State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1456-disclosure-of-provider-status
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS
CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS
Sec. 1456.001. DEFINITIONS. In this chapter:
(1) "Balance billing" means the practice of charging an enrollee
in a health benefit plan that uses a provider network to recover
from the enrollee the balance of a non-network health care
provider's fee for service received by the enrollee from the
health care provider that is not fully reimbursed by the
enrollee's health benefit plan.
(2) "Enrollee" means an individual who is eligible to receive
health care services through a health benefit plan.
(3) "Facility-based physician" means a radiologist, an
anesthesiologist, a pathologist, an emergency department
physician, or a neonatologist:
(A) to whom the facility has granted clinical privileges; and
(B) who provides services to patients of the facility under
those clinical privileges.
(4) "Health care facility" means a hospital, emergency clinic,
outpatient clinic, birthing center, ambulatory surgical center,
or other facility providing health care services.
(5) "Health care practitioner" means an individual who is
licensed to provide and provides health care services.
(6) "Provider network" means a health benefit plan under which
health care services are provided to enrollees through contracts
with health care providers and that requires those enrollees to
use health care providers participating in the plan and
procedures covered by the plan. The term includes a network
operated by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) another entity that issues a health benefit plan, including
an insurance company.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies to any health benefit plan that:
(1) provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered
by:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
842;
(C) a fraternal benefit society operating under Chapter 885;
(D) a stipulated premium company operating under Chapter 884;
(E) a health maintenance organization operating under Chapter
843;
(F) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844; or
(H) an entity not authorized under this code or another
insurance law of this state that contracts directly for health
care services on a risk-sharing basis, including a capitation
basis; or
(2) provides health and accident coverage through a risk pool
created under Chapter 172, Local Government Code, notwithstanding
Section 172.014, Local Government Code, or any other law.
(b) This chapter applies to a person to whom a health benefit
plan contracts to:
(1) process or pay claims;
(2) obtain the services of physicians or other providers to
provide health care services to enrollees; or
(3) issue verifications or preauthorizations.
(c) This chapter does not apply to:
(1) Medicaid managed care programs operated under Chapter 533,
Government Code;
(2) Medicaid programs operated under Chapter 32, Human Resources
Code; or
(3) the state child health plan operated under Chapter 62 or 63,
Health and Safety Code.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.003. REQUIRED DISCLOSURE: HEALTH BENEFIT PLAN. (a)
Each health benefit plan that provides health care through a
provider network shall provide notice to its enrollees that:
(1) a facility-based physician or other health care practitioner
may not be included in the health benefit plan's provider
network; and
(2) a health care practitioner described by Subdivision (1) may
balance bill the enrollee for amounts not paid by the health
benefit plan.
(b) The health benefit plan shall provide the disclosure in
writing to each enrollee:
(1) in any materials sent to the enrollee in conjunction with
issuance or renewal of the plan's insurance policy or evidence of
coverage;
(2) in an explanation of payment summary provided to the
enrollee or in any other analogous document that describes the
enrollee's benefits under the plan; and
(3) conspicuously displayed, on any health benefit plan website
that an enrollee is reasonably expected to access.
(c) A health benefit plan must clearly identify any health care
facilities within the provider network in which facility-based
physicians do not participate in the health benefit plan's
provider network. Health care facilities identified under this
subsection must be identified in a separate and conspicuous
manner in any provider network directory or website directory.
(d) Along with any explanation of benefits sent to an enrollee
that contains a remark code indicating a payment made to a
non-network physician has been paid at the health benefit plan's
allowable or usual and customary amount, a health benefit plan
must also include the number for the department's consumer
protection division for complaints regarding payment.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.004. REQUIRED DISCLOSURE: FACILITY-BASED PHYSICIANS.
(a) If a facility-based physician bills a patient who is covered
by a health benefit plan described in Section 1456.002 that does
not have a contract with the facility-based physician, the
facility-based physician shall send a billing statement that:
(1) contains an itemized listing of the services and supplies
provided along with the dates the services and supplies were
provided;
(2) contains a conspicuous, plain-language explanation that:
(A) the facility-based physician is not within the health plan
provider network; and
(B) the health benefit plan has paid a rate, as determined by
the health benefit plan, which is below the facility-based
physician billed amount;
(3) contains a telephone number to call to discuss the
statement, provide an explanation of any acronyms, abbreviations,
and numbers used on the statement, or discuss any payment issues;
(4) contains a statement that the patient may call to discuss
alternative payment arrangements;
(5) contains a notice that the patient may file complaints with
the Texas Medical Board and includes the Texas Medical Board
mailing address and complaint telephone number; and
(6) for billing statements that total an amount greater than
$200, over any applicable copayments or deductibles, states, in
plain language, that if the patient finalizes a payment plan
agreement within 45 days of receiving the first billing statement
and substantially complies with the agreement, the facility-based
physician may not furnish adverse information to a consumer
reporting agency regarding an amount owed by the patient for the
receipt of medical treatment.
(b) A patient may be considered by the facility-based physician
to be out of substantial compliance with the payment plan
agreement if payments are not made in compliance with the
agreement for a period of 90 days.
(c) A facility-based physician who bills a patient covered by a
preferred provider benefit plan or a health benefit plan under
Chapter 1551 that does not have a contract with the
facility-based physician shall send a billing statement to the
patient with information sufficient to notify the patient of the
mandatory mediation process available under Chapter 1467 if the
amount for which the enrollee is responsible, after copayments,
deductibles, and coinsurance, including the amount unpaid by the
administrator or insurer, is greater than $1,000.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 3, eff. June 19, 2009.
Sec. 1456.005. DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY.
(a) The commissioner may take disciplinary action against a
licensee that violates this chapter, in accordance with Chapter
84.
(b) A violation of this chapter by a facility-based physician is
grounds for disciplinary action and imposition of an
administrative penalty by the Texas Medical Board.
(c) The Texas Medical Board shall:
(1) notify a facility-based physician of a finding by the Texas
Medical Board that the facility-based physician is violating or
has violated this chapter or a rule adopted under this chapter;
and
(2) provide the facility-based physician with an opportunity to
correct the violation without penalty or reprimand.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. The
commissioner by rule may prescribe specific requirements for the
disclosure required under Section 1456.003. The form of the
disclosure must be substantially as follows:
NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN
PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE
PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER
PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH
THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS
WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR
PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL
SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT
PLAN."
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. A
health benefit plan that must comply with this chapter under
Section 1456.002 shall, on the request of an enrollee, provide an
estimate of payments that will be made for any health care
service or supply and shall also specify any deductibles,
copayments, coinsurance, or other amounts for which the enrollee
is responsible. The estimate must be provided not later than the
10th business day after the date on which the estimate was
requested. A health benefit plan must advise the enrollee that:
(1) the actual payment and charges for the services or supplies
will vary based upon the enrollee's actual medical condition and
other factors associated with performance of medical services;
and
(2) the enrollee may be personally liable for the payment of
services or supplies based upon the enrollee's health benefit
plan coverage.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1456-disclosure-of-provider-status
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS
CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS
Sec. 1456.001. DEFINITIONS. In this chapter:
(1) "Balance billing" means the practice of charging an enrollee
in a health benefit plan that uses a provider network to recover
from the enrollee the balance of a non-network health care
provider's fee for service received by the enrollee from the
health care provider that is not fully reimbursed by the
enrollee's health benefit plan.
(2) "Enrollee" means an individual who is eligible to receive
health care services through a health benefit plan.
(3) "Facility-based physician" means a radiologist, an
anesthesiologist, a pathologist, an emergency department
physician, or a neonatologist:
(A) to whom the facility has granted clinical privileges; and
(B) who provides services to patients of the facility under
those clinical privileges.
(4) "Health care facility" means a hospital, emergency clinic,
outpatient clinic, birthing center, ambulatory surgical center,
or other facility providing health care services.
(5) "Health care practitioner" means an individual who is
licensed to provide and provides health care services.
(6) "Provider network" means a health benefit plan under which
health care services are provided to enrollees through contracts
with health care providers and that requires those enrollees to
use health care providers participating in the plan and
procedures covered by the plan. The term includes a network
operated by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) another entity that issues a health benefit plan, including
an insurance company.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies to any health benefit plan that:
(1) provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered
by:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
842;
(C) a fraternal benefit society operating under Chapter 885;
(D) a stipulated premium company operating under Chapter 884;
(E) a health maintenance organization operating under Chapter
843;
(F) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844; or
(H) an entity not authorized under this code or another
insurance law of this state that contracts directly for health
care services on a risk-sharing basis, including a capitation
basis; or
(2) provides health and accident coverage through a risk pool
created under Chapter 172, Local Government Code, notwithstanding
Section 172.014, Local Government Code, or any other law.
(b) This chapter applies to a person to whom a health benefit
plan contracts to:
(1) process or pay claims;
(2) obtain the services of physicians or other providers to
provide health care services to enrollees; or
(3) issue verifications or preauthorizations.
(c) This chapter does not apply to:
(1) Medicaid managed care programs operated under Chapter 533,
Government Code;
(2) Medicaid programs operated under Chapter 32, Human Resources
Code; or
(3) the state child health plan operated under Chapter 62 or 63,
Health and Safety Code.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.003. REQUIRED DISCLOSURE: HEALTH BENEFIT PLAN. (a)
Each health benefit plan that provides health care through a
provider network shall provide notice to its enrollees that:
(1) a facility-based physician or other health care practitioner
may not be included in the health benefit plan's provider
network; and
(2) a health care practitioner described by Subdivision (1) may
balance bill the enrollee for amounts not paid by the health
benefit plan.
(b) The health benefit plan shall provide the disclosure in
writing to each enrollee:
(1) in any materials sent to the enrollee in conjunction with
issuance or renewal of the plan's insurance policy or evidence of
coverage;
(2) in an explanation of payment summary provided to the
enrollee or in any other analogous document that describes the
enrollee's benefits under the plan; and
(3) conspicuously displayed, on any health benefit plan website
that an enrollee is reasonably expected to access.
(c) A health benefit plan must clearly identify any health care
facilities within the provider network in which facility-based
physicians do not participate in the health benefit plan's
provider network. Health care facilities identified under this
subsection must be identified in a separate and conspicuous
manner in any provider network directory or website directory.
(d) Along with any explanation of benefits sent to an enrollee
that contains a remark code indicating a payment made to a
non-network physician has been paid at the health benefit plan's
allowable or usual and customary amount, a health benefit plan
must also include the number for the department's consumer
protection division for complaints regarding payment.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.004. REQUIRED DISCLOSURE: FACILITY-BASED PHYSICIANS.
(a) If a facility-based physician bills a patient who is covered
by a health benefit plan described in Section 1456.002 that does
not have a contract with the facility-based physician, the
facility-based physician shall send a billing statement that:
(1) contains an itemized listing of the services and supplies
provided along with the dates the services and supplies were
provided;
(2) contains a conspicuous, plain-language explanation that:
(A) the facility-based physician is not within the health plan
provider network; and
(B) the health benefit plan has paid a rate, as determined by
the health benefit plan, which is below the facility-based
physician billed amount;
(3) contains a telephone number to call to discuss the
statement, provide an explanation of any acronyms, abbreviations,
and numbers used on the statement, or discuss any payment issues;
(4) contains a statement that the patient may call to discuss
alternative payment arrangements;
(5) contains a notice that the patient may file complaints with
the Texas Medical Board and includes the Texas Medical Board
mailing address and complaint telephone number; and
(6) for billing statements that total an amount greater than
$200, over any applicable copayments or deductibles, states, in
plain language, that if the patient finalizes a payment plan
agreement within 45 days of receiving the first billing statement
and substantially complies with the agreement, the facility-based
physician may not furnish adverse information to a consumer
reporting agency regarding an amount owed by the patient for the
receipt of medical treatment.
(b) A patient may be considered by the facility-based physician
to be out of substantial compliance with the payment plan
agreement if payments are not made in compliance with the
agreement for a period of 90 days.
(c) A facility-based physician who bills a patient covered by a
preferred provider benefit plan or a health benefit plan under
Chapter 1551 that does not have a contract with the
facility-based physician shall send a billing statement to the
patient with information sufficient to notify the patient of the
mandatory mediation process available under Chapter 1467 if the
amount for which the enrollee is responsible, after copayments,
deductibles, and coinsurance, including the amount unpaid by the
administrator or insurer, is greater than $1,000.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 3, eff. June 19, 2009.
Sec. 1456.005. DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY.
(a) The commissioner may take disciplinary action against a
licensee that violates this chapter, in accordance with Chapter
84.
(b) A violation of this chapter by a facility-based physician is
grounds for disciplinary action and imposition of an
administrative penalty by the Texas Medical Board.
(c) The Texas Medical Board shall:
(1) notify a facility-based physician of a finding by the Texas
Medical Board that the facility-based physician is violating or
has violated this chapter or a rule adopted under this chapter;
and
(2) provide the facility-based physician with an opportunity to
correct the violation without penalty or reprimand.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. The
commissioner by rule may prescribe specific requirements for the
disclosure required under Section 1456.003. The form of the
disclosure must be substantially as follows:
NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN
PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE
PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER
PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH
THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS
WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR
PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL
SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT
PLAN."
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. A
health benefit plan that must comply with this chapter under
Section 1456.002 shall, on the request of an enrollee, provide an
estimate of payments that will be made for any health care
service or supply and shall also specify any deductibles,
copayments, coinsurance, or other amounts for which the enrollee
is responsible. The estimate must be provided not later than the
10th business day after the date on which the estimate was
requested. A health benefit plan must advise the enrollee that:
(1) the actual payment and charges for the services or supplies
will vary based upon the enrollee's actual medical condition and
other factors associated with performance of medical services;
and
(2) the enrollee may be personally liable for the payment of
services or supplies based upon the enrollee's health benefit
plan coverage.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
State Codes and Statutes
Statutes >
Texas >
Insurance-code >
Title-8-health-insurance-and-other-health-coverages >
Chapter-1456-disclosure-of-provider-status INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS
CHAPTER 1456. DISCLOSURE OF PROVIDER STATUS
Sec. 1456.001. DEFINITIONS. In this chapter:
(1) "Balance billing" means the practice of charging an enrollee
in a health benefit plan that uses a provider network to recover
from the enrollee the balance of a non-network health care
provider's fee for service received by the enrollee from the
health care provider that is not fully reimbursed by the
enrollee's health benefit plan.
(2) "Enrollee" means an individual who is eligible to receive
health care services through a health benefit plan.
(3) "Facility-based physician" means a radiologist, an
anesthesiologist, a pathologist, an emergency department
physician, or a neonatologist:
(A) to whom the facility has granted clinical privileges; and
(B) who provides services to patients of the facility under
those clinical privileges.
(4) "Health care facility" means a hospital, emergency clinic,
outpatient clinic, birthing center, ambulatory surgical center,
or other facility providing health care services.
(5) "Health care practitioner" means an individual who is
licensed to provide and provides health care services.
(6) "Provider network" means a health benefit plan under which
health care services are provided to enrollees through contracts
with health care providers and that requires those enrollees to
use health care providers participating in the plan and
procedures covered by the plan. The term includes a network
operated by:
(A) a health maintenance organization;
(B) a preferred provider benefit plan issuer; or
(C) another entity that issues a health benefit plan, including
an insurance company.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies to any health benefit plan that:
(1) provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered
by:
(A) an insurance company;
(B) a group hospital service corporation operating under Chapter
842;
(C) a fraternal benefit society operating under Chapter 885;
(D) a stipulated premium company operating under Chapter 884;
(E) a health maintenance organization operating under Chapter
843;
(F) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844; or
(H) an entity not authorized under this code or another
insurance law of this state that contracts directly for health
care services on a risk-sharing basis, including a capitation
basis; or
(2) provides health and accident coverage through a risk pool
created under Chapter 172, Local Government Code, notwithstanding
Section 172.014, Local Government Code, or any other law.
(b) This chapter applies to a person to whom a health benefit
plan contracts to:
(1) process or pay claims;
(2) obtain the services of physicians or other providers to
provide health care services to enrollees; or
(3) issue verifications or preauthorizations.
(c) This chapter does not apply to:
(1) Medicaid managed care programs operated under Chapter 533,
Government Code;
(2) Medicaid programs operated under Chapter 32, Human Resources
Code; or
(3) the state child health plan operated under Chapter 62 or 63,
Health and Safety Code.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.003. REQUIRED DISCLOSURE: HEALTH BENEFIT PLAN. (a)
Each health benefit plan that provides health care through a
provider network shall provide notice to its enrollees that:
(1) a facility-based physician or other health care practitioner
may not be included in the health benefit plan's provider
network; and
(2) a health care practitioner described by Subdivision (1) may
balance bill the enrollee for amounts not paid by the health
benefit plan.
(b) The health benefit plan shall provide the disclosure in
writing to each enrollee:
(1) in any materials sent to the enrollee in conjunction with
issuance or renewal of the plan's insurance policy or evidence of
coverage;
(2) in an explanation of payment summary provided to the
enrollee or in any other analogous document that describes the
enrollee's benefits under the plan; and
(3) conspicuously displayed, on any health benefit plan website
that an enrollee is reasonably expected to access.
(c) A health benefit plan must clearly identify any health care
facilities within the provider network in which facility-based
physicians do not participate in the health benefit plan's
provider network. Health care facilities identified under this
subsection must be identified in a separate and conspicuous
manner in any provider network directory or website directory.
(d) Along with any explanation of benefits sent to an enrollee
that contains a remark code indicating a payment made to a
non-network physician has been paid at the health benefit plan's
allowable or usual and customary amount, a health benefit plan
must also include the number for the department's consumer
protection division for complaints regarding payment.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.004. REQUIRED DISCLOSURE: FACILITY-BASED PHYSICIANS.
(a) If a facility-based physician bills a patient who is covered
by a health benefit plan described in Section 1456.002 that does
not have a contract with the facility-based physician, the
facility-based physician shall send a billing statement that:
(1) contains an itemized listing of the services and supplies
provided along with the dates the services and supplies were
provided;
(2) contains a conspicuous, plain-language explanation that:
(A) the facility-based physician is not within the health plan
provider network; and
(B) the health benefit plan has paid a rate, as determined by
the health benefit plan, which is below the facility-based
physician billed amount;
(3) contains a telephone number to call to discuss the
statement, provide an explanation of any acronyms, abbreviations,
and numbers used on the statement, or discuss any payment issues;
(4) contains a statement that the patient may call to discuss
alternative payment arrangements;
(5) contains a notice that the patient may file complaints with
the Texas Medical Board and includes the Texas Medical Board
mailing address and complaint telephone number; and
(6) for billing statements that total an amount greater than
$200, over any applicable copayments or deductibles, states, in
plain language, that if the patient finalizes a payment plan
agreement within 45 days of receiving the first billing statement
and substantially complies with the agreement, the facility-based
physician may not furnish adverse information to a consumer
reporting agency regarding an amount owed by the patient for the
receipt of medical treatment.
(b) A patient may be considered by the facility-based physician
to be out of substantial compliance with the payment plan
agreement if payments are not made in compliance with the
agreement for a period of 90 days.
(c) A facility-based physician who bills a patient covered by a
preferred provider benefit plan or a health benefit plan under
Chapter 1551 that does not have a contract with the
facility-based physician shall send a billing statement to the
patient with information sufficient to notify the patient of the
mandatory mediation process available under Chapter 1467 if the
amount for which the enrollee is responsible, after copayments,
deductibles, and coinsurance, including the amount unpaid by the
administrator or insurer, is greater than $1,000.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
1290, Sec. 3, eff. June 19, 2009.
Sec. 1456.005. DISCIPLINARY ACTION AND ADMINISTRATIVE PENALTY.
(a) The commissioner may take disciplinary action against a
licensee that violates this chapter, in accordance with Chapter
84.
(b) A violation of this chapter by a facility-based physician is
grounds for disciplinary action and imposition of an
administrative penalty by the Texas Medical Board.
(c) The Texas Medical Board shall:
(1) notify a facility-based physician of a finding by the Texas
Medical Board that the facility-based physician is violating or
has violated this chapter or a rule adopted under this chapter;
and
(2) provide the facility-based physician with an opportunity to
correct the violation without penalty or reprimand.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.006. COMMISSIONER RULES; FORM OF DISCLOSURE. The
commissioner by rule may prescribe specific requirements for the
disclosure required under Section 1456.003. The form of the
disclosure must be substantially as follows:
NOTICE: "ALTHOUGH HEALTH CARE SERVICES MAY BE OR HAVE BEEN
PROVIDED TO YOU AT A HEALTH CARE FACILITY THAT IS A MEMBER OF THE
PROVIDER NETWORK USED BY YOUR HEALTH BENEFIT PLAN, OTHER
PROFESSIONAL SERVICES MAY BE OR HAVE BEEN PROVIDED AT OR THROUGH
THE FACILITY BY PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS
WHO ARE NOT MEMBERS OF THAT NETWORK. YOU MAY BE RESPONSIBLE FOR
PAYMENT OF ALL OR PART OF THE FEES FOR THOSE PROFESSIONAL
SERVICES THAT ARE NOT PAID OR COVERED BY YOUR HEALTH BENEFIT
PLAN."
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
Sec. 1456.007. HEALTH BENEFIT PLAN ESTIMATE OF CHARGES. A
health benefit plan that must comply with this chapter under
Section 1456.002 shall, on the request of an enrollee, provide an
estimate of payments that will be made for any health care
service or supply and shall also specify any deductibles,
copayments, coinsurance, or other amounts for which the enrollee
is responsible. The estimate must be provided not later than the
10th business day after the date on which the estimate was
requested. A health benefit plan must advise the enrollee that:
(1) the actual payment and charges for the services or supplies
will vary based upon the enrollee's actual medical condition and
other factors associated with performance of medical services;
and
(2) the enrollee may be personally liable for the payment of
services or supplies based upon the enrollee's health benefit
plan coverage.
Added by Acts 2007, 80th Leg., R.S., Ch.
997, Sec. 11, eff. September 1, 2007.
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