By: Bonnen of Galveston H.B. No. 3527

A BILL TO BE ENTITLED

AN ACT

relating to the requirement that certain medical facilities and physicians give patients a good faith estimate of the expected payment for facility-based health care services before the services are provided; providing an administrative penalty.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

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

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.

SUBCHAPTER D. GOOD FAITH ESTIMATE OF ACTUAL CHARGES

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.

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.

SECTION 2. The changes in law made by this Act apply only to an admission, procedure, or service ordered or provided on or after the effective date of this Act. An admission, procedure, or service ordered or provided before the effective date of this Act is governed by the law in effect on the date the admission, procedure, or service was ordered or provided, and the former law is continued in effect for that purpose.

SECTION 3. This Act takes effect January 1, 2016.