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A BILL TO BE ENTITLED
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AN ACT
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relating to billing and reimbursement for certain medical |
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equipment, devices, and supplies provided to Medicare enrollees; |
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creating a criminal offense. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle C, Title 5, Insurance Code, is amended |
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by adding Chapter 566 to read as follows: |
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CHAPTER 566. BILLING FOR CERTAIN MEDICAL EQUIPMENT, DEVICES, AND |
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SUPPLIES |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 566.001. DEFINITIONS. In this chapter: |
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(1) "Assignment" means an agreement in which a |
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supplier agrees to accept the Medicare-approved amount as payment |
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for medical equipment or a medical device or supply. |
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(2) "Durable medical equipment" means medical |
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equipment that: |
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(A) can withstand repeated use; |
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(B) is expected to last at least three years; |
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(C) is primarily and customarily used to serve a |
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medical purpose; |
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(D) is generally not useful in the absence of an |
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illness or injury; and |
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(E) is appropriate for use in the home. |
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(3) "Enrollee" means an individual enrolled in |
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Medicare. |
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(4) "Medicare" means the health benefit coverage |
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provided under the Health Insurance for the Aged Act (42 U.S.C. |
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Section 1395 et seq.). |
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(5) "Nonparticipating supplier" means an entity or |
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person who: |
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(A) provides Medicare-covered durable medical |
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equipment, orthotic devices or supplies, or prosthetic devices or |
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supplies to Medicare enrollees; and |
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(B) is not enrolled in Medicare as a |
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participating supplier. |
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(6) "Orthotic device or supply" means: |
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(A) a custom-fitted or custom-fabricated medical |
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device designed to correct a deformity, improve function, or |
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relieve symptoms of a disease; or |
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(B) a medical supply related to a device |
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described by Paragraph (A). |
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(7) "Prosthetic device or supply" means: |
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(A) an artificial medical device designed to |
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replace all or part of a limb or internal organ; or |
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(B) a medical supply related to a device |
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described by Paragraph (A). |
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SUBCHAPTER B. REGULATION OF CERTAIN BILLING PRACTICES |
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Sec. 566.051. LIMITATIONS ON BILLING; NOTICE. (a) A |
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nonparticipating supplier may not charge an enrollee more than 115 |
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percent of the Medicare-approved amount for durable medical |
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equipment, orthotic devices or supplies, or prosthetic devices or |
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supplies covered under Medicare for which the supplier has not |
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accepted written assignment unless: |
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(1) before the enrollee is billed, the enrollee agrees |
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in writing to pay the additional amount; and |
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(2) before receiving the durable medical equipment, |
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orthotic device or supply, or prosthetic device or supply, the |
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enrollee pays the additional amount in full. |
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(b) A written agreement between a nonparticipating supplier |
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and enrollee under this section must provide notice to the enrollee |
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that: |
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(1) Medicare will reimburse 80 percent of the |
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Medicare-approved amount for durable medical equipment, orthotic |
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devices or supplies, or prosthetic devices or supplies covered |
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under Medicare; and |
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(2) a Medicare supplement benefit plan issuer is not |
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required to reimburse the nonparticipating supplier or enrollee for |
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the amount by which the charge exceeds 115 percent of the |
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Medicare-approved amount. |
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SUBCHAPTER C. ENFORCEMENT |
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Sec. 566.101. APPLICATION OF DECEPTIVE TRADE PRACTICES LAW. |
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A nonparticipating supplier who violates this chapter engages in a |
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false, misleading, or deceptive act or practice under Section |
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17.46, Business & Commerce Code. |
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Sec. 566.102. CRIMINAL OFFENSE. (a) A nonparticipating |
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supplier who intentionally violates this chapter commits an |
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offense. |
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(b) An offense under this section is a misdemeanor |
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punishable by a fine of not less than $500 or more than $1,000. |
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(c) Notwithstanding any other law, an offense under this |
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section may be prosecuted in: |
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(1) Travis County; or |
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(2) a county in which prosecution is authorized under |
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the Code of Criminal Procedure. |
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SECTION 2. Subchapter B, Chapter 1652, Insurance Code, is |
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amended by adding Section 1652.059 to read as follows: |
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Sec. 1652.059. REIMBURSEMENT FOR CERTAIN MEDICAL |
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EQUIPMENT, DEVICES, AND SUPPLIES. (a) In this section, terms |
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defined by Section 566.001 have the meanings assigned by that |
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section. |
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(b) A Medicare supplement benefit plan issuer is not |
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required to reimburse an enrollee or nonparticipating supplier for |
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the amount by which a charge for durable medical equipment, |
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orthotic devices or supplies, or prosthetic devices or supplies |
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exceeds 115 percent of the Medicare-allowed amount for the |
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equipment, device, or supply. |
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(c) This section does not prohibit a Medicare supplement |
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benefit plan issuer and a nonparticipating supplier from |
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negotiating a level and type of reimbursement for durable medical |
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equipment or orthotic or prosthetic devices or supplies. |
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SECTION 3. Chapter 566, Insurance Code, as added by this |
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Act, applies only to durable medical equipment or orthotic or |
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prosthetic devices or supplies sold on or after the effective date |
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of this Act. |
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SECTION 4. This Act takes effect September 1, 2025. |