Texas Register January 10, 2020 Volume: 45 Number: 2

Texas Department of Insurance

 

Adopted Rules

Re: Disclosures by out-of-network providers, adopting exceptions (as temporarily implemented by Emergency Rules 28 TAC §§21.4901 – 21.4904) to balance billing prohibitions in the Insurance Code

CHAPTER 21. TRADE PRACTICESSUBCHAPTER OO. DISCLOSURES BY OUT-OF-NETWORK PROVIDERS28 TAC §§21.4901 – 21.4904The Texas Department of Insurance proposes new 28 TAC §§21.4901 – 21.4904, concerning disclosures by out-of-network providers. The new rules implement exceptions to balance billing prohibitions in Insurance Code §§1271.157, 1271.158, 1301.164, 1301.165, 1551.229, 1551.230, 1575.172, 1575.173, 1579.110, and 1579.111, as enacted by Senate Bill 1264, 86th Legislature, Regular Session (2019).On December 18, 2019, the department adopted 28 TAC §§21.4901 – 21.4904 under emergency rulemaking procedures, to be effective on January 1, 2020. The emergency rules will be withdrawn at the time these proposed rules become effective.Senate Bill 1264, which prohibits balance billing for certain health benefit claims under certain health benefit plans; provides exceptions to balance billing prohibitions; and authorizes an independent dispute resolution process for claim disputes between certain out-of-network providers and health benefit plan issuers and administrators. SB 1264’s balance billing protections generally apply to enrollees of health benefit plans offered by insurers and health maintenance organizations that the department regulates, as well as to the Texas Employees Group, the Texas Public School Employees Group, and the Texas School Employees Uniform Group. The changes to law made by the bill apply to health care and medical services or supplies provided on or after January 1, 2020.The proposed exceptions in new rules 28 TAC §§21.4901 – 21.4904 are only applicable in non-emergencies when a health benefit plan enrollee elects to receive covered health care or medical services or supplies from 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 from 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.New §21.4901 addresses the purpose and applicability of new Subchapter OO.New §21.4902 provides that words and terms defined in Insurance Code Chapter 1467 have the same meaning when used in Subchapter OO, unless the context clearly indicates otherwise.New §21.4903 clarifies that, for purposes of the exceptions to the balance billing prohibitions, an enrollee’s election is only valid if the enrollee has a meaningful choice between an in-network provider and an out-of-network provider, the enrollee was not coerced by another provider or their health benefit plan into selecting the out-of-network provider, and the enrollee signs a notice and disclosure statement at least ten business days before the service or supply is provided acknowledging that the enrollee may be liable for a balance bill and chooses to proceed with the service or supply anyway. Only an out-of-network provider that chooses to balance bill an enrollee is required to provide a notice and disclosure statement to the enrollee. The out-of-network provider may choose to participate in SB 1264’s claim dispute resolution process instead of balance billing an enrollee. New §21.4903 also adopts by reference the notice and disclosure statement that must be filled out by the out-of-network provider and given to the enrollee if the provider chooses to balance bill.New §21.4904 requires health benefit plans to help their enrollees determine their financial responsibility for a service or supply for which a notice and disclosure statement has been provided, consistent with Insurance Code §1661.002.


Teachers Retirement System of Texas

Proposed Rules

Amending a TRS rule on deadlines for filing an eligibility appeal, to allow a member or retiree at least the same amount of time to file an appeal as TRS has to issue a decision

CHAPTER 41. HEALTH CARE AND INSURANCE PROGRAMSSUBCHAPTER C. TEXAS SCHOOL EMPLOYEES GROUP HEALTH (TRS-ACTIVECARE)34 TAC §41.51The Teacher Retirement System of Texas (TRS) proposes amendments to rule §41.51, concerning appeals relating to eligibility to enroll in the Texas School Employees Uniform Group Health Coverage Program (“TRS-ActiveCare”). The proposed amendments, implicating TRS deadlines for the filing of an appeal, afford a member or retiree at least the same amount of time to file an appeal as TRS has to issue a decision.Under the proposed amendments, a request for an appeal to the Committee executive director must be submitted by the Petitioner in writing and must be received by TRS by the later of: 1) 30 days after the date the initial written decision by the Committee is mailed; or 2) the number of days after the decision of the Committee is mailed equal to the number of days it took the Committee to issue its decision.


Texas Department of Insurance

Adopted Rules

Re: Requirements for short-term limited-duration accident and health insurance coverage

CHAPTER 3. LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIESSUBCHAPTER W. MISCELLANEOUS RULES FOR GROUP AND INDIVIDUAL ACCIDENT AND HEALTH INSURANCE28 TAC §3.3602The Commissioner of Insurance adopts new 28 TAC §3.3602, relating to requirements for short-term limited-duration coverage for any individual or group accident and health insurance policy or certificate issued under Insurance Code Chapters 1201 or 1251. Section 3.3602 implements Senate Bill 1852, 86th Legislature, Regular Session (2019). The new §3.3602 clarifies the definition of “short-term limited-duration insurance” and establishes minimum benefit requirements, renewability requirements, detailed disclosure form requirements, and requirements regarding notices to consumers of applicable protections.


Texas Department of Insurance

Adopted Rules

Amending Division of Workers’ Compensation rules 28 TAC § 124.2, concerning written communications, and § 124.3, concerning investigation of an injury and notice of denial/dispute

The Texas Department of Insurance, Division of Workers’ Compensation (DWC) adopts amendments to §124.2 (concerning General Rules for Written Communications to and from the Commission) and §124.3 (concerning Investigation of an Injury and Notice of Denial/Dispute). AMENDMENTS TO 28 TAC § 124.2:The adopted amendments to Rule 124.2 add subsections (f) – (h) to establish the notice requirements.Subsection (f) details the choice of actions that an insurance carrier may take during the first 15 days following receipt of a written notice of injury. Subsection (f)(3) provides that notice must be provided to both the claimant and DWC.Subsection (g) clarifies that a “claim for benefits” means the first written notice of injury as provided in Rule 124.1. Subsection (h) describes what must be included in a Notice of Continuing Investigation. Subsection (h)(3) provides a description of information or documents that may not be identified by the insurance carrier as reasonably necessary to complete its investigation through a Notice of Continuing Investigation.Subsection (j) describes additional requirements for an insurance carrier when issuing a denial notice on a claim where the insurance carrier issued a Notice of Continuing Investigation. Subsection (j)(2) clarifies if the insurance carrier concludes that a statutory presumption applies, but still denies the claim, the notice of denial must include a statement explaining why and describing the claim-specific evidence or documentation reviewed prior to issuance of the notice. Subsection (s) establishes minimum standards for plain language notices.Throughout Rule 124.2, additional non-substantive editorial changes are adopted to correct errors of grammar and punctuation, clarify wording, and to conform to the agency’s style guidelines.AMENDMENTS TO 28 TAC § 124.2:The amendments to Rule 124.3(a)(1-4) address the use of the Notice of Continuing Investigation as now allowed under §409.021(a-3). The amendments to Rule 124.3 delete penalty provisions in subsection (a)(4)(A-C) in order to conform with House Bill (HB) 7, enacted by the 79th Legislature, Regular Session, which deleted a limitation that an administrative penalty should not exceed $10,000. The amendments to subsections (d) and (e) are required to provide for the use of a Notice of Continuing Investigation in claims involving death or burial benefits. The transition language in prior subsection (f) is now obsolete and has been deleted as all claims prior to September 1, 2003, have exceeded the 15 days provided in subsection (a).Subsection (g) provides that if an insurance carrier receives written notice of injury for a disease or illness identified by Government Code Chapter 607, Subchapter B, it is required to investigate the applicability of the statutory presumption in addition to investigating the compensability of the injury, liability for the injury, and the accrual of benefits. Subsection (g) also providers guidance regarding the statutory presumption.Throughout Rule 124.3, additional non-substantive editorial changes are adopted to correct errors of grammar and punctuation, clarify wording, renumber subsections, and to conform to the agency’s style guidelines.


Texas Health and Human Services Commission

In Addition

Correction of error regarding a previously omitted figure

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposed amendments to 26 TAC §748.313 in the December 27, 2019, issue of the Texas Register (44 TexReg 8200).Due to an error by the Texas Register, the figure for 26 TAC §748.313 was inadvertently left out of the print version and the online .pdf version of the December 27 issue. The figure was included in the online .html version as well as the online Texas Register database. The figure will be republished in its entirety.


Texas Health and Human Services Commission

Adopted Rules

Notice of Public Hearing on Proposed Medicaid Payment Rates for the 2020 Annual Healthcare Common Procedure Coding System (HCPCS) Updates

The Texas Health and Human Services Commission (HHSC) will conduct a public hearing on January 28, 2020, at 1:30 p.m., to receive public comment on proposed Medicaid payment rates for the 2020 Annual Healthcare Common Procedure Coding System (HCPCS) Updates.The payment rates for the 2020 Annual HCPCS Updates are proposed to be effective January 1, 2020, for the following services:Blood – Type of Service (TOS) 0;Physician Administered Drugs – TOS 1 (Medical Services);Medical Services – TOS 1 (Medical Services);Surgery and Assistant Surgery Services – TOS 2 (Surgery Services) and TOS 8 (Assistant Surgery);Hospital Diagnostic Imaging – TOS 4 (Radiology);Radiological Services – TOS 4 (Radiology), TOS I (Professional Component), and TOS T (Technical Component);Clinical Diagnostic Laboratory Services – TOS 5 (Laboratory);Nonclinical Laboratory Services – TOS 5, TOS I, and TOS T;Durable Medical Equipment, Prosthetics, Orthotics, and Supplies – TOS 9 (Other Medical Items or Services), TOS J (DME Purchase – New), TOS L (DME Rental – Monthly);Ambulatory Surgical Center and Hospital Ambulatory Surgical Center – TOS F (Ambulatory Surgical Center); andDental Services – TOS W (Texas Health Steps Dental/Orthodontia).