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A BILL TO BE ENTITLED
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AN ACT
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relating to the requirement that certain medical facilities and |
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physicians give patients a good faith estimate of the expected |
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payment for facility-based health care services before the services |
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are provided; providing an administrative penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle G, Title 4, Health and Safety Code, is |
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amended by adding Chapter 326 to read as follows: |
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CHAPTER 326. GOOD FAITH ESTIMATE OF ACTUAL CHARGES FOR |
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FACILITY-BASED SERVICES |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 326.001. DEFINITIONS. In this chapter: |
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(1) "Facility" means: |
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(A) an ambulatory surgical center licensed under |
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Chapter 243; |
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(B) a birthing center licensed under Chapter 244; |
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(C) a hospital licensed under Chapter 241; or |
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(D) an imaging center that is not part of another |
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facility. |
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(2) "Facility-based physician" means a radiologist, |
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an anesthesiologist, a pathologist, or a neonatologist. |
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(3) "Health care provider" means a facility, a |
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facility-based physician, or another physician required to provide |
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a good faith estimate under this chapter. |
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(4) "Medical implant" means an item, other than a |
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suture, implanted in a patient's body. |
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SUBCHAPTER B. GOOD FAITH ESTIMATE BY FACILITY AND FACILITY-BASED |
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PHYSICIAN |
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Sec. 326.051. ESTIMATE BY FACILITY. (a) A facility shall |
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provide to a person a good faith estimate as provided by this |
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chapter if the person: |
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(1) is expected to be admitted to the facility on a |
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nonemergency basis or receive a nonemergency procedure or service |
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at the facility; or |
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(2) may be admitted to the facility on a nonemergency |
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basis or receive a nonemergency procedure or service at the |
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facility and the person requests a good faith estimate from the |
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facility. |
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(b) A facility must provide a good faith estimate before |
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scheduling an admission, procedure, or service described by |
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Subsection (a). |
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(c) A facility shall provide to a person described by |
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Subsection (a) a good faith estimate of the actual charges, as |
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provided by Subchapter D, for facility fees and all procedures and |
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services, including diagnostic imaging, expected to be performed by |
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the facility and by facility-based physicians with whom the |
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facility has an agreement under Section 326.052(b) based on the |
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person's medical orders. The estimate must be based on |
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Diagnosis-Related Groups codes. The facility shall include with the |
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estimate a statement that the actual services performed at the |
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facility may differ from those provided in the estimate based on the |
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person's medical needs. |
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(d) A facility is not required to include in a good faith |
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estimate provided by the facility procedures or services performed |
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by a physician who is not a facility-based physician. |
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Sec. 326.052. ESTIMATE BY FACILITY-BASED PHYSICIAN. (a) A |
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facility-based physician shall provide a good faith estimate to a |
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person described by Section 326.051(a). |
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(b) A facility-based physician by contract may agree to |
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allow a facility to provide a good faith estimate of procedures and |
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services performed by the physician at the facility. The |
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facility-based physician is responsible for the estimate provided |
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by the facility according to the terms of the contract. |
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(c) A facility-based physician who does not enter into a |
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contract as provided by Subsection (b) must provide a good faith |
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estimate to a person before performing a procedure or service at a |
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facility in the same manner as a facility under Section 326.051. |
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Sec. 326.053. ESTIMATE OF ANESTHESIOLOGY SERVICES. (a) A |
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good faith estimate for anesthesiology services must be in the form |
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of a charge per unit of time and the expected number of units of time |
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required to complete the procedure or service originally ordered. |
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(b) A facility or anesthesiologist that provides a good |
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faith estimate of anesthesiology charges shall include with the |
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estimate a statement that the actual number of units of time |
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required to complete the procedure or service may differ from the |
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number provided in the estimate based on the person's medical |
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needs. |
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Sec. 326.054. ESTIMATE OF PATHOLOGY SERVICES. (a) A good |
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faith estimate for pathology services must be in the form of a |
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charge per specimen and the expected number of specimens required |
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for the procedure or service originally ordered. |
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(b) A facility or pathologist that provides a good faith |
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estimate of pathology charges shall include with the estimate a |
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statement that the actual number of specimens required may differ |
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from the number provided in the estimate based on the person's |
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medical needs. |
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Sec. 326.055. ESTIMATE FOR MEDICAL IMPLANTS. A |
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facility-based physician who provides to a person a good faith |
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estimate for a medical implant or a facility that provides to a |
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person a good faith estimate that includes a medical implant to be |
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implanted by a facility-based physician shall provide to the person |
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a list of all available medical implants that meet the person's |
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medical needs, including a good faith estimate of the actual |
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charges for each medical implant as provided by Subchapter D. |
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SUBCHAPTER C. GOOD FAITH ESTIMATE BY PHYSICIAN WHO WILL PERFORM |
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PROCEDURE OR SERVICE AT FACILITY |
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Sec. 326.101. ESTIMATE BY PHYSICIAN. (a) A physician who is |
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not a facility-based physician and who will perform for a person a |
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nonemergency procedure or service at a facility shall provide to |
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the person a good faith estimate for the procedure or service as |
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provided by this chapter. |
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(b) A physician must provide a good faith estimate before |
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scheduling a procedure or service described by Subsection (a). |
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(c) A physician shall provide to a person described by |
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Subsection (a) a good faith estimate of the physician's actual |
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charges, as provided by Subchapter D, for the procedure or service. |
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The estimate must be based on Diagnosis-Related Groups codes, |
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Current Procedural Terminology codes, or other applicable medical |
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billing codes. The physician shall include with the estimate a |
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statement that the actual services performed by the physician may |
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differ from those provided in the estimate based on the person's |
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medical needs. |
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(d) A physician is not required to include in a good faith |
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estimate provided by the physician facility fees, procedures, or |
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services performed by a facility or by facility-based physicians. |
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Sec. 326.102. GOOD FAITH ESTIMATE FOR MEDICAL IMPLANTS. A |
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physician who is not a facility-based physician and who provides to |
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a person a good faith estimate for a medical implant shall provide |
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to the person a list of all available medical implants that meet the |
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person's medical needs, including a good faith estimate of the |
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actual charges for each medical implant as provided by Subchapter |
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D. |
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SUBCHAPTER D. GOOD FAITH ESTIMATE OF ACTUAL CHARGES |
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Sec. 326.151. DISCLOSURE OF EXPECTED PAYMENT METHOD. A |
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health care provider shall ask a person to disclose the person's |
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anticipated method of payment for purposes of complying with this |
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subchapter. |
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Sec. 326.152. GOOD FAITH ESTIMATE FOR INSURED PERSONS. If a |
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person has an individual, group, or other private or commercial |
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health insurance plan or policy, including coverage through a |
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preferred provider organization or health maintenance |
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organization, a health care provider shall provide the person a |
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good faith estimate of: |
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(1) the amount the insurance plan or policy will |
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actually pay the health care provider for the fees, procedures, and |
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services described by Subchapter B or C based on the relevant |
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billing codes, the terms of the person's insurance plan or policy, |
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and the negotiated rate between the health care provider and the |
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insurance plan or policy, if applicable; and |
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(2) the amount of any copayment, coinsurance, or other |
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amount the person is expected to pay the health care provider for |
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the fees, procedures, and services described by Subchapter B or C |
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based on the relevant billing codes, the terms of the person's |
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insurance plan or policy, and the negotiated rate between the |
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health care provider and the person's insurance plan or policy, if |
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applicable. |
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Sec. 326.153. GOOD FAITH ESTIMATE FOR RECIPIENTS OF |
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GOVERNMENT-SPONSORED PROGRAM. If a person receives benefits under |
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a government-sponsored health benefits program, including the |
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Medicaid program, the Medicare program, the Children's Health |
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Insurance Program (CHIP), and the TRICARE military health system, a |
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health care provider shall provide the person a good faith estimate |
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of: |
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(1) the amount the government-sponsored health |
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benefits program will actually pay the health care provider for the |
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fees, procedures, and services described by Subchapter B or C based |
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on the relevant billing codes; and |
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(2) any amount the person is expected to pay the health |
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care provider for fees, procedures, and services described by |
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Subchapter B or C based on the relevant billing codes under the |
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terms of the government-sponsored health benefits program. |
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Sec. 326.154. GOOD FAITH ESTIMATE FOR RECIPIENTS OF |
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WORKERS' COMPENSATION BENEFITS. If a person receives benefits under |
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a workers' compensation claim, a health care provider shall provide |
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the person a good faith estimate of: |
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(1) the amount the workers' compensation insurance |
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carrier, workers' compensation claims processor, employer, or |
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other payor will actually pay the health care provider for the fees, |
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procedures, and services described by Subchapter B or C based on the |
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relevant billing codes; and |
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(2) the amount the person is expected to pay the health |
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care provider for the fees, procedures, and services described by |
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Subchapter B or C based on the relevant billing codes, if any. |
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Sec. 326.155. STATEMENT FOR PERSONS PAYING CASH, PERSONS |
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RECEIVING CHARITY CARE, AND INDIGENT PERSONS. If a person will pay |
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cash or will receive charity care for an admission, procedure, or |
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service or if a person is indigent, a health care provider shall |
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provide the person with a statement of: |
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(1) the average amount the health care provider was |
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actually paid for the fees, procedures, and services described by |
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Subchapter B or C based on the relevant billing codes by the five |
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insurance carriers or government-sponsored programs described by |
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Sections 326.152, 326.153, and 326.154 that paid the health care |
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provider for the greatest number of the applicable fees, |
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procedures, and services in the preceding calendar year, or in the |
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current calendar year if the health care provider did not practice |
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in the preceding calendar year; and |
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(2) the average amount the health care provider was |
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actually paid by patients described by this section for the |
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applicable fees, procedures, and services in that year. |
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SUBCHAPTER E. ADMINISTRATIVE PENALTY |
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Sec. 326.201. ADMINISTRATIVE PENALTY AUTHORIZED. (a) The |
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commissioner of insurance may impose an administrative penalty on a |
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facility or physician that violates this chapter. |
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(b) The amount of the penalty may not exceed $1,000 for each |
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violation. |
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(c) Chapter 84, Insurance Code, governs the imposition, |
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enforcement, and collection of the administrative penalty. |
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SECTION 2. The changes in law made by this Act apply only to |
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an admission, procedure, or service ordered or provided on or after |
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the effective date of this Act. An admission, procedure, or service |
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ordered or provided before the effective date of this Act is |
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governed by the law in effect on the date the admission, procedure, |
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or service was ordered or provided, and the former law is continued |
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in effect for that purpose. |
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SECTION 3. This Act takes effect January 1, 2014. |