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SECTION 1. Subtitle A, Title 3, Occupations Code, is
amended by adding Chapter 117 to read as follows:
CHAPTER 117. GOOD FAITH ESTIMATE OF HEALTH CARE PAYMENT
SUBCHAPTER A. GENERAL
PROVISIONS
Sec. 117.001. DEFINITIONS.
In this chapter:
(1) "Department"
means the Department of State Health Services.
(2) "Executive
commissioner" means the executive commissioner of the Health and Human
Services Commission.
(3) "Health care
provider" means:
(A) a health care
professional who performs a health
care service or provides a health care good in this state under a license,
certificate, registration, or other authority issued by this state to
diagnose, prevent, alleviate, or cure a human illness or injury, including
a physician, dentist, pharmacy, or pharmacist;
(B) a health care facility
that provides a health care service or good in this state under a license,
certificate, registration, or other authority issued by this state to
diagnose, prevent, alleviate, or cure a human illness or injury, including
an institutional health care provider or other hospital; or
(C) a person that provides
to patients in this state ancillary health care-related services and goods
under a license, certificate, or registration issued by this state, or that
is otherwise authorized to provide to patients in this state ancillary
health care-related services and goods ordered or authorized by a licensed
health care professional, to diagnose, prevent, alleviate, or cure a human
illness or injury, including laboratory services, radiological services,
and durable medical equipment.
SUBCHAPTER B.
ADMINISTRATION OF CHAPTER
Sec. 117.051. ADMINISTRATION
BY LICENSING ENTITIES. (a) The governing body of the entity that issues a
license, certificate, registration, or other authorization to practice to a
health care provider shall administer and enforce this chapter as it
applies to the provider.
(b) A governing body
described by Subsection (a) may adopt rules governing the application of
this chapter to health care providers regulated by the entity.
Sec. 117.052. ADMINISTRATION
BY DEPARTMENT. (a) The department shall administer and enforce this chapter
as it applies to any health care provider not issued a license,
certificate, registration, or other authorization to practice described by
Section 117.051.
(b) The executive
commissioner shall adopt rules governing the application of this chapter to
a health care provider described by Subsection (a).
SUBCHAPTER C. GOOD FAITH
ESTIMATE
Sec. 117.101. GOOD FAITH
ESTIMATE REQUIRED. (a) Except as provided by Subsection (b), before a
health care provider provides to a person a health care service or a health
care good, including a drug or medical device, the health care provider
must provide the person a good faith estimate of the actual expected
payments for the service or good, as provided by this subchapter.
The health care provider
shall ask the person to disclose the person's anticipated method of payment
for purposes of complying with this subchapter.
(b) A health care provider shall:
(1) in an emergency or urgent medical situation, provide to a person
any health care service or health care good necessary to stabilize the
person's medical condition if delay required to provide a good faith
estimate of the actual payment for the service or good under Subsection (a)
could result in an adverse medical consequence to the person; or
(2) provide to a person a health care service or health care good
ordered by the person's physician or other person primarily responsible for
the person's care if the person is unable to make medical decisions and does
not have a legal representative to make medical decisions on the person's
behalf.
Sec. 117.102. GOOD FAITH
ESTIMATE FOR INSURED PERSONS.
If a person has an
individual, group, or other private or commercial health insurance plan or
policy, including coverage through a preferred provider organization or
health maintenance organization, a health care provider shall provide the
person a good faith estimate of:
(1) the amount the
insurance plan or policy will actually pay the health care provider for the
health care service or health care good based
on the
negotiated rate between
the health care provider and the insurance plan or policy; and
(2) the amount of any
copayment, coinsurance, or other amount the person will actually pay the health care provider for the health care service or health care good based on
the terms of the person's insurance plan or policy
and the negotiated rate
between the health care provider and the person's insurance plan or policy.
Sec. 117.103. GOOD FAITH
ESTIMATE FOR RECIPIENTS OF GOVERNMENT-SPONSORED PROGRAM. If a person
receives benefits under a government-sponsored health benefits program,
including the Medicaid program, the Medicare program, the Children's Health
Insurance Program (CHIP), and the TRICARE military health system, a health
care provider shall provide the person a good faith estimate of:
(1) the amount the
government-sponsored health benefits program will actually pay the health
care provider for the health care service or
health care good; and
(2) any amount the person
will actually pay the health care provider for
the health care service or health care good
under the terms of the
government-sponsored health benefits program.
Sec. 117.104. GOOD FAITH
ESTIMATE FOR RECIPIENTS OF WORKERS' COMPENSATION BENEFITS. If a person
receives benefits under a workers' compensation claim, a health care
provider shall provide the person a good faith estimate of
the amount the workers'
compensation insurance carrier
will actually pay the
health care provider for the health care
service or health care good.
Sec. 117.105. STATEMENT
FOR PERSONS PAYING CASH, PERSONS RECEIVING CHARITY CARE, AND INDIGENT
PERSONS. If a person will pay cash or will receive charity care for a
health care service or health care good or if a person is indigent, a
health care provider shall provide the person with a statement of the
average amount the health care provider was actually paid for the health care service or health care good
by the five insurance
carriers or government-sponsored programs described by Sections 117.102,
117.103, and 117.104 that paid the health care provider for
the greatest number of
that health care service or health care good
in the preceding calendar year, or in the current calendar year if the
health care provider did not practice in the preceding calendar year.
SUBCHAPTER D. AGREEMENT TO
PROVIDE GOOD FAITH ESTIMATE ON BEHALF OF ANOTHER HEALTH CARE PROVIDER
Sec. 117.151. CONTRACT TO
ALLOW ANOTHER HEALTH CARE PROVIDER TO PROVIDE GOOD FAITH ESTIMATE. (a) A
health care provider may by contract agree to allow another health care
provider to provide a good faith estimate under Subchapter C for that
health care provider's health care services and health care goods.
(b) A health care provider
who enters into a contract described by Subsection (a) is responsible for
the content of the good faith estimate provided by the other health care
provider on that provider's behalf.
Sec. 117.152. RULES
GOVERNING CONTRACTING. (a) The executive commissioner may adopt rules governing
contracts under Section 117.151.
(b) The department shall
administer rules described by Subsection (a).
SUBCHAPTER E. PENALTIES
AND ENFORCEMENT
Sec. 117.201. VIOLATION BY
LICENSED HEALTH CARE PROVIDERS. A health care provider that violates this
chapter is subject to an administrative penalty, a civil penalty, or other
disciplinary action, as applicable, in the same manner as if the health
care provider violated the law under which the health care provider is
licensed, certified, registered, or authorized to practice.
Sec. 117.202. VIOLATION BY
OTHER HEALTH CARE PROVIDERS.
(a) The executive commissioner or department may
impose an administrative penalty against a
health care provider that is not required to hold a license, certificate,
registration, or other authorization to practice and that violates
this chapter.
(b) An administrative penalty imposed under this section shall be
imposed in the same manner as other administrative penalties imposed by the
executive commissioner.
(c) The amount of the
penalty may not exceed $1,000 for each
violation.
(d) The executive commissioner may adopt rules to implement this
section.
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SECTION 1. Subtitle G, Title 4, Health and Safety Code,
is amended by adding Chapter 326 to read as follows:
CHAPTER 326. GOOD FAITH ESTIMATE OF ACTUAL CHARGES FOR FACILITY-BASED
SERVICES
(See Subchaps. A, B, and C
below, following Subchap. E.)
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
SUBCHAPTER D. GOOD FAITH
ESTIMATE OF ACTUAL CHARGES
No
equivalent provision.
Sec. 326.151. DISCLOSURE OF EXPECTED PAYMENT METHOD.
A health care provider
shall ask a person to disclose the person's anticipated method of payment
for purposes of complying with this subchapter.
Sec. 326.152. GOOD FAITH
ESTIMATE FOR INSURED PERSONS.
If a person has an
individual, group, or other private or commercial health insurance plan or
policy, including coverage through a preferred provider organization or
health maintenance organization, a health care provider shall provide the
person a good faith estimate of:
(1) the amount the
insurance plan or policy will actually pay the health care provider for the
fees, procedures, and services described by
Subchapter B or C based on the relevant billing codes, the terms of the
person's insurance plan or policy, and the
negotiated rate between
the health care provider and the insurance plan or policy, if applicable; and
(2) the amount of any
copayment, coinsurance, or other amount the person is expected to pay the health care provider for the fees, procedures, and services described by
Subchapter B or C based on the relevant billing codes, the terms of the
person's insurance plan or policy,
and the negotiated rate
between the health care provider and the person's insurance plan or policy,
if applicable.
Sec. 326.153. GOOD FAITH
ESTIMATE FOR RECIPIENTS OF GOVERNMENT-SPONSORED PROGRAM. If a person receives
benefits under a government-sponsored health benefits program, including
the Medicaid program, the Medicare program, the Children's Health Insurance
Program (CHIP), and the TRICARE military health system, a health care
provider shall provide the person a good faith estimate of:
(1) the amount the
government-sponsored health benefits program will actually pay the health
care provider for the fees, procedures, and
services described by Subchapter B or C based on the relevant billing codes;
and
(2) any amount the person
is expected to pay the health care provider for
fees, procedures, and services described by Subchapter B or C based on the
relevant billing codes
under the terms of the
government-sponsored health benefits program.
Sec. 326.154. GOOD FAITH
ESTIMATE FOR RECIPIENTS OF WORKERS' COMPENSATION BENEFITS. If a person
receives benefits under a workers' compensation claim, a health care
provider shall provide the person a good faith estimate of:
(1) the amount the workers'
compensation insurance carrier, workers'
compensation claims processor, employer, or other payor will
actually pay the health care provider for the fees,
procedures, and services described by Subchapter B or C based on the
relevant billing codes; and
(2) the amount the person is expected to pay the health care provider
for the fees, procedures, and services described by Subchapter B or C based
on the relevant billing codes, if any.
Sec. 326.155. STATEMENT
FOR PERSONS PAYING CASH, PERSONS RECEIVING CHARITY CARE, AND INDIGENT
PERSONS. If a person will pay cash or will receive charity care for an admission, procedure, or service or if a
person is indigent, a health care provider shall provide the person with a
statement of:
(1) the average amount the
health care provider was actually paid for the
fees, procedures, and services described by Subchapter B or C based on the
relevant billing codes
by the five insurance
carriers or government-sponsored programs described by Sections 326.152,
326.153, and 326.154 that paid the health care provider for
the greatest number of the
applicable fees, procedures, and services
in the preceding calendar year, or in the current calendar year if the
health care provider did not practice in the preceding calendar year; and
(2) the average amount the health care provider was actually paid by
patients described by this section for the applicable fees, procedures, and
services in that year.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
SUBCHAPTER E.
ADMINISTRATIVE PENALTY
Sec. 326.201. ADMINISTRATIVE
PENALTY AUTHORIZED.
(a) The commissioner of insurance may impose an
administrative penalty on a facility or
physician that violates this chapter.
(b) The amount of the
penalty may not exceed $1,000 for each violation.
(c) Chapter 84, Insurance Code, governs the imposition, enforcement,
and collection of the administrative penalty.
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No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
No
equivalent provision.
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SUBCHAPTER A. GENERAL
PROVISIONS
Sec. 326.001. DEFINITIONS.
In this chapter:
(1) "Facility"
means:
(A) an ambulatory surgical
center licensed under Chapter 243;
(B) a birthing center
licensed under Chapter 244;
(C) a hospital licensed
under Chapter 241; or
(D) an imaging center that
is not part of another facility.
(2) "Facility-based
physician" means a radiologist, an anesthesiologist, a pathologist, or
a neonatologist.
(3) "Health care
provider" means a facility, a facility-based physician, or another
physician required to provide a good faith estimate under this chapter.
(4) "Medical
implant" means an item, other than a suture, implanted in a patient's
body.
SUBCHAPTER B. GOOD FAITH
ESTIMATE BY FACILITY AND FACILITY-BASED PHYSICIAN
Sec. 326.051. ESTIMATE BY
FACILITY. (a) A facility shall provide to a person a good faith estimate as
provided by this chapter if the person:
(1) is expected to be admitted
to the facility on a nonemergency basis or receive a nonemergency procedure
or service at the facility; or
(2) may be admitted to the
facility on a nonemergency basis or receive a nonemergency procedure or
service at the facility and the person requests a good faith estimate from
the facility.
(b) A facility must
provide a good faith estimate before scheduling an admission, procedure, or
service described by Subsection (a).
(c) A facility shall
provide to a person described by Subsection (a) a good faith estimate of
the actual charges, as provided by Subchapter D, for facility fees and all
procedures and services, including diagnostic imaging, expected to be
performed by the facility and by facility-based physicians with whom the
facility has an agreement under Section 326.052(b) based on the person's
medical orders. The estimate must be based on Diagnosis-Related Groups
codes. The facility shall include with the estimate a statement that the
actual services performed at the facility may differ from those provided in
the estimate based on the person's medical needs.
(d) A facility is not
required to include in a good faith estimate provided by the facility
procedures or services performed by a physician who is not a facility-based
physician.
Sec. 326.052. ESTIMATE BY
FACILITY-BASED PHYSICIAN. (a) A facility-based physician shall provide a
good faith estimate to a person described by Section 326.051(a).
(b) A facility-based
physician by contract may agree to allow a facility to provide a good faith
estimate of procedures and services performed by the physician at the
facility. The facility-based physician is responsible for the estimate
provided by the facility according to the terms of the contract.
(c) A facility-based
physician who does not enter into a contract as provided by Subsection (b)
must provide a good faith estimate to a person before performing a
procedure or service at a facility in the same manner as a facility under
Section 326.051.
Sec. 326.053. ESTIMATE OF
ANESTHESIOLOGY SERVICES. (a) A good faith estimate for anesthesiology
services must be in the form of a charge per unit of time and the expected
number of units of time required to complete the procedure or service
originally ordered.
(b) A facility or
anesthesiologist that provides a good faith estimate of anesthesiology
charges shall include with the estimate a statement that the actual number
of units of time required to complete the procedure or service may differ
from the number provided in the estimate based on the person's medical
needs.
Sec. 326.054. ESTIMATE OF
PATHOLOGY SERVICES. (a) A good faith estimate for pathology services must
be in the form of a charge per specimen and the expected number of
specimens required for the procedure or service originally ordered.
(b) A facility or
pathologist that provides a good faith estimate of pathology charges shall
include with the estimate a statement that the actual number of specimens
required may differ from the number provided in the estimate based on the
person's medical needs.
Sec. 326.055. ESTIMATE FOR
MEDICAL IMPLANTS. A facility-based physician who provides to a person a
good faith estimate for a medical implant or a facility that provides to a
person a good faith estimate that includes a medical implant to be
implanted by a facility-based physician shall provide to the person a list
of all available medical implants that meet the person's medical needs,
including a good faith estimate of the actual charges for each medical
implant as provided by Subchapter D.
SUBCHAPTER C. GOOD FAITH
ESTIMATE BY PHYSICIAN WHO WILL PERFORM PROCEDURE OR SERVICE AT FACILITY
Sec. 326.101. ESTIMATE BY
PHYSICIAN. (a) A physician who is not a facility-based physician and who
will perform for a person a nonemergency procedure or service at a facility
shall provide to the person a good faith estimate for the procedure or
service as provided by this chapter.
(b) A physician must
provide a good faith estimate before scheduling a procedure or service
described by Subsection (a).
(c) A physician shall provide
to a person described by Subsection (a) a good faith estimate of the
physician's actual charges, as provided by Subchapter D, for the procedure
or service. The estimate must be based on Diagnosis-Related Groups codes,
Current Procedural Terminology codes, or other applicable medical billing
codes. The physician shall include with the estimate a statement that the
actual services performed by the physician may differ from those provided
in the estimate based on the person's medical needs.
(d) A physician is not
required to include in a good faith estimate provided by the physician
facility fees, procedures, or services performed by a facility or by
facility-based physicians.
Sec. 326.102. GOOD FAITH
ESTIMATE FOR MEDICAL IMPLANTS. A physician who is not a facility-based
physician and who provides to a person a good faith estimate for a medical
implant shall provide to the person a list of all available medical
implants that meet the person's medical needs, including a good faith
estimate of the actual charges for each medical implant as provided by
Subchapter D.
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