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A BILL TO BE ENTITLED
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AN ACT
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relating to consumer protections against certain medical and health |
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care billing by emergency medical services providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 38, Insurance Code, is |
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amended by adding Section 38.006 to read as follows: |
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Sec. 38.006. EMERGENCY MEDICAL SERVICES PROVIDER BALANCE |
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BILLING RATE DATABASE. (a) A political subdivision may submit to |
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the department a rate set, controlled, or regulated by the |
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political subdivision for purposes of Section 1271.159, 1275.054, |
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1301.166, 1551.231, 1575.174, or 1579.112. The department shall |
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establish and maintain on the department's Internet website a |
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publicly accessible database for the rates. |
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(b) This section expires September 1, 2025. |
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SECTION 2. (a) Section 1271.008, Insurance Code, is |
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amended to read as follows: |
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Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A |
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health maintenance organization shall provide written notice in |
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|
accordance with this section in an explanation of benefits provided |
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|
to the enrollee and the physician or provider in connection with a |
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|
health care service or supply or transport provided by a |
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|
non-network physician or provider. The notice must include: |
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|
(1) a statement of the billing prohibition under |
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|
Section 1271.155, 1271.157, [or] 1271.158, or 1271.159, as |
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|
applicable; |
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|
(2) the total amount the physician or provider may |
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|
bill the enrollee under the enrollee's health benefit plan and an |
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|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
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|
(3) for an explanation of benefits provided to the |
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|
physician or provider, information required by commissioner rule |
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|
advising the physician or provider of the availability of mediation |
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|
or arbitration, as applicable, under Chapter 1467. |
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|
(b) A health maintenance organization shall provide the |
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|
explanation of benefits with the notice required by this section to |
|
|
a physician or health care provider not later than the date the |
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|
health maintenance organization makes a payment under Section |
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|
1271.155, 1271.157, [or] 1271.158, or 1271.159, as applicable. |
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(b) Effective September 1, 2025, Section 1271.008, |
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|
Insurance Code, is amended to read as follows: |
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Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A |
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|
health maintenance organization shall provide written notice in |
|
|
accordance with this section in an explanation of benefits provided |
|
|
to the enrollee and the physician or provider in connection with a |
|
|
health care service or supply provided by a non-network physician |
|
|
or provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1271.155, 1271.157, or 1271.158, as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's health benefit plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
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|
(b) A health maintenance organization shall provide the |
|
|
explanation of benefits with the notice required by this section to |
|
|
a physician or health care provider not later than the date the |
|
|
health maintenance organization makes a payment under Section |
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|
1271.155, 1271.157, or 1271.158, as applicable. |
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SECTION 3. Subchapter D, Chapter 1271, Insurance Code, is |
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|
amended by adding Section 1271.159 to read as follows: |
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Sec. 1271.159. NON-NETWORK EMERGENCY MEDICAL SERVICES |
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PROVIDER. (a) In this section, "emergency medical services |
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|
provider" has the meaning assigned by Section 773.003, Health and |
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|
Safety Code, except that the term does not include an air ambulance. |
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|
(b) Except as provided by Subsection (c), a health |
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|
maintenance organization shall pay for a covered health care |
|
|
service performed for, or a covered supply or covered transport |
|
|
related to that service provided to, an enrollee by a non-network |
|
|
emergency medical services provider at: |
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|
(1) if the political subdivision has submitted the |
|
|
rate to the department under Section 38.006, the rate set, |
|
|
controlled, or regulated by the political subdivision in which: |
|
|
(A) the service originated; or |
|
|
(B) the transport originated if transport is |
|
|
provided; or |
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|
(2) if the political subdivision has not submitted the |
|
|
rate to the department, the lesser of: |
|
|
(A) the provider's billed charge; or |
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|
(B) 325 percent of the current Medicare rate, |
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|
including any applicable extenders and modifiers. |
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|
(c) A health maintenance organization shall adjust a |
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|
payment required by Subsection (b)(1) each plan year by increasing |
|
|
the payment by the lesser of the Medicare Inflation Index or 10 |
|
|
percent of the provider's previous calendar year rates. |
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|
(d) The health maintenance organization shall make a |
|
|
payment required by this section directly to the provider not later |
|
|
than, as applicable: |
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|
(1) the 30th day after the date the health maintenance |
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|
organization receives an electronic clean claim as defined by |
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|
Section 843.336 for those services that includes all information |
|
|
necessary for the health maintenance organization to pay the claim; |
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|
or |
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(2) the 45th day after the date the health maintenance |
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|
organization receives a nonelectronic clean claim as defined by |
|
|
Section 843.336 for those services that includes all information |
|
|
necessary for the health maintenance organization to pay the claim. |
|
|
(e) A non-network emergency medical services provider or a |
|
|
person asserting a claim as an agent or assignee of the provider may |
|
|
not bill an enrollee receiving a health care service or supply or |
|
|
transport described by Subsection (b) in, and the enrollee does not |
|
|
have financial responsibility for, an amount greater than an |
|
|
applicable copayment, coinsurance, and deductible under the |
|
|
enrollee's health care plan that is based on: |
|
|
(1) the amount initially determined payable by the |
|
|
health maintenance organization; or |
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|
(2) if applicable, a modified amount as determined |
|
|
under the health maintenance organization's internal appeal |
|
|
process. |
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|
(f) This section may not be construed to require the |
|
|
imposition of a penalty under Section 843.342. |
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|
(g) This section expires September 1, 2025. |
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|
SECTION 4. (a) Section 1275.003, Insurance Code, is |
|
|
amended to read as follows: |
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|
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a) |
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|
The administrator of a health benefit plan to which this chapter |
|
|
applies shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the enrollee and |
|
|
the physician or health care provider in connection with a health |
|
|
care or medical service or supply or transport provided by an |
|
|
out-of-network provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1275.051, 1275.052, [or] 1275.053, or 1275.054, as |
|
|
applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's health benefit plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1275.051, 1275.052, [or] 1275.053, or |
|
|
1275.054, as applicable. |
|
|
(b) Effective September 1, 2025, Section 1275.003, |
|
|
Insurance Code, is amended to read as follows: |
|
|
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a health benefit plan to which this chapter |
|
|
applies shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the enrollee and |
|
|
the physician or health care provider in connection with a health |
|
|
care or medical service or supply provided by an out-of-network |
|
|
provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1275.051, 1275.052, or 1275.053, as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's health benefit plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1275.051, 1275.052, or 1275.053, as |
|
|
applicable. |
|
|
SECTION 5. Subchapter B, Chapter 1275, Insurance Code, is |
|
|
amended by adding Section 1275.054 to read as follows: |
|
|
Sec. 1275.054. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES |
|
|
PROVIDER PAYMENTS. (a) In this section, "emergency medical |
|
|
services provider" has the meaning assigned by Section 773.003, |
|
|
Health and Safety Code, except that the term does not include an air |
|
|
ambulance. |
|
|
(b) Except as provided by Subsection (c), the administrator |
|
|
of a health benefit plan to which this chapter applies shall pay for |
|
|
a covered health care or medical service performed for, or a covered |
|
|
supply or covered transport related to that service provided to, an |
|
|
enrollee by an out-of-network provider who is an emergency medical |
|
|
services provider at: |
|
|
(1) if the political subdivision has submitted the |
|
|
rate to the department under Section 38.006, the rate set, |
|
|
controlled, or regulated by the political subdivision in which: |
|
|
(A) the service originated; or |
|
|
(B) the transport originated if transport is |
|
|
provided; or |
|
|
(2) if the political subdivision has not submitted the |
|
|
rate to the department, the lesser of: |
|
|
(A) the provider's billed charge; or |
|
|
(B) 325 percent of the current Medicare rate, |
|
|
including any applicable extenders and modifiers. |
|
|
(c) The administrator shall adjust a payment required by |
|
|
Subsection (b)(1) each plan year by increasing the payment by the |
|
|
lesser of the Medicare Inflation Index or 10 percent of the |
|
|
provider's previous calendar year rates. |
|
|
(d) The administrator shall make a payment required by this |
|
|
section directly to the provider not later than, as applicable: |
|
|
(1) the 30th day after the date the administrator |
|
|
receives an electronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim; or |
|
|
(2) the 45th day after the date the administrator |
|
|
receives a nonelectronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim. |
|
|
(e) An out-of-network provider who is an emergency medical |
|
|
services provider or a person asserting a claim as an agent or |
|
|
assignee of the provider may not bill an enrollee receiving a health |
|
|
care or medical service or supply or transport described by |
|
|
Subsection (b) in, and the enrollee does not have financial |
|
|
responsibility for, an amount greater than an applicable copayment, |
|
|
coinsurance, and deductible under the enrollee's health benefit |
|
|
plan that is based on: |
|
|
(1) the amount initially determined payable by the |
|
|
administrator; or |
|
|
(2) if applicable, the modified amount as determined |
|
|
under the administrator's internal appeal process. |
|
|
(f) This section expires September 1, 2025. |
|
|
SECTION 6. (a) Section 1301.0045(b), Insurance Code, is |
|
|
amended to read as follows: |
|
|
(b) Except as provided by Sections 1301.0052, 1301.0053, |
|
|
1301.155, 1301.164, [and] 1301.165, and 1301.166, this chapter may |
|
|
not be construed to require an exclusive provider benefit plan to |
|
|
compensate a nonpreferred provider for services provided to an |
|
|
insured. |
|
|
(b) Effective September 1, 2025, Section 1301.0045(b), |
|
|
Insurance Code, is amended to read as follows: |
|
|
(b) Except as provided by Sections 1301.0052, 1301.0053, |
|
|
1301.155, 1301.164, and 1301.165, this chapter may not be construed |
|
|
to require an exclusive provider benefit plan to compensate a |
|
|
nonpreferred provider for services provided to an insured. |
|
|
SECTION 7. (a) Section 1301.010, Insurance Code, is |
|
|
amended to read as follows: |
|
|
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An |
|
|
insurer shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the insured and |
|
|
the physician or health care provider in connection with a medical |
|
|
care or health care service or supply or transport provided by an |
|
|
out-of-network provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or 1301.166, |
|
|
as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the insured under the insured's preferred provider benefit |
|
|
plan and an itemization of copayments, coinsurance, deductibles, |
|
|
and other amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) An insurer shall provide the explanation of benefits |
|
|
with the notice required by this section to a physician or health |
|
|
care provider not later than the date the insurer makes a payment |
|
|
under Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or |
|
|
1301.166, as applicable. |
|
|
(b) Effective September 1, 2025, Section 1301.010, |
|
|
Insurance Code, is amended to read as follows: |
|
|
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An |
|
|
insurer shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the insured and |
|
|
the physician or health care provider in connection with a medical |
|
|
care or health care service or supply provided by an out-of-network |
|
|
provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the insured under the insured's preferred provider benefit |
|
|
plan and an itemization of copayments, coinsurance, deductibles, |
|
|
and other amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) An insurer shall provide the explanation of benefits |
|
|
with the notice required by this section to a physician or health |
|
|
care provider not later than the date the insurer makes a payment |
|
|
under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as |
|
|
applicable. |
|
|
SECTION 8. Subchapter D, Chapter 1301, Insurance Code, is |
|
|
amended by adding Section 1301.166 to read as follows: |
|
|
Sec. 1301.166. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES |
|
|
PROVIDER. (a) In this section, "emergency medical services |
|
|
provider" has the meaning assigned by Section 773.003, Health and |
|
|
Safety Code, except that the term does not include an air ambulance. |
|
|
(b) Except as provided by Subsection (c), an insurer shall |
|
|
pay for a covered medical care or health care service performed for, |
|
|
or a covered supply or covered transport related to that service |
|
|
provided to, an insured by an out-of-network provider who is an |
|
|
emergency medical services provider at: |
|
|
(1) if the political subdivision has submitted the |
|
|
rate to the department under Section 38.006, the rate set, |
|
|
controlled, or regulated by the political subdivision in which: |
|
|
(A) the service originated; or |
|
|
(B) the transport originated if transport is |
|
|
provided; or |
|
|
(2) if the political subdivision has not submitted the |
|
|
rate to the department, the lesser of: |
|
|
(A) the provider's billed charge; or |
|
|
(B) 325 percent of the current Medicare rate, |
|
|
including any applicable extenders and modifiers. |
|
|
(c) An insurer shall adjust a payment required by Subsection |
|
|
(b)(1) each plan year by increasing the payment by the lesser of the |
|
|
Medicare Inflation Index or 10 percent of the provider's previous |
|
|
calendar year rates. |
|
|
(d) The insurer shall make a payment required by this |
|
|
section directly to the provider not later than, as applicable: |
|
|
(1) the 30th day after the date the insurer receives an |
|
|
electronic clean claim as defined by Section 1301.101 for those |
|
|
services that includes all information necessary for the insurer to |
|
|
pay the claim; or |
|
|
(2) the 45th day after the date the insurer receives a |
|
|
nonelectronic clean claim as defined by Section 1301.101 for those |
|
|
services that includes all information necessary for the insurer to |
|
|
pay the claim. |
|
|
(e) An out-of-network provider who is an emergency medical |
|
|
services provider or a person asserting a claim as an agent or |
|
|
assignee of the provider may not bill an insured receiving a medical |
|
|
care or health care service or supply or transport described by |
|
|
Subsection (b) in, and the insured does not have financial |
|
|
responsibility for, an amount greater than an applicable copayment, |
|
|
coinsurance, and deductible under the insured's preferred provider |
|
|
benefit plan that is based on: |
|
|
(1) the amount initially determined payable by the |
|
|
insurer; or |
|
|
(2) if applicable, the modified amount as determined |
|
|
under the insurer's internal appeal process. |
|
|
(f) This section may not be construed to require the |
|
|
imposition of a penalty under Section 1301.137. |
|
|
(g) This section expires September 1, 2025. |
|
|
SECTION 9. (a) Section 1551.015, Insurance Code, is |
|
|
amended to read as follows: |
|
|
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a managed care plan provided under the group |
|
|
benefits program shall provide written notice in accordance with |
|
|
this section in an explanation of benefits provided to the |
|
|
participant and the physician or health care provider in connection |
|
|
with a health care or medical service or supply or transport |
|
|
provided by an out-of-network provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1551.228, 1551.229, [or] 1551.230, or 1551.231, as |
|
|
applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the participant under the participant's managed care plan and |
|
|
an itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1551.228, 1551.229, [or] 1551.230, or |
|
|
1551.231, as applicable. |
|
|
(b) Effective September 1, 2025, Section 1551.015, |
|
|
Insurance Code, is amended to read as follows: |
|
|
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a managed care plan provided under the group |
|
|
benefits program shall provide written notice in accordance with |
|
|
this section in an explanation of benefits provided to the |
|
|
participant and the physician or health care provider in connection |
|
|
with a health care or medical service or supply provided by an |
|
|
out-of-network provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1551.228, 1551.229, or 1551.230, as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the participant under the participant's managed care plan and |
|
|
an itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1551.228, 1551.229, or 1551.230, as |
|
|
applicable. |
|
|
SECTION 10. Subchapter E, Chapter 1551, Insurance Code, is |
|
|
amended by adding Section 1551.231 to read as follows: |
|
|
Sec. 1551.231. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES |
|
|
PROVIDER PAYMENTS. (a) In this section, "emergency medical |
|
|
services provider" has the meaning assigned by Section 773.003, |
|
|
Health and Safety Code, except that the term does not include an air |
|
|
ambulance. |
|
|
(b) Except as provided by Subsection (c), the administrator |
|
|
of a managed care plan provided under the group benefits program |
|
|
shall pay for a covered health care or medical service performed |
|
|
for, or a covered supply or covered transport related to that |
|
|
service provided to, a participant by an out-of-network provider |
|
|
who is an emergency medical services provider at: |
|
|
(1) if the political subdivision has submitted the |
|
|
rate to the department under Section 38.006, the rate set, |
|
|
controlled, or regulated by the political subdivision in which: |
|
|
(A) the service originated; or |
|
|
(B) the transport originated if transport is |
|
|
provided; or |
|
|
(2) if the political subdivision has not submitted the |
|
|
rate to the department, the lesser of: |
|
|
(A) the provider's billed charge; or |
|
|
(B) 325 percent of the current Medicare rate, |
|
|
including any applicable extenders and modifiers. |
|
|
(c) The administrator shall adjust a payment required by |
|
|
Subsection (b)(1) each plan year by increasing the payment by the |
|
|
lesser of the Medicare Inflation Index or 10 percent of the |
|
|
provider's previous calendar year rates. |
|
|
(d) The administrator shall make a payment required by this |
|
|
section directly to the provider not later than, as applicable: |
|
|
(1) the 30th day after the date the administrator |
|
|
receives an electronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim; or |
|
|
(2) the 45th day after the date the administrator |
|
|
receives a nonelectronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim. |
|
|
(e) An out-of-network provider who is an emergency medical |
|
|
services provider or a person asserting a claim as an agent or |
|
|
assignee of the provider may not bill a participant receiving a |
|
|
health care or medical service or supply or transport described by |
|
|
Subsection (b) in, and the participant does not have financial |
|
|
responsibility for, an amount greater than an applicable copayment, |
|
|
coinsurance, and deductible under the participant's managed care |
|
|
plan that is based on: |
|
|
(1) the amount initially determined payable by the |
|
|
administrator; or |
|
|
(2) if applicable, the modified amount as determined |
|
|
under the administrator's internal appeal process. |
|
|
(f) This section expires September 1, 2025. |
|
|
SECTION 11. (a) Section 1575.009, Insurance Code, is |
|
|
amended to read as follows: |
|
|
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a managed care plan provided under the group |
|
|
program shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the enrollee and |
|
|
the physician or health care provider in connection with a health |
|
|
care or medical service or supply or transport provided by an |
|
|
out-of-network provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1575.171, 1575.172, [or] 1575.173, or 1575.174, as |
|
|
applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's managed care plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1575.171, 1575.172, [or] 1575.173, or |
|
|
1575.174, as applicable. |
|
|
(b) Effective September 1, 2025, Section 1575.009, |
|
|
Insurance Code, is amended to read as follows: |
|
|
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a managed care plan provided under the group |
|
|
program shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the enrollee and |
|
|
the physician or health care provider in connection with a health |
|
|
care or medical service or supply provided by an out-of-network |
|
|
provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1575.171, 1575.172, or 1575.173, as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's managed care plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1575.171, 1575.172, or 1575.173, as |
|
|
applicable. |
|
|
SECTION 12. Subchapter D, Chapter 1575, Insurance Code, is |
|
|
amended by adding Section 1575.174 to read as follows: |
|
|
Sec. 1575.174. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES |
|
|
PROVIDER PAYMENTS. (a) In this section, "emergency medical |
|
|
services provider" has the meaning assigned by Section 773.003, |
|
|
Health and Safety Code, except that the term does not include an air |
|
|
ambulance. |
|
|
(b) Except as provided by Subsection (c), the administrator |
|
|
of a managed care plan provided under the group program shall pay |
|
|
for a covered health care or medical service performed for, or a |
|
|
covered supply or covered transport related to that service |
|
|
provided to, an enrollee by an out-of-network provider who is an |
|
|
emergency medical services provider at: |
|
|
(1) if the political subdivision has submitted the |
|
|
rate to the department under Section 38.006, the rate set, |
|
|
controlled, or regulated by the political subdivision in which: |
|
|
(A) the service originated; or |
|
|
(B) the transport originated if transport is |
|
|
provided; or |
|
|
(2) if the political subdivision has not submitted the |
|
|
rate to the department, the lesser of: |
|
|
(A) the provider's billed charge; or |
|
|
(B) 325 percent of the current Medicare rate, |
|
|
including any applicable extenders and modifiers. |
|
|
(c) The administrator shall adjust a payment required by |
|
|
Subsection (b)(1) each plan year by increasing the payment by the |
|
|
lesser of the Medicare Inflation Index or 10 percent of the |
|
|
provider's previous calendar year rates. |
|
|
(d) The administrator shall make a payment required by this |
|
|
section directly to the provider not later than, as applicable: |
|
|
(1) the 30th day after the date the administrator |
|
|
receives an electronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim; or |
|
|
(2) the 45th day after the date the administrator |
|
|
receives a nonelectronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim. |
|
|
(e) An out-of-network provider who is an emergency medical |
|
|
services provider or a person asserting a claim as an agent or |
|
|
assignee of the provider may not bill an enrollee receiving a health |
|
|
care or medical service or supply or transport described by |
|
|
Subsection (b) in, and the enrollee does not have financial |
|
|
responsibility for, an amount greater than an applicable copayment, |
|
|
coinsurance, and deductible under the enrollee's managed care plan |
|
|
that is based on: |
|
|
(1) the amount initially determined payable by the |
|
|
administrator; or |
|
|
(2) if applicable, the modified amount as determined |
|
|
under the administrator's internal appeal process. |
|
|
(f) This section expires September 1, 2025. |
|
|
SECTION 13. (a) Section 1579.009, Insurance Code, is |
|
|
amended to read as follows: |
|
|
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a managed care plan provided under this |
|
|
chapter shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the enrollee and |
|
|
the physician or health care provider in connection with a health |
|
|
care or medical service or supply or transport provided by an |
|
|
out-of-network provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1579.109, 1579.110, [or] 1579.111, or 1579.112, as |
|
|
applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's managed care plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1579.109, 1579.110, [or] 1579.111, or |
|
|
1579.112, as applicable. |
|
|
(b) Effective September 1, 2025, Section 1579.009, |
|
|
Insurance Code, is amended to read as follows: |
|
|
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a) |
|
|
The administrator of a managed care plan provided under this |
|
|
chapter shall provide written notice in accordance with this |
|
|
section in an explanation of benefits provided to the enrollee and |
|
|
the physician or health care provider in connection with a health |
|
|
care or medical service or supply provided by an out-of-network |
|
|
provider. The notice must include: |
|
|
(1) a statement of the billing prohibition under |
|
|
Section 1579.109, 1579.110, or 1579.111, as applicable; |
|
|
(2) the total amount the physician or provider may |
|
|
bill the enrollee under the enrollee's managed care plan and an |
|
|
itemization of copayments, coinsurance, deductibles, and other |
|
|
amounts included in that total; and |
|
|
(3) for an explanation of benefits provided to the |
|
|
physician or provider, information required by commissioner rule |
|
|
advising the physician or provider of the availability of mediation |
|
|
or arbitration, as applicable, under Chapter 1467. |
|
|
(b) The administrator shall provide the explanation of |
|
|
benefits with the notice required by this section to a physician or |
|
|
health care provider not later than the date the administrator |
|
|
makes a payment under Section 1579.109, 1579.110, or 1579.111, as |
|
|
applicable. |
|
|
SECTION 14. Subchapter C, Chapter 1579, Insurance Code, is |
|
|
amended by adding Section 1579.112 to read as follows: |
|
|
Sec. 1579.112. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES |
|
|
PROVIDER PAYMENTS. (a) In this section, "emergency medical |
|
|
services provider" has the meaning assigned by Section 773.003, |
|
|
Health and Safety Code, except that the term does not include an air |
|
|
ambulance. |
|
|
(b) Except as provided by Subsection (c), the administrator |
|
|
of a managed care plan provided under this chapter shall pay for a |
|
|
covered health care or medical service performed for, or a covered |
|
|
supply or covered transport related to that service provided to, an |
|
|
enrollee by an out-of-network provider who is an emergency medical |
|
|
services provider at: |
|
|
(1) if the political subdivision has submitted the |
|
|
rate to the department under Section 38.006, the rate set, |
|
|
controlled, or regulated by the political subdivision in which: |
|
|
(A) the service originated; or |
|
|
(B) the transport originated if transport is |
|
|
provided; or |
|
|
(2) if the political subdivision has not submitted the |
|
|
rate to the department, the lesser of: |
|
|
(A) the provider's billed charge; or |
|
|
(B) 325 percent of the current Medicare rate, |
|
|
including any applicable extenders and modifiers. |
|
|
(c) The administrator shall adjust a payment required by |
|
|
Subsection (b)(1) each plan year by increasing the payment by the |
|
|
lesser of the Medicare Inflation Index or 10 percent of the |
|
|
provider's previous calendar year rates. |
|
|
(d) The administrator shall make a payment required by this |
|
|
section directly to the provider not later than, as applicable: |
|
|
(1) the 30th day after the date the administrator |
|
|
receives an electronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim; or |
|
|
(2) the 45th day after the date the administrator |
|
|
receives a nonelectronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim. |
|
|
(e) An out-of-network provider who is an emergency medical |
|
|
services provider or a person asserting a claim as an agent or |
|
|
assignee of the provider may not bill an enrollee receiving a health |
|
|
care or medical service or supply or transport described by |
|
|
Subsection (b) in, and the enrollee does not have financial |
|
|
responsibility for, an amount greater than an applicable copayment, |
|
|
coinsurance, and deductible under the enrollee's managed care plan |
|
|
that is based on: |
|
|
(1) the amount initially determined payable by the |
|
|
administrator; or |
|
|
(2) if applicable, a modified amount as determined |
|
|
under the administrator's internal appeal process. |
|
|
(f) This section expires September 1, 2025. |
|
|
SECTION 15. The changes in law made by this Act apply only |
|
|
to a ground ambulance service provided on or after January 1, 2024. |
|
|
A ground ambulance service provided before January 1, 2024, is |
|
|
governed by the law in effect immediately before the effective date |
|
|
of this Act, and that law is continued in effect for that purpose. |
|
|
SECTION 16. Except as otherwise provided by this Act, this |
|
|
Act takes effect September 1, 2023. |