83R20802 BEF-D
By: Bonnen of Galveston, et al. H.B. No. 2700
Substitute the following for H.B. No. 2700:
By: Bonnen of Galveston C.S.H.B. No. 2700
A BILL TO BE ENTITLED
AN ACT
relating to the requirement that certain medical facilities and
physicians give patients a good faith estimate of the expected
payment for facility-based health care services before the services
are provided; providing an administrative penalty.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle G, Title 4, Health and Safety Code, is
amended by adding Chapter 326 to read as follows:
CHAPTER 326. GOOD FAITH ESTIMATE OF ACTUAL CHARGES FOR
FACILITY-BASED SERVICES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 326.001. DEFINITIONS. In this chapter:
(1) "Facility" means:
(A) an ambulatory surgical center licensed under
Chapter 243;
(B) a birthing center licensed under Chapter 244;
(C) a hospital licensed under Chapter 241; or
(D) an imaging center that is not part of another
facility.
(2) "Facility-based physician" means a radiologist,
an anesthesiologist, a pathologist, or a neonatologist.
(3) "Health care provider" means a facility, a
facility-based physician, or another physician required to provide
a good faith estimate under this chapter.
(4) "Medical implant" means an item, other than a
suture, implanted in a patient's body.
SUBCHAPTER B. GOOD FAITH ESTIMATE BY FACILITY AND FACILITY-BASED
PHYSICIAN
Sec. 326.051. ESTIMATE BY FACILITY. (a) A facility shall
provide to a person a good faith estimate as provided by this
chapter if the person:
(1) is expected to be admitted to the facility on a
nonemergency basis or receive a nonemergency procedure or service
at the facility; or
(2) may be admitted to the facility on a nonemergency
basis or receive a nonemergency procedure or service at the
facility and the person requests a good faith estimate from the
facility.
(b) A facility must provide a good faith estimate before
scheduling an admission, procedure, or service described by
Subsection (a).
(c) A facility shall provide to a person described by
Subsection (a) a good faith estimate of the actual charges, as
provided by Subchapter D, for facility fees and all procedures and
services, including diagnostic imaging, expected to be performed by
the facility and by facility-based physicians with whom the
facility has an agreement under Section 326.052(b) based on the
person's medical orders. The estimate must be based on
Diagnosis-Related Groups codes. The facility shall include with the
estimate a statement that the actual services performed at the
facility may differ from those provided in the estimate based on the
person's medical needs.
(d) A facility is not required to include in a good faith
estimate provided by the facility procedures or services performed
by a physician who is not a facility-based physician.
Sec. 326.052. ESTIMATE BY FACILITY-BASED PHYSICIAN. (a) A
facility-based physician shall provide a good faith estimate to a
person described by Section 326.051(a).
(b) A facility-based physician by contract may agree to
allow a facility to provide a good faith estimate of procedures and
services performed by the physician at the facility. The
facility-based physician is responsible for the estimate provided
by the facility according to the terms of the contract.
(c) A facility-based physician who does not enter into a
contract as provided by Subsection (b) must provide a good faith
estimate to a person before performing a procedure or service at a
facility in the same manner as a facility under Section 326.051.
Sec. 326.053. ESTIMATE OF ANESTHESIOLOGY SERVICES. (a) A
good faith estimate for anesthesiology services must be in the form
of a charge per unit of time and the expected number of units of time
required to complete the procedure or service originally ordered.
(b) A facility or anesthesiologist that provides a good
faith estimate of anesthesiology charges shall include with the
estimate a statement that the actual number of units of time
required to complete the procedure or service may differ from the
number provided in the estimate based on the person's medical
needs.
Sec. 326.054. ESTIMATE OF PATHOLOGY SERVICES. (a) A good
faith estimate for pathology services must be in the form of a
charge per specimen and the expected number of specimens required
for the procedure or service originally ordered.
(b) A facility or pathologist that provides a good faith
estimate of pathology charges shall include with the estimate a
statement that the actual number of specimens required may differ
from the number provided in the estimate based on the person's
medical needs.
Sec. 326.055. ESTIMATE FOR MEDICAL IMPLANTS. A
facility-based physician who provides to a person a good faith
estimate for a medical implant or a facility that provides to a
person a good faith estimate that includes a medical implant to be
implanted by a facility-based physician shall provide to the person
a list of all available medical implants that meet the person's
medical needs, including a good faith estimate of the actual
charges for each medical implant as provided by Subchapter D.
SUBCHAPTER C. GOOD FAITH ESTIMATE BY PHYSICIAN WHO WILL PERFORM
PROCEDURE OR SERVICE AT FACILITY
Sec. 326.101. ESTIMATE BY PHYSICIAN. (a) A physician who is
not a facility-based physician and who will perform for a person a
nonemergency procedure or service at a facility shall provide to
the person a good faith estimate for the procedure or service as
provided by this chapter.
(b) A physician must provide a good faith estimate before
scheduling a procedure or service described by Subsection (a).
(c) A physician shall provide to a person described by
Subsection (a) a good faith estimate of the physician's actual
charges, as provided by Subchapter D, for the procedure or service.
The estimate must be based on Diagnosis-Related Groups codes,
Current Procedural Terminology codes, or other applicable medical
billing codes. The physician shall include with the estimate a
statement that the actual services performed by the physician may
differ from those provided in the estimate based on the person's
medical needs.
(d) A physician is not required to include in a good faith
estimate provided by the physician facility fees, procedures, or
services performed by a facility or by facility-based physicians.
Sec. 326.102. GOOD FAITH ESTIMATE FOR MEDICAL IMPLANTS. A
physician who is not a facility-based physician and who provides to
a person a good faith estimate for a medical implant shall provide
to the person a list of all available medical implants that meet the
person's medical needs, including a good faith estimate of the
actual charges for each medical implant as provided by Subchapter
D.
SUBCHAPTER D. GOOD FAITH ESTIMATE OF ACTUAL CHARGES
Sec. 326.151. DISCLOSURE OF EXPECTED PAYMENT METHOD. A
health care provider shall ask a person to disclose the person's
anticipated method of payment for purposes of complying with this
subchapter.
Sec. 326.152. GOOD FAITH ESTIMATE FOR INSURED PERSONS. If a
person has an individual, group, or other private or commercial
health insurance plan or policy, including coverage through a
preferred provider organization or health maintenance
organization, a health care provider shall provide the person a
good faith estimate of:
(1) the amount the insurance plan or policy will
actually pay the health care provider for the fees, procedures, and
services described by Subchapter B or C based on the relevant
billing codes, the terms of the person's insurance plan or policy,
and the negotiated rate between the health care provider and the
insurance plan or policy, if applicable; and
(2) the amount of any copayment, coinsurance, or other
amount the person is expected to pay the health care provider for
the fees, procedures, and services described by Subchapter B or C
based on the relevant billing codes, the terms of the person's
insurance plan or policy, and the negotiated rate between the
health care provider and the person's insurance plan or policy, if
applicable.
Sec. 326.153. GOOD FAITH ESTIMATE FOR RECIPIENTS OF
GOVERNMENT-SPONSORED PROGRAM. If a person receives benefits under
a government-sponsored health benefits program, including the
Medicaid program, the Medicare program, the Children's Health
Insurance Program (CHIP), and the TRICARE military health system, a
health care provider shall provide the person a good faith estimate
of:
(1) the amount the government-sponsored health
benefits program will actually pay the health care provider for the
fees, procedures, and services described by Subchapter B or C based
on the relevant billing codes; and
(2) any amount the person is expected to pay the health
care provider for fees, procedures, and services described by
Subchapter B or C based on the relevant billing codes under the
terms of the government-sponsored health benefits program.
Sec. 326.154. GOOD FAITH ESTIMATE FOR RECIPIENTS OF
WORKERS' COMPENSATION BENEFITS. If a person receives benefits under
a workers' compensation claim, a health care provider shall provide
the person a good faith estimate of:
(1) the amount the workers' compensation insurance
carrier, workers' compensation claims processor, employer, or
other payor will actually pay the health care provider for the fees,
procedures, and services described by Subchapter B or C based on the
relevant billing codes; and
(2) the amount the person is expected to pay the health
care provider for the fees, procedures, and services described by
Subchapter B or C based on the relevant billing codes, if any.
Sec. 326.155. STATEMENT FOR PERSONS PAYING CASH, PERSONS
RECEIVING CHARITY CARE, AND INDIGENT PERSONS. If a person will pay
cash or will receive charity care for an admission, procedure, or
service or if a person is indigent, a health care provider shall
provide the person with a statement of:
(1) the average amount the health care provider was
actually paid for the fees, procedures, and services described by
Subchapter B or C based on the relevant billing codes by the five
insurance carriers or government-sponsored programs described by
Sections 326.152, 326.153, and 326.154 that paid the health care
provider for the greatest number of the applicable fees,
procedures, and services in the preceding calendar year, or in the
current calendar year if the health care provider did not practice
in the preceding calendar year; and
(2) the average amount the health care provider was
actually paid by patients described by this section for the
applicable fees, procedures, and services in that year.
SUBCHAPTER E. ADMINISTRATIVE PENALTY
Sec. 326.201. ADMINISTRATIVE PENALTY AUTHORIZED. (a) The
commissioner of insurance may impose an administrative penalty on a
facility or physician that violates this chapter.
(b) The amount of the penalty may not exceed $1,000 for each
violation.
(c) Chapter 84, Insurance Code, governs the imposition,
enforcement, and collection of the administrative penalty.
SECTION 2. The changes in law made by this Act apply only to
an admission, procedure, or service ordered or provided on or after
the effective date of this Act. An admission, procedure, or service
ordered or provided before the effective date of this Act is
governed by the law in effect on the date the admission, procedure,
or service was ordered or provided, and the former law is continued
in effect for that purpose.
SECTION 3. This Act takes effect January 1, 2014.