Texas 2021 - 87th Regular

Texas House Bill HB4115 Compare Versions

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

Old	New	Differences
1	1	87R6484 SCL-F
2	2	By: Oliverson H.B. No. 4115
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to consumer protections against certain medical and health
8	8	care billing by out-of-network ground ambulance service providers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 38.004(a), Insurance Code, is amended to
11	11	read as follows:
12	12	(a) The department shall, each biennium, conduct a study on
13	13	the impacts of S.B. No. 1264, Acts of the 86th Legislature, Regular
14	14	Session, 2019, and subsequently enacted laws prohibiting an
15	15	individual or entity from billing an insured, participant, or
16	16	enrollee in an amount greater than an applicable copayment,
17	17	coinsurance, or deductible under the insured's, participant's, or
18	18	enrollee's managed care plan or imposing a requirement related to
19	19	that prohibition, on Texas consumers and health coverage in this
20	20	state, including:
21	21	(1) trends in billed amounts for health care or
22	22	medical services or supplies, especially emergency services,
23	23	laboratory services, diagnostic imaging services, ground ambulance
24	24	services, and facility-based services;
25	25	(2) comparison of the total amount spent on
26	26	out-of-network emergency services, laboratory services, diagnostic
27	27	imaging services, ground ambulance services, and facility-based
28	28	services by calendar year and provider type or physician specialty;
29	29	(3) trends and changes in network participation by
30	30	providers of emergency services, laboratory services, diagnostic
31	31	imaging services, ground ambulance services, and facility-based
32	32	services by provider type or physician specialty, including whether
33	33	any terminations were initiated by a health benefit plan issuer,
34	34	administrator, or provider;
35	35	(4) trends and changes in the amounts paid to
36	36	participating providers;
37	37	(5) the number of complaints, completed
38	38	investigations, and disciplinary sanctions for billing by
39	39	providers of emergency services, laboratory services, diagnostic
40	40	imaging services, ground ambulance services, or facility-based
41	41	services of enrollees for amounts greater than the enrollee's
42	42	responsibility under an applicable health benefit plan, including
43	43	applicable copayments, coinsurance, and deductibles;
44	44	(6) trends in amounts paid to out-of-network
45	45	providers;
46	46	(7) trends in the usual and customary rate for health
47	47	care or medical services or supplies, especially emergency
48	48	services, laboratory services, diagnostic imaging services, ground
49	49	ambulance services, and facility-based services; and
50	50	(8) the effectiveness of the claim dispute resolution
51	51	process under Chapter 1467.
52	52	SECTION 2. The heading to Section 1271.158, Insurance Code,
53	53	is amended to read as follows:
54	54	Sec. 1271.158. CERTAIN NON-NETWORK ANCILLARY [DIAGNOSTIC
55	55	IMAGING PROVIDER OR LABORATORY] SERVICE PROVIDERS [PROVIDER].
56	56	SECTION 3. Sections 1271.158(a), (b), and (c), Insurance
57	57	Code, are amended to read as follows:
58	58	(a) In this section, "diagnostic imaging provider,"
59	59	[provider" and] "laboratory service provider," and "ground
60	60	ambulance service provider" have the meanings assigned by Section
61	61	1467.001.
62	62	(b) Except as provided by Subsection (d), a health
63	63	maintenance organization shall pay for a covered health care
64	64	service performed by or a covered supply related to that service
65	65	provided to an enrollee by a non-network diagnostic imaging
66	66	provider, [or] laboratory service provider, or ground ambulance
67	67	service provider at the usual and customary rate or at an agreed
68	68	rate if the provider performed the service in connection with a
69	69	health care service performed by a network physician or provider.
70	70	The health maintenance organization shall make a payment required
71	71	by this subsection directly to the physician or provider not later
72	72	than, as applicable:
73	73	(1) the 30th day after the date the health maintenance
74	74	organization receives an electronic clean claim as defined by
75	75	Section 843.336 for those services that includes all information
76	76	necessary for the health maintenance organization to pay the claim;
77	77	or
78	78	(2) the 45th day after the date the health maintenance
79	79	organization receives a nonelectronic clean claim as defined by
80	80	Section 843.336 for those services that includes all information
81	81	necessary for the health maintenance organization to pay the claim.
82	82	(c) Except as provided by Subsection (d), a non-network
83	83	diagnostic imaging provider, [or] laboratory service provider, or
84	84	ground ambulance service provider or a person asserting a claim as
85	85	an agent or assignee of the provider may not bill an enrollee
86	86	receiving a health care service or supply described by Subsection
87	87	(b) in, and the enrollee does not have financial responsibility
88	88	for, an amount greater than an applicable copayment, coinsurance,
89	89	and deductible under the enrollee's health care plan that:
90	90	(1) is based on:
91	91	(A) the amount initially determined payable by
92	92	the health maintenance organization; or
93	93	(B) if applicable, a modified amount as
94	94	determined under the health maintenance organization's internal
95	95	appeal process; and
96	96	(2) is not based on any additional amount determined
97	97	to be owed to the provider under Chapter 1467.
98	98	SECTION 4. The heading to Section 1301.165, Insurance Code,
99	99	is amended to read as follows:
100	100	Sec. 1301.165. CERTAIN OUT-OF-NETWORK ANCILLARY
101	101	[DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE PROVIDERS
102	102	[PROVIDER].
103	103	SECTION 5. Sections 1301.165(a), (b), and (c), Insurance
104	104	Code, are amended to read as follows:
105	105	(a) In this section, "diagnostic imaging provider,"
106	106	[provider" and] "laboratory service provider," and "ground
107	107	ambulance service provider" have the meanings assigned by Section
108	108	1467.001.
109	109	(b) Except as provided by Subsection (d), an insurer shall
110	110	pay for a covered medical care or health care service performed by
111	111	or a covered supply related to that service provided to an insured
112	112	by an out-of-network provider who is a diagnostic imaging provider,
113	113	[or] laboratory service provider, or ground ambulance service
114	114	provider at the usual and customary rate or at an agreed rate if the
115	115	provider performed the service in connection with a medical care or
116	116	health care service performed by a preferred provider. The insurer
117	117	shall make a payment required by this subsection directly to the
118	118	provider not later than, as applicable:
119	119	(1) the 30th day after the date the insurer receives an
120	120	electronic clean claim as defined by Section 1301.101 for those
121	121	services that includes all information necessary for the insurer to
122	122	pay the claim; or
123	123	(2) the 45th day after the date the insurer receives a
124	124	nonelectronic clean claim as defined by Section 1301.101 for those
125	125	services that includes all information necessary for the insurer to
126	126	pay the claim.
127	127	(c) Except as provided by Subsection (d), an out-of-network
128	128	provider who is a diagnostic imaging provider, [or] laboratory
129	129	service provider, or ground ambulance service provider or a person
130	130	asserting a claim as an agent or assignee of the provider may not
131	131	bill an insured receiving a medical care or health care service or
132	132	supply described by Subsection (b) in, and the insured does not have
133	133	financial responsibility for, an amount greater than an applicable
134	134	copayment, coinsurance, and deductible under the insured's
135	135	preferred provider benefit plan that:
136	136	(1) is based on:
137	137	(A) the amount initially determined payable by
138	138	the insurer; or
139	139	(B) if applicable, the modified amount as
140	140	determined under the insurer's internal appeal process; and
141	141	(2) is not based on any additional amount determined
142	142	to be owed to the provider under Chapter 1467.
143	143	SECTION 6. The heading to Section 1551.230, Insurance Code,
144	144	is amended to read as follows:
145	145	Sec. 1551.230. PAYMENTS TO CERTAIN OUT-OF-NETWORK
146	146	ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE
147	147	PROVIDERS [PROVIDER PAYMENTS].
148	148	SECTION 7. Sections 1551.230(a), (b), and (c), Insurance
149	149	Code, are amended to read as follows:
150	150	(a) In this section, "diagnostic imaging provider,"
151	151	[provider" and] "laboratory service provider," and "ground
152	152	ambulance service provider" have the meanings assigned by Section
153	153	1467.001.
154	154	(b) Except as provided by Subsection (d), the administrator
155	155	of a managed care plan provided under the group benefits program
156	156	shall pay for a covered health care or medical service performed for
157	157	or a covered supply related to that service provided to a
158	158	participant by an out-of-network provider who is a diagnostic
159	159	imaging provider, [or] laboratory service provider, or ground
160	160	ambulance service provider at the usual and customary rate or at an
161	161	agreed rate if the provider performed the service in connection
162	162	with a health care or medical service performed by a participating
163	163	provider. The administrator shall make a payment required by this
164	164	subsection directly to the provider not later than, as applicable:
165	165	(1) the 30th day after the date the administrator
166	166	receives an electronic claim for those services that includes all
167	167	information necessary for the administrator to pay the claim; or
168	168	(2) the 45th day after the date the administrator
169	169	receives a nonelectronic claim for those services that includes all
170	170	information necessary for the administrator to pay the claim.
171	171	(c) Except as provided by Subsection (d), an out-of-network
172	172	provider who is a diagnostic imaging provider, [or] laboratory
173	173	service provider, or ground ambulance service provider or a person
174	174	asserting a claim as an agent or assignee of the provider may not
175	175	bill a participant receiving a health care or medical service or
176	176	supply described by Subsection (b) in, and the participant does not
177	177	have financial responsibility for, an amount greater than an
178	178	applicable copayment, coinsurance, and deductible under the
179	179	participant's managed care plan that:
180	180	(1) is based on:
181	181	(A) the amount initially determined payable by
182	182	the administrator; or
183	183	(B) if applicable, the modified amount as
184	184	determined under the administrator's internal appeal process; and
185	185	(2) is not based on any additional amount determined
186	186	to be owed to the provider under Chapter 1467.
187	187	SECTION 8. The heading to Section 1575.173, Insurance Code,
188	188	is amended to read as follows:
189	189	Sec. 1575.173. PAYMENTS TO CERTAIN OUT-OF-NETWORK
190	190	ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE
191	191	PROVIDERS [PROVIDER PAYMENTS].
192	192	SECTION 9. Sections 1575.173(a), (b), and (c), Insurance
193	193	Code, are amended to read as follows:
194	194	(a) In this section, "diagnostic imaging provider,"
195	195	[provider" and] "laboratory service provider," and "ground
196	196	ambulance service provider" have the meanings assigned by Section
197	197	1467.001.
198	198	(b) Except as provided by Subsection (d), the administrator
199	199	of a managed care plan provided under the group program shall pay
200	200	for a covered health care or medical service performed for or a
201	201	covered supply related to that service provided to an enrollee by an
202	202	out-of-network provider who is a diagnostic imaging provider, [or]
203	203	laboratory service provider, or ground ambulance service provider
204	204	at the usual and customary rate or at an agreed rate if the provider
205	205	performed the service in connection with a health care or medical
206	206	service performed by a participating provider. The administrator
207	207	shall make a payment required by this subsection directly to the
208	208	provider not later than, as applicable:
209	209	(1) the 30th day after the date the administrator
210	210	receives an electronic claim for those services that includes all
211	211	information necessary for the administrator to pay the claim; or
212	212	(2) the 45th day after the date the administrator
213	213	receives a nonelectronic claim for those services that includes all
214	214	information necessary for the administrator to pay the claim.
215	215	(c) Except as provided by Subsection (d), an out-of-network
216	216	provider who is a diagnostic imaging provider, [or] laboratory
217	217	service provider, or ground ambulance service provider or a person
218	218	asserting a claim as an agent or assignee of the provider may not
219	219	bill an enrollee receiving a health care or medical service or
220	220	supply described by Subsection (b) in, and the enrollee does not
221	221	have financial responsibility for, an amount greater than an
222	222	applicable copayment, coinsurance, and deductible under the
223	223	enrollee's managed care plan that:
224	224	(1) is based on:
225	225	(A) the amount initially determined payable by
226	226	the administrator; or
227	227	(B) if applicable, the modified amount as
228	228	determined under the administrator's internal appeal process; and
229	229	(2) is not based on any additional amount determined
230	230	to be owed to the provider under Chapter 1467.
231	231	SECTION 10. The heading to Section 1579.111, Insurance
232	232	Code, is amended to read as follows:
233	233	Sec. 1579.111. PAYMENTS TO CERTAIN OUT-OF-NETWORK
234	234	ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE
235	235	PROVIDERS [PROVIDER PAYMENTS].
236	236	SECTION 11. Sections 1579.111(a), (b), and (c), Insurance
237	237	Code, are amended to read as follows:
238	238	(a) In this section, "diagnostic imaging provider,"
239	239	[provider" and] "laboratory service provider," and "ground
240	240	ambulance service provider" have the meanings assigned by Section
241	241	1467.001.
242	242	(b) Except as provided by Subsection (d), the administrator
243	243	of a managed care plan provided under this chapter shall pay for a
244	244	covered health care or medical service performed for or a covered
245	245	supply related to that service provided to an enrollee by an
246	246	out-of-network provider who is a diagnostic imaging provider, [or]
247	247	laboratory service provider, or ground ambulance service provider
248	248	at the usual and customary rate or at an agreed rate if the provider
249	249	performed the service in connection with a health care or medical
250	250	service performed by a participating provider. The administrator
251	251	shall make a payment required by this subsection directly to the
252	252	provider not later than, as applicable:
253	253	(1) the 30th day after the date the administrator
254	254	receives an electronic claim for those services that includes all
255	255	information necessary for the administrator to pay the claim; or
256	256	(2) the 45th day after the date the administrator
257	257	receives a nonelectronic claim for those services that includes all
258	258	information necessary for the administrator to pay the claim.
259	259	(c) Except as provided by Subsection (d), an out-of-network
260	260	provider who is a diagnostic imaging provider, [or] laboratory
261	261	service provider, or ground ambulance service provider or a person
262	262	asserting a claim as an agent or assignee of the provider may not
263	263	bill an enrollee receiving a health care or medical service or
264	264	supply described by Subsection (b) in, and the enrollee does not
265	265	have financial responsibility for, an amount greater than an
266	266	applicable copayment, coinsurance, and deductible under the
267	267	enrollee's managed care plan that:
268	268	(1) is based on:
269	269	(A) the amount initially determined payable by
270	270	the administrator; or
271	271	(B) if applicable, a modified amount as
272	272	determined under the administrator's internal appeal process; and
273	273	(2) is not based on any additional amount determined
274	274	to be owed to the provider under Chapter 1467.
275	275	SECTION 12. Section 1467.001, Insurance Code, is amended by
276	276	adding Subdivision (3-b) and amending Subdivisions (4) and (6-a) to
277	277	read as follows:
278	278	(3-b) [(4)] "Facility-based provider" means a
279	279	physician, health care practitioner, or other health care provider
280	280	who provides health care or medical services to patients of a
281	281	facility.
282	282	(4) "Ground ambulance service provider" means a
283	283	private entity or municipality providing emergency and
284	284	nonemergency ground ambulance services. The term includes all
285	285	personnel employed by the private entity or municipality who bill
286	286	separately for ground ambulance services.
287	287	(6-a) "Out-of-network provider" means a diagnostic
288	288	imaging provider, emergency care provider, facility-based
289	289	provider, [or] laboratory service provider, or ground ambulance
290	290	service provider that is not a participating provider for a health
291	291	benefit plan.
292	292	SECTION 13. Section 1467.050(a), Insurance Code, is amended
293	293	to read as follows:
294	294	(a) This subchapter applies only with respect to a health
295	295	benefit claim submitted by an out-of-network provider that is a
296	296	facility or ground ambulance service provider.
297	297	SECTION 14. Section 1467.051(a), Insurance Code, is amended
298	298	to read as follows:
299	299	(a) An out-of-network provider or a health benefit plan
300	300	issuer or administrator may request mediation of a settlement of an
301	301	out-of-network health benefit claim through a portal on the
302	302	department's Internet website if:
303	303	(1) there is an amount billed by the provider and
304	304	unpaid by the issuer or administrator after copayments,
305	305	deductibles, and coinsurance for which an enrollee may not be
306	306	billed; and
307	307	(2) the health benefit claim is for:
308	308	(A) emergency care;
309	309	(B) an out-of-network laboratory service; [or]
310	310	(C) an out-of-network diagnostic imaging
311	311	service; or
312	312	(D) an out-of-network ground ambulance service.
313	313	SECTION 15. Section 1467.081, Insurance Code, is amended to
314	314	read as follows:
315	315	Sec. 1467.081. APPLICABILITY OF SUBCHAPTER. This
316	316	subchapter applies only with respect to a health benefit claim
317	317	submitted by an out-of-network provider who is not a facility or
318	318	ground ambulance service provider.
319	319	SECTION 16. The changes in law made by this Act apply only
320	320	to a ground ambulance service provided on or after January 1, 2022.
321	321	A ground ambulance service provided before January 1, 2022, is
322	322	governed by the law in effect immediately before the effective date
323	323	of this Act, and that law is continued in effect for that purpose.
324	324	SECTION 17. This Act takes effect September 1, 2021.