TX
Texas Senate Bill SB999

Texas 2021 - 87th Regular

Texas Senate Bill SB999 Compare Versions

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1-87R24929 SCL-F
2- By: Hancock, et al. S.B. No. 999
3- (Oliverson)
4- Substitute the following for S.B. No. 999: No.
1+By: Hancock, Whitmire S.B. No. 999
52
63
74 A BILL TO BE ENTITLED
85 AN ACT
9- relating to consumer protections against and county and municipal
10- authority regarding certain medical and health care billing by
11- ambulance service providers.
6+ relating to county and municipal authority and a study regarding
7+ certain medical and health care billing by ambulance service
8+ providers.
129 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13- ARTICLE 1. ELIMINATING SURPRISE BILLING FOR CERTAIN GROUND
14- AMBULANCE SERVICES UNDER CERTAIN HEALTH BENEFIT PLANS
15- SECTION 1.01. Section 1271.008, Insurance Code, is amended
16- to read as follows:
17- Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A
18- health maintenance organization shall provide written notice in
19- accordance with this section in an explanation of benefits provided
20- to the enrollee and the physician or provider in connection with a
21- health care service or supply provided by a non-network physician
22- or provider. The notice must include:
23- (1) a statement of the billing prohibition under
24- Section 1271.155, 1271.157, [or] 1271.158, or 1271.159, as
25- applicable;
26- (2) the total amount the physician or provider may
27- bill the enrollee under the enrollee's health benefit plan and an
28- itemization of copayments, coinsurance, deductibles, and other
29- amounts included in that total; and
30- (3) for an explanation of benefits provided to the
31- physician or provider, information required by commissioner rule
32- advising the physician or provider of the availability of mediation
33- or arbitration, as applicable, under Chapter 1467.
34- (b) A health maintenance organization shall provide the
35- explanation of benefits with the notice required by this section to
36- a physician or health care provider not later than the date the
37- health maintenance organization makes a payment under Section
38- 1271.155, 1271.157, [or] 1271.158, or 1271.159, as applicable.
39- SECTION 1.02. Subchapter D, Chapter 1271, Insurance Code,
40- is amended by adding Section 1271.159 to read as follows:
41- Sec. 1271.159. NON-NETWORK GROUND AMBULANCE SERVICE
42- PROVIDER. (a) In this section, "ground ambulance service
43- provider" has the meaning assigned by Section 1467.001.
44- (b) A health maintenance organization shall pay for a
45- covered health care service performed by or a covered supply
46- related to that service provided to an enrollee by a non-network
47- ground ambulance service provider at the usual and customary rate
48- or at an agreed rate. The health maintenance organization shall
49- make a payment required by this subsection directly to the provider
50- not later than, as applicable:
51- (1) the 30th day after the date the health maintenance
52- organization receives an electronic clean claim as defined by
53- Section 843.336 for those services that includes all information
54- necessary for the health maintenance organization to pay the claim;
55- or
56- (2) the 45th day after the date the health maintenance
57- organization receives a nonelectronic clean claim as defined by
58- Section 843.336 for those services that includes all information
59- necessary for the health maintenance organization to pay the claim.
60- (c) A non-network ground ambulance service provider or a
61- person asserting a claim as an agent or assignee of the provider may
62- not bill an enrollee receiving a health care service or supply
63- described by Subsection (b) in, and the enrollee does not have
64- financial responsibility for, an amount greater than an applicable
65- copayment, coinsurance, and deductible under the enrollee's health
66- care plan that:
67- (1) is based on:
68- (A) the amount initially determined payable by
69- the health maintenance organization; or
70- (B) if applicable, a modified amount as
71- determined under the health maintenance organization's internal
72- appeal process; and
73- (2) is not based on any additional amount determined
74- to be owed to the provider under Chapter 1467.
75- (d) This section may not be construed to require the
76- imposition of a penalty under Section 843.342.
77- SECTION 1.03. Section 1301.0045(b), Insurance Code, is
10+ SECTION 1. Section 113.902(a), Local Government Code, is
7811 amended to read as follows:
79- (b) Except as provided by Sections 1301.0052, 1301.0053,
80- 1301.155, 1301.164, [and] 1301.165, and 1301.166, this chapter may
81- not be construed to require an exclusive provider benefit plan to
82- compensate a nonpreferred provider for services provided to an
83- insured.
84- SECTION 1.04. Section 1301.010, Insurance Code, is amended
85- to read as follows:
86- Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An
87- insurer shall provide written notice in accordance with this
88- section in an explanation of benefits provided to the insured and
89- the physician or health care provider in connection with a medical
90- care or health care service or supply provided by an out-of-network
91- provider. The notice must include:
92- (1) a statement of the billing prohibition under
93- Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or 1301.166,
94- as applicable;
95- (2) the total amount the physician or provider may
96- bill the insured under the insured's preferred provider benefit
97- plan and an itemization of copayments, coinsurance, deductibles,
98- and other amounts included in that total; and
99- (3) for an explanation of benefits provided to the
100- physician or provider, information required by commissioner rule
101- advising the physician or provider of the availability of mediation
102- or arbitration, as applicable, under Chapter 1467.
103- (b) An insurer shall provide the explanation of benefits
104- with the notice required by this section to a physician or health
105- care provider not later than the date the insurer makes a payment
106- under Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or
107- 1301.166, as applicable.
108- SECTION 1.05. Subchapter D, Chapter 1301, Insurance Code,
109- is amended by adding Section 1301.166 to read as follows:
110- Sec. 1301.166. OUT-OF-NETWORK GROUND AMBULANCE SERVICE
111- PROVIDER. (a) In this section, "ground ambulance service
112- provider" has the meaning assigned by Section 1467.001.
113- (b) An insurer shall pay for a covered medical care or
114- health care service performed for or a covered supply related to
115- that service provided to an insured by an out-of-network provider
116- who is a ground ambulance service provider at the usual and
117- customary rate or at an agreed rate. The insurer shall make a
118- payment required by this subsection directly to the provider not
119- later than, as applicable:
120- (1) the 30th day after the date the insurer receives an
121- electronic clean claim as defined by Section 1301.101 for those
122- services that includes all information necessary for the insurer to
123- pay the claim; or
124- (2) the 45th day after the date the insurer receives a
125- nonelectronic clean claim as defined by Section 1301.101 for those
126- services that includes all information necessary for the insurer to
127- pay the claim.
128- (c) An out-of-network provider who is a ground ambulance
129- service provider or a person asserting a claim as an agent or
130- assignee of the provider may not bill an insured receiving a medical
131- care or health care service or supply described by Subsection (b)
132- in, and the insured does not have financial responsibility for, an
133- amount greater than an applicable copayment, coinsurance, and
134- deductible under the insured's preferred provider benefit plan
135- that:
136- (1) is based on:
137- (A) the amount initially determined payable by
138- the insurer; or
139- (B) if applicable, the modified amount as
140- determined under the insurer's internal appeal process; and
141- (2) is not based on any additional amount determined
142- to be owed to the provider under Chapter 1467.
143- (d) This section may not be construed to require the
144- imposition of a penalty under Section 1301.137.
145- SECTION 1.06. Section 1551.015, Insurance Code, is amended
146- to read as follows:
147- Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a)
148- The administrator of a managed care plan provided under the group
149- benefits program shall provide written notice in accordance with
150- this section in an explanation of benefits provided to the
151- participant and the physician or health care provider in connection
152- with a health care or medical service or supply provided by an
153- out-of-network provider. The notice must include:
154- (1) a statement of the billing prohibition under
155- Section 1551.228, 1551.229, [or] 1551.230, or 1551.231, as
156- applicable;
157- (2) the total amount the physician or provider may
158- bill the participant under the participant's managed care plan and
159- an itemization of copayments, coinsurance, deductibles, and other
160- amounts included in that total; and
161- (3) for an explanation of benefits provided to the
162- physician or provider, information required by commissioner rule
163- advising the physician or provider of the availability of mediation
164- or arbitration, as applicable, under Chapter 1467.
165- (b) The administrator shall provide the explanation of
166- benefits with the notice required by this section to a physician or
167- health care provider not later than the date the administrator
168- makes a payment under Section 1551.228, 1551.229, [or] 1551.230, or
169- 1551.231, as applicable.
170- SECTION 1.07. Subchapter E, Chapter 1551, Insurance Code,
171- is amended by adding Section 1551.231 to read as follows:
172- Sec. 1551.231. OUT-OF-NETWORK GROUND AMBULANCE SERVICE
173- PROVIDER PAYMENTS. (a) In this section, "ground ambulance service
174- provider" has the meaning assigned by Section 1467.001.
175- (b) The administrator of a managed care plan provided under
176- the group benefits program shall pay for a covered health care or
177- medical service performed for or a covered supply related to that
178- service provided to a participant by an out-of-network provider who
179- is a ground ambulance service provider at the usual and customary
180- rate or at an agreed rate. The administrator shall make a payment
181- required by this subsection directly to the provider not later
182- than, as applicable:
183- (1) the 30th day after the date the administrator
184- receives an electronic claim for those services that includes all
185- information necessary for the administrator to pay the claim; or
186- (2) the 45th day after the date the administrator
187- receives a nonelectronic claim for those services that includes all
188- information necessary for the administrator to pay the claim.
189- (c) An out-of-network provider who is a ground ambulance
190- service provider or a person asserting a claim as an agent or
191- assignee of the provider may not bill a participant receiving a
192- health care or medical service or supply described by Subsection
193- (b) in, and the participant does not have financial responsibility
194- for, an amount greater than an applicable copayment, coinsurance,
195- and deductible under the participant's managed care plan that:
196- (1) is based on:
197- (A) the amount initially determined payable by
198- the administrator; or
199- (B) if applicable, the modified amount as
200- determined under the administrator's internal appeal process; and
201- (2) is not based on any additional amount determined
202- to be owed to the provider under Chapter 1467.
203- SECTION 1.08. Section 1575.009, Insurance Code, is amended
204- to read as follows:
205- Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a)
206- The administrator of a managed care plan provided under the group
207- program shall provide written notice in accordance with this
208- section in an explanation of benefits provided to the enrollee and
209- the physician or health care provider in connection with a health
210- care or medical service or supply provided by an out-of-network
211- provider. The notice must include:
212- (1) a statement of the billing prohibition under
213- Section 1575.171, 1575.172, [or] 1575.173, or 1575.174, as
214- applicable;
215- (2) the total amount the physician or provider may
216- bill the enrollee under the enrollee's managed care plan and an
217- itemization of copayments, coinsurance, deductibles, and other
218- amounts included in that total; and
219- (3) for an explanation of benefits provided to the
220- physician or provider, information required by commissioner rule
221- advising the physician or provider of the availability of mediation
222- or arbitration, as applicable, under Chapter 1467.
223- (b) The administrator shall provide the explanation of
224- benefits with the notice required by this section to a physician or
225- health care provider not later than the date the administrator
226- makes a payment under Section 1575.171, 1575.172, [or] 1575.173, or
227- 1575.174, as applicable.
228- SECTION 1.09. Subchapter D, Chapter 1575, Insurance Code,
229- is amended by adding Section 1575.174 to read as follows:
230- Sec. 1575.174. OUT-OF-NETWORK GROUND AMBULANCE SERVICE
231- PROVIDER PAYMENTS. (a) In this section, "ground ambulance service
232- provider" has the meaning assigned by Section 1467.001.
233- (b) The administrator of a managed care plan provided under
234- the group program shall pay for a covered health care or medical
235- service performed for or a covered supply related to that service
236- provided to an enrollee by an out-of-network provider who is a
237- ground ambulance service provider at the usual and customary rate
238- or at an agreed rate. The administrator shall make a payment
239- required by this subsection directly to the provider not later
240- than, as applicable:
241- (1) the 30th day after the date the administrator
242- receives an electronic claim for those services that includes all
243- information necessary for the administrator to pay the claim; or
244- (2) the 45th day after the date the administrator
245- receives a nonelectronic claim for those services that includes all
246- information necessary for the administrator to pay the claim.
247- (c) An out-of-network provider who is a ground ambulance
248- service provider or a person asserting a claim as an agent or
249- assignee of the provider may not bill an enrollee receiving a health
250- care or medical service or supply described by Subsection (b) in,
251- and the enrollee does not have financial responsibility for, an
252- amount greater than an applicable copayment, coinsurance, and
253- deductible under the enrollee's managed care plan that:
254- (1) is based on:
255- (A) the amount initially determined payable by
256- the administrator; or
257- (B) if applicable, the modified amount as
258- determined under the administrator's internal appeal process; and
259- (2) is not based on any additional amount determined
260- to be owed to the provider under Chapter 1467.
261- SECTION 1.10. Section 1579.009, Insurance Code, is amended
262- to read as follows:
263- Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a)
264- The administrator of a managed care plan provided under this
265- chapter shall provide written notice in accordance with this
266- section in an explanation of benefits provided to the enrollee and
267- the physician or health care provider in connection with a health
268- care or medical service or supply provided by an out-of-network
269- provider. The notice must include:
270- (1) a statement of the billing prohibition under
271- Section 1579.109, 1579.110, [or] 1579.111, or 1579.112, as
272- applicable;
273- (2) the total amount the physician or provider may
274- bill the enrollee under the enrollee's managed care plan and an
275- itemization of copayments, coinsurance, deductibles, and other
276- amounts included in that total; and
277- (3) for an explanation of benefits provided to the
278- physician or provider, information required by commissioner rule
279- advising the physician or provider of the availability of mediation
280- or arbitration, as applicable, under Chapter 1467.
281- (b) The administrator shall provide the explanation of
282- benefits with the notice required by this section to a physician or
283- health care provider not later than the date the administrator
284- makes a payment under Section 1579.109, 1579.110, [or] 1579.111, or
285- 1579.112, as applicable.
286- SECTION 1.11. Subchapter C, Chapter 1579, Insurance Code,
287- is amended by adding Section 1579.112 to read as follows:
288- Sec. 1579.112. OUT-OF-NETWORK GROUND AMBULANCE SERVICE
289- PROVIDER PAYMENTS. (a) In this section, "ground ambulance service
290- provider" has the meaning assigned by Section 1467.001.
291- (b) The administrator of a managed care plan provided under
292- this chapter shall pay for a covered health care or medical service
293- performed for or a covered supply related to that service provided
294- to an enrollee by an out-of-network provider who is a ground
295- ambulance service provider at the usual and customary rate or at an
296- agreed rate. The administrator shall make a payment required by
297- this subsection directly to the provider not later than, as
298- applicable:
299- (1) the 30th day after the date the administrator
300- receives an electronic claim for those services that includes all
301- information necessary for the administrator to pay the claim; or
302- (2) the 45th day after the date the administrator
303- receives a nonelectronic claim for those services that includes all
304- information necessary for the administrator to pay the claim.
305- (c) An out-of-network provider who is a ground ambulance
306- service provider or a person asserting a claim as an agent or
307- assignee of the provider may not bill an enrollee receiving a health
308- care or medical service or supply described by Subsection (b) in,
309- and the enrollee does not have financial responsibility for, an
310- amount greater than an applicable copayment, coinsurance, and
311- deductible under the enrollee's managed care plan that:
312- (1) is based on:
313- (A) the amount initially determined payable by
314- the administrator; or
315- (B) if applicable, a modified amount as
316- determined under the administrator's internal appeal process; and
317- (2) is not based on any additional amount determined
318- to be owed to the provider under Chapter 1467.
319- ARTICLE 2. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
320- SECTION 2.01. Section 1467.001, Insurance Code, is amended
321- by adding Subdivision (3-b) and amending Subdivisions (4) and (6-a)
322- to read as follows:
323- (3-b) [(4)] "Facility-based provider" means a
324- physician, health care practitioner, or other health care provider
325- who provides health care or medical services to patients of a
326- facility.
327- (4) "Ground ambulance service provider" means a health
328- care provider using a ground vehicle in transporting an ill or
329- injured individual from a facility to another facility. The term
330- includes an emergency medical services provider and a provider
331- using emergency medical services vehicles, as those terms are
332- defined by Section 773.003, Health and Safety Code, except the
333- terms do not include an air ambulance. The term does not include a
334- ground ambulance service provided by a county or municipality.
335- (6-a) "Out-of-network provider" means a diagnostic
336- imaging provider, emergency care provider, facility-based
337- provider, [or] laboratory service provider, or ground ambulance
338- service provider that is not a participating provider for a health
339- benefit plan.
340- SECTION 2.02. The heading to Subchapter B, Chapter 1467,
341- Insurance Code, is amended to read as follows:
342- SUBCHAPTER B. MANDATORY MEDIATION FOR OUT-OF-NETWORK FACILITIES
343- AND GROUND AMBULANCE SERVICE PROVIDERS
344- SECTION 2.03. Section 1467.050(a), Insurance Code, is
345- amended to read as follows:
346- (a) This subchapter applies only with respect to a health
347- benefit claim submitted by an out-of-network provider that is a
348- facility or ground ambulance service provider.
349- SECTION 2.04. Section 1467.051(a), Insurance Code, is
350- amended to read as follows:
351- (a) An out-of-network provider or a health benefit plan
352- issuer or administrator may request mediation of a settlement of an
353- out-of-network health benefit claim through a portal on the
354- department's Internet website if:
355- (1) there is an amount billed by the provider and
356- unpaid by the issuer or administrator after copayments,
357- deductibles, and coinsurance for which an enrollee may not be
358- billed; and
359- (2) the health benefit claim is for:
360- (A) emergency care;
361- (B) an out-of-network laboratory service; [or]
362- (C) an out-of-network diagnostic imaging
363- service; or
364- (D) an out-of-network ground ambulance service.
365- SECTION 2.05. Subchapter B, Chapter 1467, Insurance Code,
366- is amended by adding Section 1467.0555 to read as follows:
367- Sec. 1467.0555. MEDIATION INVOLVING GROUND AMBULANCE
368- SERVICE PROVIDER. (a) A ground ambulance service provider may
369- elect to submit multiple claims to mediation in one proceeding if:
370- (1) the total amount in controversy for the claims
371- does not exceed $5,000; and
372- (2) the claims are limited to the same administrator
373- or health benefit plan issuer.
374- (b) A mediation of a settlement of a health benefit claim
375- for an out-of-network ground ambulance service must be completed
376- not later than the 90th day after the date of the request for
377- mediation.
378- ARTICLE 3. BALANCE BILLING FOR COUNTY AMBULANCE SERVICES
379- SECTION 3.01. Chapter 140, Local Government Code, is
380- amended by adding Section 140.013 to read as follows:
12+ (a) Except as provided by Section 140.013, the [The] county
13+ treasurer shall direct prosecution for the recovery of any debt
14+ owed to the county, as provided by law, and shall supervise the
15+ collection of the debt.
16+ SECTION 2. Chapter 140, Local Government Code, is amended
17+ by adding Section 140.013 to read as follows:
38118 Sec. 140.013. BALANCE BILLING FOR COUNTY AND MUNICIPAL
38219 AMBULANCE SERVICES. (a) "Balance billing" means the practice of
38320 charging an enrollee in a health benefit plan to recover from the
38421 enrollee the balance of a health care provider's fee for a service
38522 received by the enrollee from the health care provider that is not
38623 fully reimbursed by the enrollee's health benefit plan.
38724 (b) A county or municipality may elect to consider a health
388- benefit plan payment toward a claim for air or ground ambulance
25+ benefit plan payment towards a claim for air or ground ambulance
38926 services provided by the county or municipality as payment in full
39027 for those services regardless of the amount the county or
39128 municipality charged for those services.
39229 (c) A county or municipality may not practice balance
39330 billing for a claim for which the county or municipality makes an
39431 election under Subsection (b).
395- ARTICLE 4. STUDY
396- SECTION 4.01. (a) In this section, "department" means the
32+ SECTION 3. (a) In this section, "department" means the
39733 Texas Department of Insurance.
39834 (b) The department shall conduct a study on the balance
39935 billing practices of county and municipal ground ambulance service
400- providers, the variations in prices for county and municipal ground
401- ambulance services, the proportion of ground ambulances that are
402- in-network, trends in network inclusion, and factors contributing
403- to the network status of ground ambulances. The department may seek
404- the assistance of the Department of State Health Services in
405- conducting the study.
36+ providers and the variations in prices for county and municipal
37+ ground ambulance services.
40638 (c) Not later than December 1, 2022, the department shall
40739 provide a written report of the results of the study conducted under
40840 Subsection (b) of this section to the governor, lieutenant
40941 governor, speaker of the house of representatives, and members of
41042 the standing committees of the legislature with primary
41143 jurisdiction over the department.
41244 (d) This section expires September 1, 2023.
413- ARTICLE 5. TRANSITION AND EFFECTIVE DATE
414- SECTION 5.01. The changes in law made by Articles 1 and 2 of
415- this Act apply only to a ground ambulance service provided on or
416- after January 1, 2022. A ground ambulance service provided before
417- January 1, 2022, is governed by the law in effect immediately before
418- the effective date of this Act, and that law is continued in effect
419- for that purpose.
420- SECTION 5.02. This Act takes effect September 1, 2021.
45+ SECTION 4. This Act takes effect September 1, 2021.