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A BILL TO BE ENTITLED
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AN ACT
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relating to an enrollee's cost-sharing liability for emergency care |
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under a health benefit plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle A, Title 8, Insurance Code, is amended |
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by adding Chapter 1224 to read as follows: |
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CHAPTER 1224. COST-SHARING LIABILITY |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1224.001. DEFINITIONS. In this chapter: |
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(1) "Cost-sharing liability" means the amount an |
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enrollee is responsible for paying for a covered health care |
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service or supply under the terms of a health benefit plan. The |
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term includes deductibles, coinsurance, and copayments but does not |
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include premiums, balance billing amounts by out-of-network |
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providers, or the cost of health care services or supplies that are |
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not covered under a health benefit plan. |
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(2) "Emergency care" has the meaning assigned by |
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Section 1301.155. |
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(3) "Enrollee" means an individual, including a |
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dependent, entitled to coverage under a health benefit plan. |
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(4) "Health care provider" means a practitioner, |
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institutional provider, or other person or organization that |
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furnishes health care services and that is licensed or otherwise |
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authorized to practice in this state. The term includes a |
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pharmacist and a pharmacy. |
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Sec. 1224.002. APPLICABILITY OF CHAPTER. This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document that is issued by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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Sec. 1224.003. EXCEPTION. This chapter does not apply to |
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the state Medicaid program, including the Medicaid managed care |
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program operated under Chapter 540, Government Code. |
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Sec. 1224.004. RULES. The commissioner may adopt rules to |
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implement this chapter. |
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SUBCHAPTER B. REGULATION OF COST-SHARING LIABILITY FOR EMERGENCY |
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CARE |
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Sec. 1224.051. ISSUER REQUIREMENTS. Notwithstanding any |
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other law, a health benefit plan issuer: |
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(1) shall pay a health care provider the full amount |
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payable to the provider under the terms of the enrollee's health |
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benefit plan, including the enrollee's cost-sharing liability, for |
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covered emergency care; |
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(2) has the sole responsibility for collecting the |
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amount due for an enrollee's cost-sharing liability under the |
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enrollee's health benefit plan for emergency care; and |
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(3) on an enrollee's request, shall collect the amount |
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due for the enrollee's cost-sharing liability for emergency care |
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throughout the plan year in increments determined by the issuer. |
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Sec. 1224.052. ISSUER PROHIBITIONS. A health benefit plan |
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issuer may not: |
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(1) withhold any amount for an enrollee's cost-sharing |
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liability from a payment to a health care provider for covered |
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emergency care; |
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(2) require a health care provider to offer additional |
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discounts for emergency care to enrollees outside the terms of a |
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contract between the issuer and the provider; |
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(3) cancel an enrollee's health benefit plan for |
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failure to collect amounts due under the enrollee's cost-sharing |
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liability for emergency care; or |
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(4) use additional expenses incurred by complying with |
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this chapter as a basis for increasing an enrollee's premiums or |
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decreasing payments to a health care provider. |
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Sec. 1224.053. ENFORCEMENT OF SUBCHAPTER. (a) A violation |
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of this chapter is an unfair method of competition or an unfair or |
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deceptive act or practice in the business of insurance under |
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Chapter 541 and is subject to enforcement under that chapter. |
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(b) Notwithstanding Section 541.002, a health benefit plan |
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issuer is considered a person for purposes of enforcing this |
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subchapter under Chapter 541. |
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SECTION 2. Section 1271.008(a), Insurance Code, as |
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effective September 1, 2025, is amended to read as follows: |
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(a) A health maintenance organization shall provide written |
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notice in accordance with this section in an explanation of |
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benefits provided to the enrollee and the physician or provider in |
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connection with a health care service or supply provided by a |
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non-network physician or provider. The notice must include: |
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(1) a statement of the billing prohibition under |
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Section 1271.155, 1271.157, or 1271.158, as applicable; |
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(2) a statement of: |
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(A) with respect to emergency care subject to |
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Section 1271.155, the total amount payable to the physician or |
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provider under the enrollee's health benefit plan, the total amount |
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the physician or provider may bill the enrollee, if applicable, the |
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total amount of the enrollee's cost-sharing liability owed to the |
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health maintenance organization, and an itemization of copayments, |
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coinsurance, deductibles, and other amounts included in that |
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cost-sharing liability; and |
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(B) with respect to a health care service or |
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supply subject to Section 1271.157 or 1271.158, the total amount |
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the physician or provider may bill the enrollee under the |
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enrollee's health benefit plan and an itemization of copayments, |
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coinsurance, deductibles, and other amounts included in that total; |
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and |
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(3) for an explanation of benefits provided to the |
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physician or provider, information required by commissioner rule |
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advising the physician or provider of the availability of mediation |
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or arbitration, as applicable, under Chapter 1467. |
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SECTION 3. Section 1271.155(g), Insurance Code, is amended |
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to read as follows: |
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(g) For emergency care subject to this section or a supply |
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related to that care, [a non-network physician or provider or a |
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person asserting a claim as an agent or assignee of the physician or |
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provider may not bill] an enrollee [in, and the enrollee] 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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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 physician or provider under Chapter 1467. |
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SECTION 4. Section 1301.0053(b), Insurance Code, is amended |
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to read as follows: |
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(b) For emergency care or post-emergency stabilization care |
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subject to this section or a supply related to that care, [an |
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out-of-network provider or a person asserting a claim as an agent or |
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assignee of the provider may not bill] an insured [in, and the |
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insured] does not have financial responsibility for[,] an amount |
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greater than an applicable copayment, coinsurance, and deductible |
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under the insured's exclusive 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, a 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 5. Section 1301.010(a), Insurance Code, as |
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effective September 1, 2025, is amended to read as follows: |
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(a) An insurer shall provide written notice in accordance |
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with this section in an explanation of benefits provided to the |
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insured and the physician or health care provider in connection |
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with a medical care or health care service or supply provided by an |
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out-of-network provider. The notice must include: |
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(1) a statement of the billing prohibition under |
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Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable; |
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(2) a statement of: |
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(A) with respect to emergency care subject to |
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Section 1301.0053 or 1301.155, the total amount payable to the |
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physician or provider under the insured's preferred provider |
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benefit plan, the total amount the physician or provider may bill |
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the insured, if applicable, the total amount of the insured's |
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cost-sharing liability owed to the insurer, and an itemization of |
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copayments, coinsurance, deductibles, and other amounts included |
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in that cost-sharing liability; and |
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(B) with respect to a health care service or |
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supply subject to Section 1301.164 or 1301.165, the total amount |
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the physician or provider may bill the insured under the insured's |
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preferred provider benefit plan and an itemization of copayments, |
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coinsurance, deductibles, and other amounts included in that total; |
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and |
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(3) for an explanation of benefits provided to the |
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physician or provider, information required by commissioner rule |
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advising the physician or provider of the availability of mediation |
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or arbitration, as applicable, under Chapter 1467. |
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SECTION 6. Section 1301.155(d), Insurance Code, is amended |
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to read as follows: |
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(d) For emergency care subject to this section or a supply |
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related to that care, [an out-of-network 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 [in, and the insured] does not have financial |
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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, a 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 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, 2026. A health benefit plan delivered, issued |
|
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for delivery, or renewed before January 1, 2026, 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, 2025. |