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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 health care providers give |
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patients a good faith estimate of the expected payment for health |
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care services and goods before the services or goods are provided; |
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providing penalties. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 3, Occupations Code, is |
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amended by adding Chapter 117 to read as follows: |
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CHAPTER 117. GOOD FAITH ESTIMATE OF HEALTH CARE PAYMENTS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 117.001. DEFINITIONS. In this chapter: |
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(1) "Department" means the Department of State Health |
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Services. |
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(2) "Executive commissioner" means the executive |
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commissioner of the Health and Human Services Commission. |
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(3) "Health care provider" means: |
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(A) a health care professional who performs a |
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health care service or provides a health care good in this state |
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under a license, certificate, registration, or other authority |
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issued by this state to diagnose, prevent, alleviate, or cure a |
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human illness or injury, including a physician, dentist, pharmacy, |
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or pharmacist; |
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(B) a health care facility that provides a health |
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care service or good in this state under a license, certificate, |
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registration, or other authority issued by this state to diagnose, |
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prevent, alleviate, or cure a human illness or injury, including an |
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institutional health care provider or other hospital; or |
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(C) a person that provides to patients in this |
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state ancillary health care-related services and goods under a |
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license, certificate, or registration issued by this state, or that |
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is otherwise authorized to provide to patients in this state |
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ancillary health care-related services and goods ordered or |
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authorized by a licensed health care professional, to diagnose, |
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prevent, alleviate, or cure a human illness or injury, including |
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laboratory services, radiological services, and durable medical |
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equipment. |
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SUBCHAPTER B. ADMINISTRATION OF CHAPTER |
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Sec. 117.051. ADMINISTRATION BY LICENSING ENTITIES. (a) |
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The governing body of the entity that issues a license, |
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certificate, registration, or other authorization to practice to a |
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health care provider shall administer and enforce this chapter as |
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it applies to the provider. |
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(b) A governing body described by Subsection (a) may adopt |
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rules governing the application of this chapter to health care |
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providers regulated by the entity. |
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Sec. 117.052. ADMINISTRATION BY DEPARTMENT. (a) The |
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department shall administer and enforce this chapter as it applies |
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to any health care provider not issued a license, certificate, |
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registration, or other authorization to practice described by |
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Section 117.051. |
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(b) The executive commissioner shall adopt rules governing |
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the application of this chapter to a health care provider described |
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by Subsection (a). |
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SUBCHAPTER C. GOOD FAITH ESTIMATE |
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Sec. 117.101. GOOD FAITH ESTIMATE REQUIRED. (a) Except as |
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provided by Subsection (b), before a health care provider provides |
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to a person a health care service or a health care good, including a |
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drug or medical device, the health care provider must provide the |
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person a good faith estimate of the actual expected payments for the |
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service or good, as provided by this subchapter. The health care |
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provider shall ask the person to disclose the person's anticipated |
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method of payment for purposes of complying with this subchapter. |
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(b) A health care provider shall: |
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(1) in an emergency or urgent medical situation, |
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provide to a person any health care service or health care good |
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necessary to stabilize the person's medical condition if delay |
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required to provide a good faith estimate of the actual payment for |
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the service or good under Subsection (a) could result in an adverse |
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medical consequence to the person; or |
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(2) provide to a person a health care service or health |
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care good ordered by the person's physician or other person |
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primarily responsible for the person's care if the person is unable |
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to make medical decisions and does not have a legal representative |
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to make medical decisions on the person's behalf. |
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Sec. 117.102. 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 health care service or |
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health care good based on the negotiated rate between the health |
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care provider and the insurance plan or policy; and |
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(2) the amount of any copayment, coinsurance, or other |
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amount the person will actually pay the health care provider for the |
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health care service or health care good based on the terms of the |
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person's insurance plan or policy and the negotiated rate between |
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the health care provider and the person's insurance plan or policy. |
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Sec. 117.103. 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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health care service or health care good; and |
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(2) any amount the person will actually pay the health |
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care provider for the health care service or health care good under |
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the terms of the government-sponsored health benefits program. |
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Sec. 117.104. 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 the amount the workers' |
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compensation insurance carrier will actually pay the health care |
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provider for the health care service or health care good. |
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Sec. 117.105. 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 a health care service or |
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health care good or if a person is indigent, a health care provider |
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shall provide the person with a statement of the average amount the |
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health care provider was actually paid for the health care service |
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or health care good by the five insurance carriers or |
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government-sponsored programs described by Sections 117.102, |
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117.103, and 117.104 that paid the health care provider for the |
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greatest number of that health care service or health care good in |
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the preceding calendar year, or in the current calendar year if the |
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health care provider did not practice in the preceding calendar |
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year. |
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SUBCHAPTER D. AGREEMENT TO PROVIDE GOOD FAITH ESTIMATE ON BEHALF OF |
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ANOTHER HEALTH CARE PROVIDER |
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Sec. 117.151. CONTRACT TO ALLOW ANOTHER HEALTH CARE |
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PROVIDER TO PROVIDE GOOD FAITH ESTIMATE. (a) A health care provider |
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may by contract agree to allow another health care provider to |
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provide a good faith estimate under Subchapter C for that health |
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care provider's health care services and health care goods. |
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(b) A health care provider who enters into a contract |
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described by Subsection (a) is responsible for the content of the |
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good faith estimate provided by the other health care provider on |
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that provider's behalf. |
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Sec. 117.152. RULES GOVERNING CONTRACTING. (a) The |
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executive commissioner may adopt rules governing contracts under |
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Section 117.151. |
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(b) The department shall administer rules described by |
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Subsection (a). |
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SUBCHAPTER E. PENALTIES AND ENFORCEMENT |
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Sec. 117.201. VIOLATION BY LICENSED HEALTH CARE PROVIDERS. A |
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health care provider that violates this chapter is subject to an |
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administrative penalty, a civil penalty, or other disciplinary |
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action, as applicable, in the same manner as if the health care |
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provider violated the law under which the health care provider is |
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licensed, certified, registered, or authorized to practice. |
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Sec. 117.202. VIOLATION BY OTHER HEALTH CARE PROVIDERS. |
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(a) The executive commissioner or department may impose an |
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administrative penalty against a health care provider that is not |
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required to hold a license, certificate, registration, or other |
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authorization to practice and that violates this chapter. |
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(b) An administrative penalty imposed under this section |
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shall be imposed in the same manner as other administrative |
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penalties imposed by the executive commissioner. |
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(c) The amount of the penalty may not exceed $1,000 for each |
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violation. |
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(d) The executive commissioner may adopt rules to implement |
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this section. |
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SECTION 2. The changes in law made by this Act apply only to |
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a health care service or health care good ordered or provided on or |
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after the effective date of this Act. A health care service or |
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health care good ordered or provided before the effective date of |
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this Act is governed by the law in effect on the date the service or |
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good was ordered or provided, and the former law is continued in |
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effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2013. |