By: Oliverson, Raymond H.B. No. 1236
A BILL TO BE ENTITLED
AN ACT
relating to the definition of and certain determinations regarding
emergency care for purposes of certain health benefit plan
coverage.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.002(7), Insurance Code, is amended
to read as follows:
(7) "Emergency care" means health care services
provided in a hospital emergency facility, freestanding emergency
medical care facility, or comparable emergency facility to evaluate
and stabilize medical conditions of a recent onset and severity,
including severe pain, regardless of the final diagnosis of the
conditions, that would lead a prudent layperson possessing an
average knowledge of medicine and health to believe that the
individual's condition, sickness, or injury is of such a nature
that failure to get immediate medical care could:
(A) place the individual's health in serious
jeopardy;
(B) result in serious impairment to bodily
functions;
(C) result in serious dysfunction of a bodily
organ or part;
(D) result in serious disfigurement; or
(E) for a pregnant woman, result in serious
jeopardy to the health of the fetus.
SECTION 2. Subchapter A, Chapter 843, Insurance Code, is
amended by adding Section 843.011 to read as follows:
Sec. 843.011. EMERGENCY SERVICE DETERMINATIONS. Nothing in
this subchapter prohibits a health maintenance organization from
considering diagnosis codes to detect fraud or abuse.
SECTION 3. Section 1301.155(a), Insurance Code, is amended
to read as follows:
(a) In this section, "emergency care" means health care
services provided in a hospital emergency facility, freestanding
emergency medical care facility, or comparable emergency facility
to evaluate and stabilize a medical condition of a recent onset and
severity, including severe pain, regardless of the final diagnosis
of the condition, that would lead a prudent layperson possessing an
average knowledge of medicine and health to believe that the
person's condition, sickness, or injury is of such a nature that
failure to get immediate medical care could result in:
(1) placing the person's health in serious jeopardy;
(2) serious impairment to bodily functions;
(3) serious dysfunction of a bodily organ or part;
(4) serious disfigurement; or
(5) in the case of a pregnant woman, serious jeopardy
to the health of the fetus.
SECTION 4. Subchapter D, Chapter 1301, Insurance Code, is
amended by adding Section 1301.166 to read as follows:
Sec. 1301.166. EMERGENCY SERVICE DETERMINATIONS. Nothing
in this subchapter prohibits a preferred provider benefit plan from
considering diagnosis codes to detect fraud or abuse.
SECTION 5. Section 4201.002(2), Insurance Code, is amended
to read as follows:
(2) "Emergency care" means health care services
provided in a hospital emergency facility or comparable facility to
evaluate and stabilize medical conditions of a recent onset and
severity, including severe pain, regardless of the final diagnosis
of the conditions, that would lead a prudent layperson possessing
an average knowledge of medicine and health to believe that the
individual's condition, sickness, or injury is of such a nature
that failure to get immediate medical care could:
(A) place the individual's health in serious
jeopardy;
(B) result in serious impairment to bodily
functions;
(C) result in serious dysfunction of a bodily
organ or part;
(D) result in serious disfigurement; or
(E) for a pregnant woman, result in serious
jeopardy to the health of the fetus.
SECTION 6. Subchapter A, Chapter 4201, Insurance Code, is
amended by adding Section 4201.005 to read as follows:
Sec. 4201.005. EMERGENCY SERVICE DETERMINATIONS. Nothing
in this subchapter prohibits a payor from considering diagnosis
codes to detect fraud or abuse.
SECTION 7. The changes in law made by this Act apply only to
a health benefit plan delivered, issued for delivery, or renewed on
or after January 1, 2024. A health benefit plan delivered, issued
for delivery, or renewed before January 1, 2024, is governed by the
law as it existed immediately before the effective date of this Act,
and that law is continued in effect for that purpose.
SECTION 8. This Act takes effect September 1, 2023.