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A BILL TO BE ENTITLED
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AN ACT
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relating to consumer protections against certain medical and health |
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care billing by out-of-network ground ambulance service providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 38.004(a), Insurance Code, is amended to |
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read as follows: |
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(a) The department shall, each biennium, conduct a study on |
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the impacts of S.B. No. 1264, Acts of the 86th Legislature, Regular |
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Session, 2019, and subsequently enacted laws prohibiting an |
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individual or entity from billing an insured, participant, or |
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enrollee in an amount greater than an applicable copayment, |
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coinsurance, or deductible under the insured's, participant's, or |
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enrollee's managed care plan or imposing a requirement related to |
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that prohibition, on Texas consumers and health coverage in this |
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state, including: |
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(1) trends in billed amounts for health care or |
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medical services or supplies, especially emergency services, |
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laboratory services, diagnostic imaging services, ground ambulance |
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services, and facility-based services; |
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(2) comparison of the total amount spent on |
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out-of-network emergency services, laboratory services, diagnostic |
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imaging services, ground ambulance services, and facility-based |
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services by calendar year and provider type or physician specialty; |
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(3) trends and changes in network participation by |
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providers of emergency services, laboratory services, diagnostic |
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imaging services, ground ambulance services, and facility-based |
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services by provider type or physician specialty, including whether |
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any terminations were initiated by a health benefit plan issuer, |
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administrator, or provider; |
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(4) trends and changes in the amounts paid to |
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participating providers; |
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(5) the number of complaints, completed |
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investigations, and disciplinary sanctions for billing by |
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providers of emergency services, laboratory services, diagnostic |
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imaging services, ground ambulance services, or facility-based |
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services of enrollees for amounts greater than the enrollee's |
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responsibility under an applicable health benefit plan, including |
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applicable copayments, coinsurance, and deductibles; |
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(6) trends in amounts paid to out-of-network |
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providers; |
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(7) trends in the usual and customary rate for health |
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care or medical services or supplies, especially emergency |
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services, laboratory services, diagnostic imaging services, ground |
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ambulance services, and facility-based services; and |
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(8) the effectiveness of the claim dispute resolution |
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process under Chapter 1467. |
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SECTION 2. The heading to Section 1271.158, Insurance Code, |
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is amended to read as follows: |
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Sec. 1271.158. CERTAIN NON-NETWORK ANCILLARY [DIAGNOSTIC |
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IMAGING PROVIDER OR LABORATORY] SERVICE PROVIDERS [PROVIDER]. |
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SECTION 3. Sections 1271.158(a), (b), and (c), Insurance |
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Code, are amended to read as follows: |
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(a) In this section, "diagnostic imaging provider," |
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[provider" and] "laboratory service provider," and "ground |
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ambulance service provider" have the meanings assigned by Section |
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1467.001. |
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(b) Except as provided by Subsection (d), a health |
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maintenance organization shall pay for a covered health care |
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service performed by or a covered supply related to that service |
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provided to an enrollee by a non-network diagnostic imaging |
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provider, [or] laboratory service provider, or ground ambulance |
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service provider at the usual and customary rate or at an agreed |
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rate if the provider performed the service in connection with a |
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health care service performed by a network physician or provider. |
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The health maintenance organization shall make a payment required |
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by this subsection directly to the physician or provider not later |
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than, as applicable: |
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(1) the 30th day after the date the health maintenance |
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organization receives an electronic clean claim as defined by |
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Section 843.336 for those services that includes all information |
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necessary for the health maintenance organization to pay the claim; |
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or |
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(2) the 45th day after the date the health maintenance |
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organization receives a nonelectronic clean claim as defined by |
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Section 843.336 for those services that includes all information |
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necessary for the health maintenance organization to pay the claim. |
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(c) Except as provided by Subsection (d), a non-network |
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diagnostic imaging provider, [or] laboratory service provider, or |
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ground ambulance service provider or a person asserting a claim as |
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an agent or assignee of the provider may not bill an enrollee |
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receiving a health care service or supply described by Subsection |
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(b) in, and the enrollee does not have financial responsibility |
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for, an amount greater than an applicable copayment, coinsurance, |
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and deductible under the enrollee's health care plan that: |
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(1) is based on: |
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(A) the amount initially determined payable by |
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the health maintenance organization; or |
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(B) if applicable, a modified amount as |
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determined under the health maintenance organization's internal |
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appeal process; and |
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(2) is not based on any additional amount determined |
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to be owed to the provider under Chapter 1467. |
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SECTION 4. The heading to Section 1301.165, Insurance Code, |
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is amended to read as follows: |
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Sec. 1301.165. CERTAIN OUT-OF-NETWORK ANCILLARY |
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[DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE PROVIDERS |
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[PROVIDER]. |
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SECTION 5. Sections 1301.165(a), (b), and (c), Insurance |
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Code, are amended to read as follows: |
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(a) In this section, "diagnostic imaging provider," |
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[provider" and] "laboratory service provider," and "ground |
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ambulance service provider" have the meanings assigned by Section |
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1467.001. |
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(b) Except as provided by Subsection (d), an insurer shall |
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pay for a covered medical care or health care service performed by |
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or a covered supply related to that service provided to an insured |
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by an out-of-network provider who is a diagnostic imaging provider, |
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[or] laboratory service provider, or ground ambulance service |
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provider at the usual and customary rate or at an agreed rate if the |
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provider performed the service in connection with a medical care or |
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health care service performed by a preferred provider. The insurer |
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shall make a payment required by this subsection directly to the |
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provider not later than, as applicable: |
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(1) the 30th day after the date the insurer receives an |
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electronic clean claim as defined by Section 1301.101 for those |
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services that includes all information necessary for the insurer to |
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pay the claim; or |
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(2) the 45th day after the date the insurer receives a |
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nonelectronic clean claim as defined by Section 1301.101 for those |
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services that includes all information necessary for the insurer to |
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pay the claim. |
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(c) Except as provided by Subsection (d), an out-of-network |
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provider who is a diagnostic imaging provider, [or] laboratory |
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service provider, or ground ambulance service provider or a person |
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asserting a claim as an agent or assignee of the provider may not |
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bill an insured receiving a medical care or health care service or |
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supply described by Subsection (b) in, and the insured does not have |
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financial responsibility for, an amount greater than an applicable |
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copayment, coinsurance, and deductible under the insured's |
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preferred provider benefit plan that: |
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(1) is based on: |
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(A) the amount initially determined payable by |
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the insurer; or |
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(B) if applicable, the modified amount as |
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determined under the insurer's internal appeal process; and |
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(2) is not based on any additional amount determined |
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to be owed to the provider under Chapter 1467. |
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SECTION 6. The heading to Section 1551.230, Insurance Code, |
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is amended to read as follows: |
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Sec. 1551.230. PAYMENTS TO CERTAIN OUT-OF-NETWORK |
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ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE |
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PROVIDERS [PROVIDER PAYMENTS]. |
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SECTION 7. Sections 1551.230(a), (b), and (c), Insurance |
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Code, are amended to read as follows: |
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(a) In this section, "diagnostic imaging provider," |
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[provider" and] "laboratory service provider," and "ground |
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ambulance service provider" have the meanings assigned by Section |
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1467.001. |
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(b) Except as provided by Subsection (d), the administrator |
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of a managed care plan provided under the group benefits program |
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shall pay for a covered health care or medical service performed for |
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or a covered supply related to that service provided to a |
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participant by an out-of-network provider who is a diagnostic |
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imaging provider, [or] laboratory service provider, or ground |
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ambulance service provider at the usual and customary rate or at an |
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agreed rate if the provider performed the service in connection |
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with a health care or medical service performed by a participating |
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provider. The administrator shall make a payment required by this |
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subsection directly to the provider not later than, as applicable: |
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(1) the 30th day after the date the administrator |
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receives an electronic claim for those services that includes all |
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information necessary for the administrator to pay the claim; or |
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(2) the 45th day after the date the administrator |
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receives a nonelectronic claim for those services that includes all |
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information necessary for the administrator to pay the claim. |
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(c) Except as provided by Subsection (d), an out-of-network |
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provider who is a diagnostic imaging provider, [or] laboratory |
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service provider, or ground ambulance service provider or a person |
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asserting a claim as an agent or assignee of the provider may not |
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bill a participant receiving a health care or medical service or |
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supply described by Subsection (b) in, and the participant does not |
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have financial responsibility for, an amount greater than an |
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applicable copayment, coinsurance, and deductible under the |
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participant's managed care plan that: |
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(1) is based on: |
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(A) the amount initially determined payable by |
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the administrator; or |
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(B) if applicable, the modified amount as |
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determined under the administrator's internal appeal process; and |
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(2) is not based on any additional amount determined |
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to be owed to the provider under Chapter 1467. |
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SECTION 8. The heading to Section 1575.173, Insurance Code, |
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is amended to read as follows: |
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Sec. 1575.173. PAYMENTS TO CERTAIN OUT-OF-NETWORK |
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ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE |
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PROVIDERS [PROVIDER PAYMENTS]. |
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SECTION 9. Sections 1575.173(a), (b), and (c), Insurance |
|
|
Code, are amended to read as follows: |
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(a) In this section, "diagnostic imaging provider," |
|
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[provider" and] "laboratory service provider," and "ground |
|
|
ambulance service provider" have the meanings assigned by Section |
|
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1467.001. |
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(b) Except as provided by Subsection (d), the administrator |
|
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of a managed care plan provided under the group program shall pay |
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for a covered health care or medical service performed for or a |
|
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covered supply related to that service provided to an enrollee by an |
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out-of-network provider who is a diagnostic imaging provider, [or] |
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laboratory service provider, or ground ambulance service provider |
|
|
at the usual and customary rate or at an agreed rate if the provider |
|
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performed the service in connection with a health care or medical |
|
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service performed by a participating provider. The administrator |
|
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shall make a payment required by this subsection directly to the |
|
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provider not later than, as applicable: |
|
|
(1) the 30th day after the date the administrator |
|
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receives an electronic claim for those services that includes all |
|
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information necessary for the administrator to pay the claim; or |
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(2) the 45th day after the date the administrator |
|
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receives a nonelectronic claim for those services that includes all |
|
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information necessary for the administrator to pay the claim. |
|
|
(c) Except as provided by Subsection (d), an out-of-network |
|
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provider who is a diagnostic imaging provider, [or] laboratory |
|
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service provider, or ground ambulance service provider or a person |
|
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asserting a claim as an agent or assignee of the provider may not |
|
|
bill an enrollee receiving a health care or medical service or |
|
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supply described by Subsection (b) in, and the enrollee does not |
|
|
have financial responsibility for, an amount greater than an |
|
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applicable copayment, coinsurance, and deductible under the |
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enrollee's managed care plan that: |
|
|
(1) is based on: |
|
|
(A) the amount initially determined payable by |
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the administrator; or |
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(B) if applicable, the modified amount as |
|
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determined under the administrator's internal appeal process; and |
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(2) is not based on any additional amount determined |
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to be owed to the provider under Chapter 1467. |
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SECTION 10. The heading to Section 1579.111, Insurance |
|
|
Code, is amended to read as follows: |
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Sec. 1579.111. PAYMENTS TO CERTAIN OUT-OF-NETWORK |
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ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE |
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PROVIDERS [PROVIDER PAYMENTS]. |
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SECTION 11. Sections 1579.111(a), (b), and (c), Insurance |
|
|
Code, are amended to read as follows: |
|
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(a) In this section, "diagnostic imaging provider," |
|
|
[provider" and] "laboratory service provider," and "ground |
|
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ambulance service provider" have the meanings assigned by Section |
|
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1467.001. |
|
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(b) Except as provided by Subsection (d), the administrator |
|
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of a managed care plan provided under this chapter shall pay for a |
|
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covered health care or medical service performed for or a covered |
|
|
supply related to that service provided to an enrollee by an |
|
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out-of-network provider who is a diagnostic imaging provider, [or] |
|
|
laboratory service provider, or ground ambulance service provider |
|
|
at the usual and customary rate or at an agreed rate if the provider |
|
|
performed the service in connection with a health care or medical |
|
|
service performed by a participating provider. The administrator |
|
|
shall make a payment required by this subsection directly to the |
|
|
provider not later than, as applicable: |
|
|
(1) the 30th day after the date the administrator |
|
|
receives an electronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim; or |
|
|
(2) the 45th day after the date the administrator |
|
|
receives a nonelectronic claim for those services that includes all |
|
|
information necessary for the administrator to pay the claim. |
|
|
(c) Except as provided by Subsection (d), an out-of-network |
|
|
provider who is a diagnostic imaging provider, [or] laboratory |
|
|
service provider, or ground ambulance service provider or a person |
|
|
asserting a claim as an agent or assignee of the provider may not |
|
|
bill an enrollee receiving a health care or medical service or |
|
|
supply described by Subsection (b) in, and the enrollee does not |
|
|
have financial responsibility for, an amount greater than an |
|
|
applicable copayment, coinsurance, and deductible under the |
|
|
enrollee's managed care plan that: |
|
|
(1) is based on: |
|
|
(A) the amount initially determined payable by |
|
|
the administrator; or |
|
|
(B) if applicable, a modified amount as |
|
|
determined under the administrator's internal appeal process; and |
|
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(2) is not based on any additional amount determined |
|
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to be owed to the provider under Chapter 1467. |
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SECTION 12. Section 1467.001, Insurance Code, is amended by |
|
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adding Subdivision (3-b) and amending Subdivisions (4) and (6-a) to |
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read as follows: |
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(3-b) [(4)] "Facility-based provider" means a |
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physician, health care practitioner, or other health care provider |
|
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who provides health care or medical services to patients of a |
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facility. |
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(4) "Ground ambulance service provider" means a |
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private entity or municipality providing emergency and |
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nonemergency ground ambulance services. The term includes all |
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personnel employed by the private entity or municipality who bill |
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separately for ground ambulance services. |
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(6-a) "Out-of-network provider" means a diagnostic |
|
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imaging provider, emergency care provider, facility-based |
|
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provider, [or] laboratory service provider, or ground ambulance |
|
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service provider that is not a participating provider for a health |
|
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benefit plan. |
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SECTION 13. Section 1467.050(a), Insurance Code, is amended |
|
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to read as follows: |
|
|
(a) This subchapter applies only with respect to a health |
|
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benefit claim submitted by an out-of-network provider that is a |
|
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facility or ground ambulance service provider. |
|
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SECTION 14. Section 1467.051(a), Insurance Code, is amended |
|
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to read as follows: |
|
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(a) An out-of-network provider or a health benefit plan |
|
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issuer or administrator may request mediation of a settlement of an |
|
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out-of-network health benefit claim through a portal on the |
|
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department's Internet website if: |
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(1) there is an amount billed by the provider and |
|
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unpaid by the issuer or administrator after copayments, |
|
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deductibles, and coinsurance for which an enrollee may not be |
|
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billed; and |
|
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(2) the health benefit claim is for: |
|
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(A) emergency care; |
|
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(B) an out-of-network laboratory service; [or] |
|
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(C) an out-of-network diagnostic imaging |
|
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service; or |
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(D) an out-of-network ground ambulance service. |
|
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SECTION 15. Section 1467.081, Insurance Code, is amended to |
|
|
read as follows: |
|
|
Sec. 1467.081. APPLICABILITY OF SUBCHAPTER. This |
|
|
subchapter applies only with respect to a health benefit claim |
|
|
submitted by an out-of-network provider who is not a facility or |
|
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ground ambulance service provider. |
|
|
SECTION 16. The changes in law made by this Act apply only |
|
|
to a ground ambulance service provided on or after January 1, 2022. |
|
|
A ground ambulance service provided before January 1, 2022, is |
|
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governed by the law in effect immediately before the effective date |
|
|
of this Act, and that law is continued in effect for that purpose. |
|
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SECTION 17. This Act takes effect September 1, 2021. |