BILL ANALYSIS

C.S.H.B. 2241

By: Oliverson

Insurance

Committee Report (Substituted)

BACKGROUND AND PURPOSE

Currently, state law defines "emergency care" as health care services provided to evaluate and stabilize a medical condition that would lead a prudent layperson possessing an average knowledge of medicine to believe that a failure to get immediate medical care could result in a serious threat to their health. This is known as the prudent layperson standard. Stakeholders contend that it is fundamental that the prudent layperson standard assesses a patient’s health based on the patient’s presenting symptoms, rather than their diagnosis. They also contend that this position has been supported by state administrative guidance and federal case law. Stakeholders suggest that despite this guidance, some health insurance plans have interpreted the definition of emergency care to include the patient’s final diagnosis, rather than simply the presenting symptoms. Consequently, there are calls to clarify these specific definitions, as indicated in certain state administrative guidance and federal case law. C.S.H.B. 2241 seeks to provide this clarification.

CRIMINAL JUSTICE IMPACT

It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

ANALYSIS

C.S.H.B. 2241 amends the Insurance Code to clarify that the health care services provided in certain settings to evaluate and stabilize recently onset and severe medical conditions are defined as "emergency care" if they meet the prudent layperson standard based on presenting symptoms regardless of the final diagnosis of the conditions. The bill makes this clarification for purposes of health benefit plans issued by health maintenance organizations, preferred provider benefit plans, and provisions governing utilization review agents.

C.S.H.B. 2241 clarifies, with respect to utilization review agents, that utilization review includes a determination that health care services do not meet the definition of emergency care.

C.S.H.B. 2241 applies only to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2022.

EFFECTIVE DATE

September 1, 2021.

COMPARISON OF ORIGINAL AND SUBSTITUTE

While C.S.H.B. 2241 may differ from the original in minor or nonsubstantive ways, the following summarizes the substantial differences between the introduced and committee substitute versions of the bill.

The substitute includes a clarification of the definition of "utilization review," which the original did not include.