Texas 2015 - 84th Regular

Texas House Bill HB3527 Compare Versions

Only one version of the bill is available at this time.

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1	1	By: Bonnen of Galveston H.B. No. 3527
2	2
3	3
4	4	A BILL TO BE ENTITLED
5	5	AN ACT
6	6	relating to the requirement that certain medical facilities and
7	7	physicians give patients a good faith estimate of the expected
8	8	payment for facility-based health care services before the services
9	9	are provided; providing an administrative penalty.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Subtitle G, Title 4, Health and Safety Code, is
12	12	amended by adding Chapter 326 to read as follows:
13	13	CHAPTER 326. GOOD FAITH ESTIMATE OF ACTUAL CHARGES FOR
14	14	FACILITY-BASED SERVICES
15	15	SUBCHAPTER A. GENERAL PROVISIONS
16	16	Sec. 326.001. DEFINITIONS. In this chapter:
17	17	(1) "Facility" means:
18	18	(A) an ambulatory surgical center licensed under
19	19	Chapter 243;
20	20	(B) a birthing center licensed under Chapter 244;
21	21	(C) a hospital licensed under Chapter 241; or
22	22	(D) an imaging center that is not part of another
23	23	facility.
24	24	(2) "Facility-based physician" means a radiologist,
25	25	an anesthesiologist, a pathologist, or a neonatologist.
26	26	(3) "Health care provider" means a facility, a
27	27	facility-based physician, or another physician required to provide
28	28	a good faith estimate under this chapter.
29	29	(4) "Medical implant" means an item, other than a
30	30	suture, implanted in a patient's body.
31	31	SUBCHAPTER B. GOOD FAITH ESTIMATE BY FACILITY AND FACILITY-BASED
32	32	PHYSICIAN
33	33	Sec. 326.051. ESTIMATE BY FACILITY. (a) A facility shall
34	34	provide to a person a good faith estimate as provided by this
35	35	chapter if the person:
36	36	(1) is expected to be admitted to the facility on a
37	37	nonemergency basis or receive a nonemergency procedure or service
38	38	at the facility; or
39	39	(2) may be admitted to the facility on a nonemergency
40	40	basis or receive a nonemergency procedure or service at the
41	41	facility and the person requests a good faith estimate from the
42	42	facility.
43	43	(b) A facility must provide a good faith estimate before
44	44	scheduling an admission, procedure, or service described by
45	45	Subsection (a).
46	46	(c) A facility shall provide to a person described by
47	47	Subsection (a) a good faith estimate of the actual charges, as
48	48	provided by Subchapter D, for facility fees and all procedures and
49	49	services, including diagnostic imaging, expected to be performed by
50	50	the facility and by facility-based physicians with whom the
51	51	facility has an agreement under Section 326.052(b) based on the
52	52	person's medical orders. The estimate must be based on
53	53	Diagnosis-Related Groups codes. The facility shall include with
54	54	the estimate a statement that the actual services performed at the
55	55	facility may differ from those provided in the estimate based on the
56	56	person's medical needs.
57	57	(d) A facility is not required to include in a good faith
58	58	estimate provided by the facility procedures or services performed
59	59	by a physician who is not a facility-based physician.
60	60	Sec. 326.052. ESTIMATE BY FACILITY-BASED PHYSICIAN. (a) A
61	61	facility-based physician shall provide a good faith estimate to a
62	62	person described by Section 326.051(a).
63	63	(b) A facility-based physician by contract may agree to
64	64	allow a facility to provide a good faith estimate of procedures and
65	65	services performed by the physician at the facility. The
66	66	facility-based physician is responsible for the estimate provided
67	67	by the facility according to the terms of the contract.
68	68	(c) A facility-based physician who does not enter into a
69	69	contract as provided by Subsection (b) must provide a good faith
70	70	estimate to a person before performing a procedure or service at a
71	71	facility in the same manner as a facility under Section 326.051.
72	72	Sec. 326.053. ESTIMATE OF ANESTHESIOLOGY SERVICES. (a) A
73	73	good faith estimate for anesthesiology services must be in the form
74	74	of a charge per unit of time and the expected number of units of time
75	75	required to complete the procedure or service originally ordered.
76	76	(b) A facility or anesthesiologist that provides a good
77	77	faith estimate of anesthesiology charges shall include with the
78	78	estimate a statement that the actual number of units of time
79	79	required to complete the procedure or service may differ from the
80	80	number provided in the estimate based on the person's medical
81	81	needs.
82	82	Sec. 326.054. ESTIMATE OF PATHOLOGY SERVICES. (a) A good
83	83	faith estimate for pathology services must be in the form of a
84	84	charge per specimen and the expected number of specimens required
85	85	for the procedure or service originally ordered.
86	86	(b) A facility or pathologist that provides a good faith
87	87	estimate of pathology charges shall include with the estimate a
88	88	statement that the actual number of specimens required may differ
89	89	from the number provided in the estimate based on the person's
90	90	medical needs.
91	91	Sec. 326.055. ESTIMATE FOR MEDICAL IMPLANTS. A
92	92	facility-based physician who provides to a person a good faith
93	93	estimate for a medical implant or a facility that provides to a
94	94	person a good faith estimate that includes a medical implant to be
95	95	implanted by a facility-based physician shall provide to the person
96	96	a list of all available medical implants that meet the person's
97	97	medical needs, including a good faith estimate of the actual
98	98	charges for each medical implant as provided by Subchapter D.
99	99	SUBCHAPTER C. GOOD FAITH ESTIMATE BY PHYSICIAN WHO WILL PERFORM
100	100	PROCEDURE OR SERVICE AT FACILITY
101	101	Sec. 326.101. ESTIMATE BY PHYSICIAN. (a) A physician who
102	102	is not a facility-based physician and who will perform for a person
103	103	a nonemergency procedure or service at a facility shall provide to
104	104	the person a good faith estimate for the procedure or service as
105	105	provided by this chapter.
106	106	(b) A physician must provide a good faith estimate before
107	107	scheduling a procedure or service described by Subsection (a).
108	108	(c) A physician shall provide to a person described by
109	109	Subsection (a) a good faith estimate of the physician's actual
110	110	charges, as provided by Subchapter D, for the procedure or service.
111	111	The estimate must be based on Diagnosis-Related Groups codes,
112	112	Current Procedural Terminology codes, or other applicable medical
113	113	billing codes. The physician shall include with the estimate a
114	114	statement that the actual services performed by the physician may
115	115	differ from those provided in the estimate based on the person's
116	116	medical needs.
117	117	(d) A physician is not required to include in a good faith
118	118	estimate provided by the physician facility fees, procedures, or
119	119	services performed by a facility or by facility-based physicians.
120	120	Sec. 326.102. GOOD FAITH ESTIMATE FOR MEDICAL IMPLANTS. A
121	121	physician who is not a facility-based physician and who provides to
122	122	a person a good faith estimate for a medical implant shall provide
123	123	to the person a list of all available medical implants that meet the
124	124	person's medical needs, including a good faith estimate of the
125	125	actual charges for each medical implant as provided by Subchapter
126	126	D.
127	127	SUBCHAPTER D. GOOD FAITH ESTIMATE OF ACTUAL CHARGES
128	128	Sec. 326.151. DISCLOSURE OF EXPECTED PAYMENT METHOD. A
129	129	health care provider shall ask a person to disclose the person's
130	130	anticipated method of payment for purposes of complying with this
131	131	subchapter.
132	132	Sec. 326.152. GOOD FAITH ESTIMATE FOR INSURED PERSONS. If a
133	133	person has an individual, group, or other private or commercial
134	134	health insurance plan or policy, including coverage through a
135	135	preferred provider organization or health maintenance
136	136	organization, a health care provider shall provide the person a
137	137	good faith estimate of:
138	138	(1) the amount the insurance plan or policy will
139	139	actually pay the health care provider for the fees, procedures, and
140	140	services described by Subchapter B or C based on the relevant
141	141	billing codes, the terms of the person's insurance plan or policy,
142	142	and the negotiated rate between the health care provider and the
143	143	insurance plan or policy, if applicable; and
144	144	(2) the amount of any copayment, coinsurance, or other
145	145	amount the person is expected to pay the health care provider for
146	146	the fees, procedures, and services described by Subchapter B or C
147	147	based on the relevant billing codes, the terms of the person's
148	148	insurance plan or policy, and the negotiated rate between the
149	149	health care provider and the person's insurance plan or policy, if
150	150	applicable.
151	151	Sec. 326.153. GOOD FAITH ESTIMATE FOR RECIPIENTS OF
152	152	GOVERNMENT-SPONSORED PROGRAM. If a person receives benefits under
153	153	a government-sponsored health benefits program, including the
154	154	Medicaid program, the Medicare program, the Children's Health
155	155	Insurance Program (CHIP), and the TRICARE military health system, a
156	156	health care provider shall provide the person a good faith estimate
157	157	of:
158	158	(1) the amount the government-sponsored health
159	159	benefits program will actually pay the health care provider for the
160	160	fees, procedures, and services described by Subchapter B or C based
161	161	on the relevant billing codes; and
162	162	(2) any amount the person is expected to pay the health
163	163	care provider for fees, procedures, and services described by
164	164	Subchapter B or C based on the relevant billing codes under the
165	165	terms of the government-sponsored health benefits program.
166	166	Sec. 326.154. GOOD FAITH ESTIMATE FOR RECIPIENTS OF
167	167	WORKERS' COMPENSATION BENEFITS. If a person receives benefits
168	168	under a workers' compensation claim, a health care provider shall
169	169	provide the person a good faith estimate of:
170	170	(1) the amount the workers' compensation insurance
171	171	carrier, workers' compensation claims processor, employer, or
172	172	other payor will actually pay the health care provider for the fees,
173	173	procedures, and services described by Subchapter B or C based on the
174	174	relevant billing codes; and
175	175	(2) the amount the person is expected to pay the health
176	176	care provider for the fees, procedures, and services described by
177	177	Subchapter B or C based on the relevant billing codes, if any.
178	178	Sec. 326.155. STATEMENT FOR PERSONS PAYING CASH, PERSONS
179	179	RECEIVING CHARITY CARE, AND INDIGENT PERSONS. If a person will pay
180	180	cash or will receive charity care for an admission, procedure, or
181	181	service or if a person is indigent, a health care provider shall
182	182	provide the person with a statement of:
183	183	(1) the average amount the health care provider was
184	184	actually paid for the fees, procedures, and services described by
185	185	Subchapter B or C based on the relevant billing codes by the five
186	186	insurance carriers or government-sponsored programs described by
187	187	Sections 326.152, 326.153, and 326.154 that paid the health care
188	188	provider for the greatest number of the applicable fees,
189	189	procedures, and services in the preceding calendar year, or in the
190	190	current calendar year if the health care provider did not practice
191	191	in the preceding calendar year; and
192	192	(2) the average amount the health care provider was
193	193	actually paid by patients described by this section for the
194	194	applicable fees, procedures, and services in that year.
195	195	SUBCHAPTER E. ADMINISTRATIVE PENALTY
196	196	Sec. 326.201. ADMINISTRATIVE PENALTY AUTHORIZED. (a) The
197	197	commissioner of insurance may impose an administrative penalty on a
198	198	facility or physician that violates this chapter.
199	199	(b) The amount of the penalty may not exceed $1,000 for each
200	200	violation.
201	201	(c) Chapter 84, Insurance Code, governs the imposition,
202	202	enforcement, and collection of the administrative penalty.
203	203	SECTION 2. The changes in law made by this Act apply only to
204	204	an admission, procedure, or service ordered or provided on or after
205	205	the effective date of this Act. An admission, procedure, or service
206	206	ordered or provided before the effective date of this Act is
207	207	governed by the law in effect on the date the admission, procedure,
208	208	or service was ordered or provided, and the former law is continued
209	209	in effect for that purpose.
210	210	SECTION 3. This Act takes effect January 1, 2016.