plan provided under Chapter 1551.

(c) Notwithstanding any other law, this chapter applies to

an administrator of a health benefit plan described by this

section.

Sec. 1276.003. RULES. The commissioner may adopt rules

necessary to implement this chapter.

SUBCHAPTER B. PROGRAM REQUIREMENTS

Sec. 1276.051. PROGRAM REQUIRED. (a) A health benefit plan

issuer or administrator to which this chapter applies shall

establish a shared savings program in accordance with this chapter.

(b) A health benefit plan issuer or administrator shall

provide written notice to its enrollees of the program.

Sec. 1276.052. AVERAGE CONTRACTED RATE DISCLOSURE. (a) As

part of the program, a health benefit plan issuer or administrator

shall establish and operate a toll-free telephone number and

publicly accessible Internet website for a plan enrollee to request

disclosure of the average contracted rate paid under the plan to a

health care provider in the plan's provider network for a

particular health care service or supply in the preceding 12

months.

(b) A health benefit plan issuer or administrator shall

disclose to the enrollee the rate the enrollee requested under

Subsection (a).

Sec. 1276.053. HEALTH CARE PROVIDER ESTIMATE. An

out-of-network provider shall, on an enrollee's request, provide

the enrollee a written estimate of the final charge for a proposed

health care service or supply eligible for the enrollee's program.

The estimate must include all costs associated with the service or

supply and reflect the enrollee's final out-of-pocket cost

associated with the proposed service or supply.

Sec. 1276.054. SHARED SAVINGS PAYMENT. (a) Except as

provided by Subsection (b), if an enrollee who requests a

disclosure under Section 1276.052 elects and receives a health care

service or supply with an actual cost equal to an amount less than

the rate disclosed under Section 1276.052, the health benefit plan

issuer or administrator shall pay to the enrollee 50 percent of the

difference between the disclosed rate and the actual cost, minus

any applicable deductible, copayment, or coinsurance.

(b) A health benefit plan issuer is not required to pay an

enrollee under Subsection (a) if the difference described by that

subsection is less than $50.

(c) A health benefit plan issuer or administrator shall pay

an enrollee under Subsection (a) not later than the 30th day after

the date on which the enrollee submits a program claim.

Sec. 1276.055. DEDUCTIBLES UNDER PROGRAM. (a) This section

applies only to a health care service or supply for which an

enrollee received:

(1) a disclosure under Section 1276.052; and

(2) an estimate under Section 1276.053 equal to an

amount at least $50 less than the rate provided under the

disclosure.

(b) A health benefit plan issuer or administrator shall

apply a deductible for a health care service or supply to which this

section applies in an amount equivalent to the deductible applied

to a network service or supply.

Sec. 1276.056. LIABILITY FOR UNFORESEEN CHARGE OVER

ESTIMATE. If the final charge for the health care service or supply

described by Section 1276.055(a) is an amount greater than the

amount estimated under Section 1276.053 due to unforeseen

circumstances, the enrollee's health benefit plan issuer or

administrator shall pay 95 percent of the difference not to exceed

the allowed amount for the service or supply and the enrollee is

responsible for the remaining difference.

SECTION 2. Chapter 1276, Insurance Code, as added by this

Act, applies only to a health benefit plan delivered, issued for

delivery, or renewed on or after January 1, 2026.

SECTION 3. This Act takes effect September 1, 2025.