HB5099 - Relating to establishment of a shared savings program for certain managed care plans.

  89R8002 SCL-D     By: Bonnen H.B. No. 5099       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.