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A BILL TO BE ENTITLED
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AN ACT
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relating to the definition of and certain determinations regarding |
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emergency care for purposes of certain health benefit plan |
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coverage. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.002(7), Insurance Code, is amended |
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to read as follows: |
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(7) "Emergency care" means health care services |
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provided in a hospital emergency facility, freestanding emergency |
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medical care facility, or comparable emergency facility to evaluate |
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and stabilize medical conditions of a recent onset and severity, |
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including severe pain, regardless of the final diagnosis of the |
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conditions, that would lead a prudent layperson possessing an |
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average knowledge of medicine and health to believe that the |
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individual's condition, sickness, or injury is of such a nature |
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that failure to get immediate medical care could: |
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(A) place the individual's health in serious |
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jeopardy; |
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(B) result in serious impairment to bodily |
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functions; |
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(C) result in serious dysfunction of a bodily |
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organ or part; |
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(D) result in serious disfigurement; or |
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(E) for a pregnant woman, result in serious |
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jeopardy to the health of the fetus. |
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SECTION 2. Subchapter A, Chapter 843, Insurance Code, is |
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amended by adding Section 843.011 to read as follows: |
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Sec. 843.011. EMERGENCY SERVICE DETERMINATIONS. Nothing in |
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this subchapter prohibits a health maintenance organization from |
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considering diagnosis codes to detect fraud or abuse. |
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SECTION 3. Section 1301.155(a), Insurance Code, is amended |
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to read as follows: |
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(a) In this section, "emergency care" means health care |
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services provided in a hospital emergency facility, freestanding |
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emergency medical care facility, or comparable emergency facility |
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to evaluate and stabilize a medical condition of a recent onset and |
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severity, including severe pain, regardless of the final diagnosis |
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of the condition, that would lead a prudent layperson possessing an |
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average knowledge of medicine and health to believe that the |
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person's condition, sickness, or injury is of such a nature that |
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failure to get immediate medical care could result in: |
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(1) placing the person's health in serious jeopardy; |
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(2) serious impairment to bodily functions; |
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(3) serious dysfunction of a bodily organ or part; |
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(4) serious disfigurement; or |
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(5) in the case of a pregnant woman, serious jeopardy |
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to the health of the fetus. |
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SECTION 4. Subchapter D, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.166 to read as follows: |
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Sec. 1301.166. EMERGENCY SERVICE DETERMINATIONS. Nothing |
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in this subchapter prohibits a preferred provider benefit plan from |
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considering diagnosis codes to detect fraud or abuse. |
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SECTION 5. Section 4201.002(2), Insurance Code, is amended |
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to read as follows: |
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(2) "Emergency care" means health care services |
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provided in a hospital emergency facility or comparable facility to |
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|
evaluate and stabilize medical conditions of a recent onset and |
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|
severity, including severe pain, regardless of the final diagnosis |
|
|
of the conditions, that would lead a prudent layperson possessing |
|
|
an average knowledge of medicine and health to believe that the |
|
|
individual's condition, sickness, or injury is of such a nature |
|
|
that failure to get immediate medical care could: |
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|
(A) place the individual's health in serious |
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jeopardy; |
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|
(B) result in serious impairment to bodily |
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functions; |
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(C) result in serious dysfunction of a bodily |
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organ or part; |
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(D) result in serious disfigurement; or |
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(E) for a pregnant woman, result in serious |
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jeopardy to the health of the fetus. |
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SECTION 6. Subchapter A, Chapter 4201, Insurance Code, is |
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amended by adding Section 4201.005 to read as follows: |
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Sec. 4201.005. EMERGENCY SERVICE DETERMINATIONS. Nothing |
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in this subchapter prohibits a payor from considering diagnosis |
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codes to detect fraud or abuse. |
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SECTION 7. The changes in law made by this Act apply only to |
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a health benefit plan delivered, issued for delivery, or renewed on |
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or after January 1, 2024. A health benefit plan delivered, issued |
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for delivery, or renewed before January 1, 2024, is governed by the |
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law as it existed immediately before the effective date of this Act, |
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and that law is continued in effect for that purpose. |
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SECTION 8. This Act takes effect September 1, 2023. |