89R13049 DNC-D

By: Hughes S.B. No. 1118

A BILL TO BE ENTITLED

AN ACT

relating to anesthesia coverage and patient assessment requirements for certain health benefit plans.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subtitle E, Title 8, Insurance Code, is amended by adding Chapter 1381 to read as follows:

CHAPTER 1381. ANESTHESIA

Sec. 1381.001. APPLICABILITY OF CHAPTER. (a) Except as otherwise provided by this chapter, this chapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage or similar coverage document that is issued by:

(1) an insurance company;

(2) a group hospital service corporation operating under Chapter 842;

(3) a health maintenance organization operating under Chapter 843;

(4) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844;

(5) a multiple employer welfare arrangement that holds a certificate of authority under Chapter 846;

(6) a stipulated premium company operating under Chapter 884;

(7) a fraternal benefit society operating under Chapter 885;

(8) a Lloyd's plan operating under Chapter 941; or

(9) an exchange operating under Chapter 942.

(b) Notwithstanding any other law, this chapter applies to:

(1) a small employer health benefit plan subject to Chapter 1501, including coverage provided through a health group cooperative under Subchapter B of that chapter;

(2) a standard health benefit plan issued under Chapter 1507;

(3) a basic coverage plan under Chapter 1551;

(4) a basic plan under Chapter 1575; and

(5) a primary care coverage plan under Chapter 1579.

Sec. 1381.002. COVERAGE REQUIRED. A health benefit plan that provides coverage for medically necessary anesthesia must provide coverage for the full time that the anesthesia services are performed.

SECTION 2. Subchapter B, Chapter 1551, Insurance Code, is amended by adding Section 1551.0551 to read as follows:

Sec. 1551.0551. NETWORK ADEQUACY. The board of trustees shall ensure that a managed care plan provided under the group benefits program has an adequate network of health care providers by requiring continued coverage and payment calculations that account for:

(1) the assessment of patient physical status, as determined by a participant's treating physician or health care provider; and

(2) the complexity and urgency of care, as determined by a participant's treating physician or health care provider.

SECTION 3. Section 1551.219, Insurance Code, is amended by adding Subsection (c) to read as follows:

(c) Disease management services provided or covered under Subsection (b) must take into account patient physical status and complexity of care as identified by a clinician for patient care.

SECTION 4. Subchapter E, Chapter 1551, Insurance Code, is amended by adding Section 1551.2195 to read as follows:

Sec. 1551.2195. FACTORS FOR NECESSITY AND BENEFIT PAYMENT AMOUNT DETERMINATIONS. A group health benefit plan offered under the group benefits program must provide for the following factors to be taken into account in determining necessity of services and calculation of benefits payment amounts:

(1) the assessment of patient physical status, as determined by the patient's treating physician or health care provider; and

(2) the complexity and urgency of care, as determined by the patient's treating physician or health care provider.

SECTION 5. Section 1575.164, Insurance Code, is amended by adding Subsection (c) to read as follows:

(c) Disease management services provided or covered under Subsection (b) must take into account patient physical status and complexity of care as identified by a clinician for patient care.

SECTION 6. Subchapter D, Chapter 1575, Insurance Code, is amended by adding Section 1575.1645 to read as follows:

Sec. 1575.1645. FACTORS FOR NECESSITY AND BENEFIT PAYMENT AMOUNT DETERMINATIONS. A health benefit plan provided under this chapter must provide for the following factors to be taken into account in determining necessity of services and calculation of benefits payment amounts:

(1) the assessment of patient physical status, as determined by the patient's treating physician or health care provider; and

(2) the complexity and urgency of care, as determined by the patient's treating physician or health care provider.

SECTION 7. Section 1579.107, Insurance Code, is amended by adding Subsection (c) to read as follows:

(c) Disease management services provided or covered under Subsection (b) must take into account patient physical status and complexity of care as identified by a clinician for patient care.

SECTION 8. Subchapter C, Chapter 1579, Insurance Code, is amended by adding Section 1579.1075 to read as follows:

Sec. 1579.1075. FACTORS FOR NECESSITY AND BENEFIT PAYMENT AMOUNT DETERMINATIONS. A health coverage plan provided under this chapter must provide for the following factors to be taken into account in determining necessity of services and calculation of benefits payment amounts:

(1) the assessment of patient physical status, as determined by the patient's treating physician or health care provider; and

(2) the complexity and urgency of care, as determined by the patient's treating physician or health care provider.

SECTION 9. Chapter 1381, Insurance Code, as added by this Act, applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2026.

SECTION 10. The changes in law made by this Act to Chapters 1551, 1575, and 1579, Insurance Code, apply only to a plan year that commences on or after January 1, 2026. A plan year that commenced before January 1, 2026, is governed by the law as it existed immediately before the effective date of this Act, and that law is continued in effect for that purpose.

SECTION 11. This Act takes effect September 1, 2025.