87R6484 SCL-F
By: Hancock, Whitmire S.B. No. 999
A BILL TO BE ENTITLED
AN ACT
relating to consumer protections against certain medical and health
care billing by out-of-network ground ambulance service providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 38.004(a), Insurance Code, is amended to
read as follows:
(a) The department shall, each biennium, conduct a study on
the impacts of S.B. No. 1264, Acts of the 86th Legislature, Regular
Session, 2019, and subsequently enacted laws prohibiting an
individual or entity from billing an insured, participant, or
enrollee in an amount greater than an applicable copayment,
coinsurance, or deductible under the insured's, participant's, or
enrollee's managed care plan or imposing a requirement related to
that prohibition, on Texas consumers and health coverage in this
state, including:
(1) trends in billed amounts for health care or
medical services or supplies, especially emergency services,
laboratory services, diagnostic imaging services, ground ambulance
services, and facility-based services;
(2) comparison of the total amount spent on
out-of-network emergency services, laboratory services, diagnostic
imaging services, ground ambulance services, and facility-based
services by calendar year and provider type or physician specialty;
(3) trends and changes in network participation by
providers of emergency services, laboratory services, diagnostic
imaging services, ground ambulance services, and facility-based
services by provider type or physician specialty, including whether
any terminations were initiated by a health benefit plan issuer,
administrator, or provider;
(4) trends and changes in the amounts paid to
participating providers;
(5) the number of complaints, completed
investigations, and disciplinary sanctions for billing by
providers of emergency services, laboratory services, diagnostic
imaging services, ground ambulance services, or facility-based
services of enrollees for amounts greater than the enrollee's
responsibility under an applicable health benefit plan, including
applicable copayments, coinsurance, and deductibles;
(6) trends in amounts paid to out-of-network
providers;
(7) trends in the usual and customary rate for health
care or medical services or supplies, especially emergency
services, laboratory services, diagnostic imaging services, ground
ambulance services, and facility-based services; and
(8) the effectiveness of the claim dispute resolution
process under Chapter 1467.
SECTION 2. The heading to Section 1271.158, Insurance Code,
is amended to read as follows:
Sec. 1271.158. CERTAIN NON-NETWORK ANCILLARY [DIAGNOSTIC
IMAGING PROVIDER OR LABORATORY] SERVICE PROVIDERS [PROVIDER].
SECTION 3. Sections 1271.158(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) In this section, "diagnostic imaging provider,"
[provider" and] "laboratory service provider," and "ground
ambulance service provider" have the meanings assigned by Section
1467.001.
(b) Except as provided by Subsection (d), a health
maintenance organization shall pay for a covered health care
service performed by or a covered supply related to that service
provided to an enrollee by a non-network diagnostic imaging
provider, [or] laboratory service provider, or ground ambulance
service provider at the usual and customary rate or at an agreed
rate if the provider performed the service in connection with a
health care service performed by a network physician or provider.
The health maintenance organization shall make a payment required
by this subsection directly to the physician or provider not later
than, as applicable:
(1) the 30th day after the date the health maintenance
organization receives an electronic clean claim as defined by
Section 843.336 for those services that includes all information
necessary for the health maintenance organization to pay the claim;
or
(2) the 45th day after the date the health maintenance
organization receives a nonelectronic clean claim as defined by
Section 843.336 for those services that includes all information
necessary for the health maintenance organization to pay the claim.
(c) Except as provided by Subsection (d), a non-network
diagnostic imaging provider, [or] laboratory service provider, or
ground ambulance service provider or a person asserting a claim as
an agent or assignee of the provider may not bill an enrollee
receiving a health care service or supply described by Subsection
(b) in, and the enrollee does not have financial responsibility
for, an amount greater than an applicable copayment, coinsurance,
and deductible under the enrollee's health care plan that:
(1) is based on:
(A) the amount initially determined payable by
the health maintenance organization; or
(B) if applicable, a modified amount as
determined under the health maintenance organization's internal
appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 4. The heading to Section 1301.165, Insurance Code,
is amended to read as follows:
Sec. 1301.165. CERTAIN OUT-OF-NETWORK ANCILLARY
[DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE PROVIDERS
[PROVIDER].
SECTION 5. Sections 1301.165(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) In this section, "diagnostic imaging provider,"
[provider" and] "laboratory service provider," and "ground
ambulance service provider" have the meanings assigned by Section
1467.001.
(b) Except as provided by Subsection (d), an insurer shall
pay for a covered medical care or health care service performed by
or a covered supply related to that service provided to an insured
by an out-of-network provider who is a diagnostic imaging provider,
[or] laboratory service provider, or ground ambulance service
provider at the usual and customary rate or at an agreed rate if the
provider performed the service in connection with a medical care or
health care service performed by a preferred provider. The insurer
shall make a payment required by this subsection directly to the
provider not later than, as applicable:
(1) the 30th day after the date the insurer receives an
electronic clean claim as defined by Section 1301.101 for those
services that includes all information necessary for the insurer to
pay the claim; or
(2) the 45th day after the date the insurer receives a
nonelectronic clean claim as defined by Section 1301.101 for those
services that includes all information necessary for the insurer to
pay the claim.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a diagnostic imaging provider, [or] laboratory
service provider, or ground ambulance service provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an insured receiving a medical care or health care service or
supply described by Subsection (b) in, and the insured does not have
financial responsibility for, an amount greater than an applicable
copayment, coinsurance, and deductible under the insured's
preferred provider benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) if applicable, the modified amount as
determined under the insurer's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 6. The heading to Section 1551.230, Insurance Code,
is amended to read as follows:
Sec. 1551.230. PAYMENTS TO CERTAIN OUT-OF-NETWORK
ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE
PROVIDERS [PROVIDER PAYMENTS].
SECTION 7. Sections 1551.230(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) In this section, "diagnostic imaging provider,"
[provider" and] "laboratory service provider," and "ground
ambulance service provider" have the meanings assigned by Section
1467.001.
(b) Except as provided by Subsection (d), the administrator
of a managed care plan provided under the group benefits program
shall pay for a covered health care or medical service performed for
or a covered supply related to that service provided to a
participant by an out-of-network provider who is a diagnostic
imaging provider, [or] laboratory service provider, or ground
ambulance service provider at the usual and customary rate or at an
agreed rate if the provider performed the service in connection
with a health care or medical service performed by a participating
provider. The administrator shall make a payment required by this
subsection directly to the provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a diagnostic imaging provider, [or] laboratory
service provider, or ground ambulance service provider or a person
asserting a claim as an agent or assignee of the provider may not
bill a participant receiving a health care or medical service or
supply described by Subsection (b) in, and the participant does not
have financial responsibility for, an amount greater than an
applicable copayment, coinsurance, and deductible under the
participant's managed care plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) if applicable, the modified amount as
determined under the administrator's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 8. The heading to Section 1575.173, Insurance Code,
is amended to read as follows:
Sec. 1575.173. PAYMENTS TO CERTAIN OUT-OF-NETWORK
ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE
PROVIDERS [PROVIDER PAYMENTS].
SECTION 9. Sections 1575.173(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) In this section, "diagnostic imaging provider,"
[provider" and] "laboratory service provider," and "ground
ambulance service provider" have the meanings assigned by Section
1467.001.
(b) Except as provided by Subsection (d), the administrator
of a managed care plan provided under the group program shall pay
for a covered health care or medical service performed for or a
covered supply related to that service provided to an enrollee by an
out-of-network provider who is a diagnostic imaging provider, [or]
laboratory service provider, or ground ambulance service provider
at the usual and customary rate or at an agreed rate if the provider
performed the service in connection with a health care or medical
service performed by a participating provider. The administrator
shall make a payment required by this subsection directly to the
provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a diagnostic imaging provider, [or] laboratory
service provider, or ground ambulance service provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an enrollee receiving a health care or medical service or
supply described by Subsection (b) in, and the enrollee does not
have financial responsibility for, an amount greater than an
applicable copayment, coinsurance, and deductible under the
enrollee's managed care plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) if applicable, the modified amount as
determined under the administrator's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 10. The heading to Section 1579.111, Insurance
Code, is amended to read as follows:
Sec. 1579.111. PAYMENTS TO CERTAIN OUT-OF-NETWORK
ANCILLARY [DIAGNOSTIC IMAGING PROVIDER OR LABORATORY] SERVICE
PROVIDERS [PROVIDER PAYMENTS].
SECTION 11. Sections 1579.111(a), (b), and (c), Insurance
Code, are amended to read as follows:
(a) In this section, "diagnostic imaging provider,"
[provider" and] "laboratory service provider," and "ground
ambulance service provider" have the meanings assigned by Section
1467.001.
(b) Except as provided by Subsection (d), the administrator
of a managed care plan provided under this chapter shall pay for a
covered health care or medical service performed for or a covered
supply related to that service provided to an enrollee by an
out-of-network provider who is a diagnostic imaging provider, [or]
laboratory service provider, or ground ambulance service provider
at the usual and customary rate or at an agreed rate if the provider
performed the service in connection with a health care or medical
service performed by a participating provider. The administrator
shall make a payment required by this subsection directly to the
provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(c) Except as provided by Subsection (d), an out-of-network
provider who is a diagnostic imaging provider, [or] laboratory
service provider, or ground ambulance service provider or a person
asserting a claim as an agent or assignee of the provider may not
bill an enrollee receiving a health care or medical service or
supply described by Subsection (b) in, and the enrollee does not
have financial responsibility for, an amount greater than an
applicable copayment, coinsurance, and deductible under the
enrollee's managed care plan that:
(1) is based on:
(A) the amount initially determined payable by
the administrator; or
(B) if applicable, a modified amount as
determined under the administrator's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
SECTION 12. Section 1467.001, Insurance Code, is amended by
adding Subdivision (3-b) and amending Subdivisions (4) and (6-a) to
read as follows:
(3-b) [(4)] "Facility-based provider" means a
physician, health care practitioner, or other health care provider
who provides health care or medical services to patients of a
facility.
(4) "Ground ambulance service provider" means a
private entity or municipality providing emergency and
nonemergency ground ambulance services. The term includes all
personnel employed by the private entity or municipality who bill
separately for ground ambulance services.
(6-a) "Out-of-network provider" means a diagnostic
imaging provider, emergency care provider, facility-based
provider, [or] laboratory service provider, or ground ambulance
service provider that is not a participating provider for a health
benefit plan.
SECTION 13. Section 1467.050(a), Insurance Code, is amended
to read as follows:
(a) This subchapter applies only with respect to a health
benefit claim submitted by an out-of-network provider that is a
facility or ground ambulance service provider.
SECTION 14. Section 1467.051(a), Insurance Code, is amended
to read as follows:
(a) An out-of-network provider or a health benefit plan
issuer or administrator may request mediation of a settlement of an
out-of-network health benefit claim through a portal on the
department's Internet website if:
(1) there is an amount billed by the provider and
unpaid by the issuer or administrator after copayments,
deductibles, and coinsurance for which an enrollee may not be
billed; and
(2) the health benefit claim is for:
(A) emergency care;
(B) an out-of-network laboratory service; [or]
(C) an out-of-network diagnostic imaging
service; or
(D) an out-of-network ground ambulance service.
SECTION 15. Section 1467.081, Insurance Code, is amended to
read as follows:
Sec. 1467.081. APPLICABILITY OF SUBCHAPTER. This
subchapter applies only with respect to a health benefit claim
submitted by an out-of-network provider who is not a facility or
ground ambulance service provider.
SECTION 16. The changes in law made by this Act apply only
to a ground ambulance service provided on or after January 1, 2022.
A ground ambulance service provided before January 1, 2022, is
governed by the law in effect immediately before the effective date
of this Act, and that law is continued in effect for that purpose.
SECTION 17. This Act takes effect September 1, 2021.