Texas

SUMMARY

Texas has enacted legislation to explore the desirability and feasibility of deploying an APCD in the state. In addition to exploring payment-for-performance models in tandem with its existing rate review processes, Texas maintains a number of consumer resources for finding and using health insurance.

 

LEGISLATION/REGULATION

Legislative Calendar 

Texas’ current regular legislative session has ended.

 

Recent Legislative Developments

Healthcare Transparency

2017 HB 1206 Proposes that the commission adopt preferred drug lists for the Medicaid vendor drug program and for prescription drugs purchased through the child health plan program and for community mental health centers, state mental health hospitals, and any other state program administered by the commission or a state health and human services agency. Inactive – Died.
HB 2396 Requires health maintenance organizations and insurers to file an annual report with the comptroller showing their earnings and profit for the previous calendar year. Inactive – Died.
2015-2016 HB1624/SB1520 TRANSPARENCY RELATED TO CERTAIN HEALTH BENEFIT PLAN COVERAGE: requires health benefit plan issuers to display formulary information, via a direct and conspicuous electronic link, on the issuer’s Internet website. The formulary disclosures must include, for each drug the cost-sharing amount, including: (i) the dollar amount of a copayment; or (ii) for a drug subject to coinsurance, the cost-sharing range (e.g., “under $100 – $;” $100-250 – $,” etc.). The formulary disclosures must also identify prior authorizations, step therapies, other protocol requirements, tier the drug is in (if a tier-based system), whether drug is included in plan deductible or not and how so, preferred formulary drugs, and an explanation of coverage for each formulary drug. Passed – Signed by the Governor on 6/19/15. Effective 9/1/15.
HB1624/SB1520 HEALTH CARE PROVIDER DIRECTORIES: requires certain health benefit plan issuers to create physician and health care provider directories on the Internet. The directory needs to include the name, street address, and telephone number of each physician and health care provider and whether they are accepting new patients or not. The health benefit plan issuer must update the directories at least once per month. Passed  Signed by the Governor on 6/19/15. Effective 9/1/15.
SB203 CONTINUATION AND FUNCTIONS OF TEXAS HEALTH AUTHORITY AS A QUASI-GOVERNMENTAL ENTITY AND THE ELECTRONIC EXCHANGE OF HEALTH CARE INFORMATION: Requires that the advisory committee shall collaborate with the Texas Health Services Authority to ensure that the health information exchange system is interoperable with, and not an impediment to, the electronic health information infrastructure that the authority assists in developing. Passed Signed by Governor on 5/15/2015.
HB3102 DISCLOSURE OF PATIENT LIABILITY FOR PAYMENTS: would require health benefit plans to, on request of a plan enrollee, provide an estimate of payments that will be made for any health care services or supply and must also specify applicable deductibles, copayments, or coinsurances—within 10 business days.

H.B. 3102 would also require health care practitioners and facilities to, at least 3 business days prior to providing a patient with a non-emergency care, disclose the price, in writing, that would be accepted as payment in full for the service. The bill prohibits health care practitioners and facilities who do not provide proper notice from attempting to collect any payment for such services, transferring or sell a third party the right to collect any billed amount from the patient, or furnishing adverse information to a consumer reporting agency regarding the billed amount.

Inactive – Died.
HB 2084 TRANSPARENCY OF PREMIUM PAYMENT RATE SETTING PROCESS FOR MEDICAID PROGRAM. This bill creates format for the rate setting process for the Medicaid managed care program and child health care programs. Inactive -Passed, but vetoed by Governor 6/20/2015.
HB 3036 Creates a study conducted by the Health and Human Services Commission on the savings to the state achieved by the expansion of Medicaid managed care in regards to the number of persons served and the scope of services provided.  Inactive – Died.

 

Healthcare Cost

  • None identified.

 

Healthcare Markets

2017 HB1296 Proposes a health benefit plan that provides benefits for prescription drugs that would prorate any cost-sharing amount charged for a prescription drug dispensed in a quantity that is less than a 30 days ’ supply if: the pharmacy or the enrollee ’s prescribing physician or health care provider notifies the health benefit plan that the quantity dispensed is to synchronize the dates that the pharmacy dispenses the enrollee ’s prescription drugs; and the synchronization of the dates is in the best interest of the enrollee; and the enrollee agrees to the synchronization. Passed – Signed by Governor 6/15/17. Subchapter J will be amended into Chapter 1369 of the Insurance Code. Effective 9/1/17
HB292 Proposes that on the request of the county, that the executive commissioner shall seek a waiver under the Social Security Act to expand the categories of persons eligible for Medicaid benefits. Inactive – Died.
HB224  This proposes to Amend Chapter 1509 of the Texas Insurance code to prohibit health plans from denying or refusing to enroll individuals because of their pre-existing conditions. It also proposes to prohibit health plans from limiting or excluding treatment of the conditions, or charge the individual more than someone who does not have a pre-existing condition.  Inactive – Died.
HB3493  Allows the commissioner to seek on behalf of a county, a federal waiver to expand the categories of persons eligible for Medicaid benefits.  Inactive – Died.

 

Key Statutes

We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.

 

Transparency in Healthcare

  • Government Code §531.904 The commission shall establish the Electronic Health Information Exchange System Advisory Committee to assist the commission in the performance of the commission’s duties under this subchapter. (b)  The executive commissioner shall appoint to the advisory committee at least 12 and not more than 16 members who have an interest in health information technology and who have experience in serving persons receiving health care through the child health plan program and Medicaid.

 

  • Insurance Code 1369.0542 through 1369.0544 TRANSPARENCY RELATED TO CERTAIN HEALTH BENEFIT PLAN COVERAGE: requires health benefit plan issuers to display formulary information, via a direct and conspicuous electronic link, on the issuer’s Internet website. The formulary disclosures must include, for each drug the cost-sharing amount, including: (i) the dollar amount of a copayment; or (ii) for a drug subject to coinsurance, the cost-sharing range (e.g., “under $100 – $;” $100-250 – $,” etc.). The formulary disclosures must also identify prior authorizations, step therapies, other protocol requirements, tier the drug is in (if a tier-based system), whether drug is included in plan deductible or not and how so, preferred formulary drugs, and an explanation of coverage for each formulary drug.
    • HEALTH CARE PROVIDER DIRECTORIES: requires certain health benefit plan issuers to create physician and health care provider directories on the Internet. The directory needs to include the name, street address, and telephone number of each physician and health care provider and whether they are accepting new patients or not. The health benefit plan issuer must update the directories at least once per month.

 

 

  • Health and Safety Code § 324.101 requires a healthcare facility to develop, implement and enforce a billing policy for services and supplies, addressing any facility discounts to an uninsured indigent consumer, providing of an itemized bill, providing of a conspicuous written disclosure at the time of admittance, and other material disclosures.

 

  • Insurance Code § 1456.007 allows consumers to request a health care cost estimate from their health insurance company before receiving care.

 

  • Health Insurance Code § 1661.002 mandates that a health benefit plan issuer use information technology to providing an enroller with information respecting copayments and coinsurance, applicable deductibles, covered benefits and services, as well as the enrollee’s financial responsibility for health care.

 

  • Health and Safety Code § 1002.001 through 1002.202 creates the Texas Institute of Health Care Quality and Efficiency for the purpose of providing reports and recommendations to the legislature on quality and efficiency reform in healthcare, including improving transparency in health care information. The Institute shall develop recommendations for a statewide plan for quality and efficiency in the delivery of healthcare. Additionally, the Institute is charged with studying the feasibility and desirability of establishing a centralized database for health care claims information across all payers (APCD).

 

  • Insurance Code § 38.252 requires health insurers to report cost and utilization data including amount of premiums, the benefits provided, and other data as the Commissioner requires.

 

  • Texas Insurance Code § 38.351 through 38.358 authorizes the Texas Department of Insurance to: 1) collect data concerning health benefit plan reimbursement rates in a uniform format; and2) disseminate, on an aggregate basis for geographical regions in this state, information concerning health care reimbursement rates derived from the data. This subchapter applies to the following: 1) an insurance company; 2) a group hospital service corporation; 3) a fraternal benefit society; 4) a stipulated premium company; 5) a reciprocal or inter-insurance exchange; and 6) a health maintenance organization.

 

  • Insurance Code § 1201.109 requires individual health insurers to notify consumers 60 days before a premium rate increase takes effect.

 

Healthcare Markets

  • Government Code §531.0082 Amends provisions of the Government Code, Health and Safety Code, and Human Resource Code to establish a data analysis unit within the Health and Human Services Commission (HHSC) to improve contract management, detect data trends, and compliance with Medicaid and child health plan program provider contract requirements. The Bill also authorizes the HHSC Office of Inspector General to employ peace officers to assist in investigations of fraud, waste, or abuse in the Medicaid program.

 

  • Government Code § 536.002 through 536.007 creates a Medicaid and CHIP-Quality Based Payment Advisory Committee for the purpose of establishing a reimbursement system that rewards providers under those programs based on quality of care outcomes instead of pure fee-for-service.

 

  • Insurance Code § 848.001 et seq. establishes standards for engaging in business as a Health Care Collaborative, which is an entity that undertakes to arrange for healthcare services for insurers, health maintenance organizations, and other payers in exchange for payment that consist of some combination of physicians, other health care providers, and/or insurers.

 

  • Insurance Code § 560.002 et seq. mandates a system of rate review for health insurers and HMOs, providing that a rate must be just, fair, reasonable, and adequate. The rate may not be confiscatory, excessive for the risks to which the rate applies, or unfairly discriminatory.

 

2018-2019 BUDGET

Texas’ biennium budget begins September 1 after each regular legislative session. The budget for the next biennium (2018-2019) will cover September 1, 2017 through August 31, 2019. Texas enacted its 2018-2019 Budget during the regular legislative session.  To view the Governor’s most recent proposal on Texas’ health spending, go to pages 24-29.

 

LITIGATION/ENFORCEMENT

  • None identified

 

KEY RESOURCES

Texas State Legislature

Texas Office of the Attorney General

Texas Department of Insurance

 Texas PricePoint

Texas Health Options