| (a) Purpose. The purpose of this section is to implement
the requirements of the Insurance Code §§1271.157, 1271.158,
1301.164, 1301.165, 1551.229, 1551.230, 1575.172, 1575.173, 1579.110,
and 1579.111 and the Insurance Code Chapter 1467 and notify licensees
of their responsibilities under those sections.
(b) Definitions and Applicability of Section.
(1) Definitions. Terms defined in the Insurance Code §1467.001
have the same meanings when used in this section, unless the context
clearly indicates otherwise. Additionally, for purposes of this section,
a "balance bill" is a bill for an amount greater than an applicable
copayment, coinsurance, and deductible under an enrollee's health
benefit plan, as specified in the Insurance Code §§1271.157(c),
1271.158(c), 1301.164(c), 1301.165(c), 1551.229(c), 1551.230(c), 1575.172(c),
1575.173(c), 1579.110(c), or 1579.111(c).
(2) Applicability. This section only applies to a covered
non-emergency health care or medical service or supply provided on
or after January 1, 2020, by:
(A) a facility based provider that is not a participating
provider for a health benefit plan, if the service or supply is provided
at a health care facility that is a participating provider; or
(B) a diagnostic imaging provider or laboratory service
provider that is not a participating provider for a health benefit
plan, if the service or supply is provided in connection with a health
care or medical service or supply provided by a participating provider.
Further, this section is limited to providers that are subject to
the Board's jurisdiction.
(c) Responsibilities of Licensee.
(1) An out of network provider may not balance bill
an enrollee receiving a non-emergency health care or medical service
or supply, and the enrollee does not have financial responsibility
for a balance bill, unless the enrollee elects to obtain the service
or supply from the out of network provider knowing that the provider
is out of network and the enrollee may be financially responsible
for a balance bill. An enrollee's legal representative or guardian
may elect on behalf of an enrollee.
(2) An enrollee elects to obtain a service or supply
only if:
(A) the enrollee has a meaningful choice between a
participating provider for a health benefit plan issuer or administrator
and an out of network provider. No meaningful choice exists if an
out of network provider was selected for or assigned to an enrollee
by another provider or health benefit plan issuer or administrator;
(B) the enrollee is not coerced by a provider or health
benefit plan issuer or administrator when making the election. A provider
engages in coercion if the provider charges or attempts to charge
a nonrefundable fee, deposit, or cancellation fee for the service
or supply prior to the enrollee's election; and
(C) the out of network provider or the agent or assignee
of the provider provides written notice and disclosure to the enrollee
and obtains the enrollee's written consent, as specified in paragraph
(3) of this subsection.
(3) If an out of network provider elects to balance
bill an enrollee rather than participate in the claim dispute resolution
process authorized by the Insurance Code Chapter 1467, the out of
network provider or agent or assignee of the provider must provide
the enrollee with the notice and disclosure statement specified in
subparagraph (B) of this paragraph prior to scheduling the non-emergency
health care or medical service or supply. To be effective, the notice
and disclosure statement must be signed and dated by the enrollee
no less than 10 business days before the date the service or supply
is performed or provided. The enrollee may rescind acceptance within
five business days from the date the notice and disclosure statement
was signed, as explained in the notice and disclosure statement form
referenced in subparagraph (B) of this paragraph.
(A) Each out of network provider, or the provider's
agent or assignee, must maintain a copy of the notice and disclosure
statement, signed and dated by the enrollee, for four years if the
medical service or supply is provided and a balance bill is sent to
the enrollee. The provider must provide the enrollee with a copy of
the signed notice and disclosure statement on the same date the statement
is received by the provider.
(B) The Texas Department of Insurance has adopted Form
AH025 as the notice and disclosure statement to be used under this
subsection. The notice and disclosure statement may not be modified,
including its format or font size, and must be presented to an enrollee
as a standalone document and not incorporated into any other document.
The form is available from the Texas Department of Insurance by accessing
its website at www.tdi.texas.gov/forms.
(4) A provider who seeks and obtains an enrollee's
signature on a notice and disclosure statement under this subsection
is not eligible to participate in the claim dispute resolution process
authorized by the Insurance Code Chapter 1467. This prohibition does
not apply if the election is defective or rescinded by the enrollee
under paragraph (3) of this subsection.
(d) Complaint Investigation and Resolution. The Board
is authorized under the Insurance Code §752.0003 to take disciplinary
action against a licensee that violates a law that prohibits the licensee
from billing an insured, participant, or enrollee in an amount greater
than an applicable copayment, coinsurance, and deductible under the
insured's, participant's, or enrollee's managed care plan or that
imposes a requirement related to that prohibition. Licensees may also
be subject to additional consequences pursuant to the Insurance Code §752.0002.
Complaints that do not involve delayed health care or medical care
shall be assigned a Priority 4 status, as described in §213.13
of this title (relating to Complaint Investigation and Disposition).
After investigation, if the Board determines that a licensee has engaged
in improper billing practices or bad faith participation or has committed
a violation of the Nursing Practice Act, the Insurance Code Chapter
1467, or other applicable law, the Board will impose appropriate disciplinary
action.
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