88R12546 SCL-D
By: Zaffirini S.B. No. 2476
A BILL TO BE ENTITLED
AN ACT
relating to consumer protections against certain medical and health
care billing by municipal ground ambulance service providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. ELIMINATING SURPRISE BILLING FOR MUNICIPAL GROUND
AMBULANCE SERVICES UNDER CERTAIN HEALTH BENEFIT PLANS
SECTION 1.01. Section 1271.008, Insurance Code, is amended
to read as follows:
Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A
health maintenance organization shall provide written notice in
accordance with this section in an explanation of benefits provided
to the enrollee and the physician or provider in connection with a
health care service or supply or transportation provided by a
non-network physician or provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1271.155, 1271.157, [or] 1271.158, or 1271.159, as
applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's health benefit plan and an
itemization of copayments, coinsurance, deductibles, and other
amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) A health maintenance organization shall provide the
explanation of benefits with the notice required by this section to
a physician or health care provider not later than the date the
health maintenance organization makes a payment under Section
1271.155, 1271.157, [or] 1271.158, or 1271.159, as applicable.
SECTION 1.02. Subchapter D, Chapter 1271, Insurance Code,
is amended by adding Section 1271.159 to read as follows:
Sec. 1271.159. NON-NETWORK MUNICIPAL GROUND AMBULANCE
SERVICE PROVIDER. (a) In this section, "municipal ground
ambulance service provider" has the meaning assigned by Section
1467.001.
(b) A health maintenance organization shall pay for a
covered health care service performed for, or a covered supply or
covered transportation related to that service provided to, an
enrollee by a non-network municipal ground ambulance service
provider at the usual and customary rate or at an agreed rate. The
health maintenance organization 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 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) A non-network municipal 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 or transportation 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.
(d) This section may not be construed to require the
imposition of a penalty under Section 843.342.
SECTION 1.03. Section 1275.003, Insurance Code, is amended
to read as follows:
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a health benefit plan to which this chapter
applies shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply or transportation provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1275.051, 1275.052, [or] 1275.053, or 1275.054, as
applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's health benefit plan and an
itemization of copayments, coinsurance, deductibles, and other
amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1275.051, 1275.052, [or] 1275.053, or
1275.054, as applicable.
SECTION 1.04. Subchapter B, Chapter 1275, Insurance Code,
is amended by adding Section 1275.054 to read as follows:
Sec. 1275.054. OUT-OF-NETWORK MUNICIPAL GROUND AMBULANCE
SERVICE PROVIDER PAYMENTS. (a) In this section, "municipal ground
ambulance service provider" has the meaning assigned by Section
1467.001.
(b) The administrator of a health benefit plan to which this
chapter applies shall pay for a covered health care or medical
service performed for, or a covered supply or covered
transportation related to that service provided to, an enrollee by
an out-of-network provider who is a municipal ground ambulance
service provider at the usual and customary rate or at an agreed
rate. 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) An out-of-network provider who is a municipal 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 or transportation
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
benefit 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 1.05. Section 1301.0045(b), Insurance Code, is
amended to read as follows:
(b) Except as provided by Sections 1301.0052, 1301.0053,
1301.155, 1301.164, [and] 1301.165, and 1301.166, this chapter may
not be construed to require an exclusive provider benefit plan to
compensate a nonpreferred provider for services provided to an
insured.
SECTION 1.06. Section 1301.010, Insurance Code, is amended
to read as follows:
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An
insurer shall provide written notice in accordance with this
section in an explanation of benefits provided to the insured and
the physician or health care provider in connection with a medical
care or health care service or supply or transportation provided by
an out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or 1301.166,
as applicable;
(2) the total amount the physician or provider may
bill the insured under the insured's preferred provider benefit
plan and an itemization of copayments, coinsurance, deductibles,
and other amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) An insurer shall provide the explanation of benefits
with the notice required by this section to a physician or health
care provider not later than the date the insurer makes a payment
under Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or
1301.166, as applicable.
SECTION 1.07. Subchapter D, Chapter 1301, Insurance Code,
is amended by adding Section 1301.166 to read as follows:
Sec. 1301.166. OUT-OF-NETWORK MUNICIPAL GROUND AMBULANCE
SERVICE PROVIDER. (a) In this section, "municipal ground
ambulance service provider" has the meaning assigned by Section
1467.001.
(b) An insurer shall pay for a covered medical care or
health care service performed for, or a covered supply or covered
transportation related to that service provided to, an insured by
an out-of-network provider who is a municipal ground ambulance
service provider at the usual and customary rate or at an agreed
rate. 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) An out-of-network provider who is a municipal 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 or transportation
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.
(d) This section may not be construed to require the
imposition of a penalty under Section 1301.137.
SECTION 1.08. Section 1551.015, Insurance Code, is amended
to read as follows:
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under the group
benefits program shall provide written notice in accordance with
this section in an explanation of benefits provided to the
participant and the physician or health care provider in connection
with a health care or medical service or supply or transportation
provided by an out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1551.228, 1551.229, [or] 1551.230, or 1551.231, as
applicable;
(2) the total amount the physician or provider may
bill the participant under the participant's managed care plan and
an itemization of copayments, coinsurance, deductibles, and other
amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1551.228, 1551.229, [or] 1551.230, or
1551.231, as applicable.
SECTION 1.09. Subchapter E, Chapter 1551, Insurance Code,
is amended by adding Section 1551.231 to read as follows:
Sec. 1551.231. OUT-OF-NETWORK MUNICIPAL GROUND AMBULANCE
SERVICE PROVIDER PAYMENTS. (a) In this section, "municipal ground
ambulance service provider" has the meaning assigned by Section
1467.001.
(b) 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 or covered
transportation related to that service provided to, a participant
by an out-of-network provider who is a municipal ground ambulance
service provider at the usual and customary rate or at an agreed
rate. 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) An out-of-network provider who is a municipal 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 or transportation
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 1.10. Section 1575.009, Insurance Code, is amended
to read as follows:
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under the group
program shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply or transportation provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1575.171, 1575.172, [or] 1575.173, or 1575.174, as
applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's managed care plan and an
itemization of copayments, coinsurance, deductibles, and other
amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1575.171, 1575.172, [or] 1575.173, or
1575.174, as applicable.
SECTION 1.11. Subchapter D, Chapter 1575, Insurance Code,
is amended by adding Section 1575.174 to read as follows:
Sec. 1575.174. OUT-OF-NETWORK MUNICIPAL GROUND AMBULANCE
SERVICE PROVIDER PAYMENTS. (a) In this section, "municipal ground
ambulance service provider" has the meaning assigned by Section
1467.001.
(b) 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 or covered
transportation related to that service provided to, an enrollee by
an out-of-network provider who is a municipal ground ambulance
service provider at the usual and customary rate or at an agreed
rate. 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) An out-of-network provider who is a municipal 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 or transportation
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 1.12. Section 1579.009, Insurance Code, is amended
to read as follows:
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under this
chapter shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply or transportation provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1579.109, 1579.110, [or] 1579.111, or 1579.112, as
applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's managed care plan and an
itemization of copayments, coinsurance, deductibles, and other
amounts included in that total; and
(3) for an explanation of benefits provided to the
physician or provider, information required by commissioner rule
advising the physician or provider of the availability of mediation
or arbitration, as applicable, under Chapter 1467.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1579.109, 1579.110, [or] 1579.111, or
1579.112, as applicable.
SECTION 1.13. Subchapter C, Chapter 1579, Insurance Code,
is amended by adding Section 1579.112 to read as follows:
Sec. 1579.112. OUT-OF-NETWORK MUNICIPAL GROUND AMBULANCE
SERVICE PROVIDER PAYMENTS. (a) In this section, "municipal ground
ambulance service provider" has the meaning assigned by Section
1467.001.
(b) 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 or covered transportation
related to that service provided to, an enrollee by an
out-of-network provider who is a municipal ground ambulance service
provider at the usual and customary rate or at an agreed rate. 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) An out-of-network provider who is a municipal 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 or transportation
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.
ARTICLE 2. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION
SECTION 2.01. Section 1467.001, Insurance Code, is amended
by amending Subdivision (6-a) and adding Subdivision (6-b) to read
as follows:
(6-a) "Municipal ground ambulance service provider"
means a health care provider employed by or contracted with a
municipality to use a ground vehicle for the transportation,
including nonemergency transportation, of an ill or injured
individual to a facility. The term includes an emergency medical
services provider and a provider using emergency medical services
vehicles, as those terms are defined by Section 773.003, Health and
Safety Code, except the terms do not include an air ambulance.
(6-b) "Out-of-network provider" means a diagnostic
imaging provider, emergency care provider, facility-based
provider, [or] laboratory service provider, or municipal ground
ambulance service provider that is not a participating provider for
a health benefit plan.
SECTION 2.02. The heading to Subchapter B, Chapter 1467,
Insurance Code, is amended to read as follows:
SUBCHAPTER B. MANDATORY MEDIATION FOR OUT-OF-NETWORK FACILITIES
AND MUNICIPAL GROUND AMBULANCE SERVICE PROVIDERS
SECTION 2.03. 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 municipal ground ambulance service provider.
SECTION 2.04. 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 municipal ground ambulance
service.
SECTION 2.05. Subchapter B, Chapter 1467, Insurance Code,
is amended by adding Section 1467.0555 to read as follows:
Sec. 1467.0555. MEDIATION INVOLVING MUNICIPAL GROUND
AMBULANCE SERVICE PROVIDER. (a) A municipal ground ambulance
service provider may elect to submit multiple claims to mediation
in one proceeding if:
(1) the total amount in controversy for the claims
does not exceed $5,000; and
(2) the claims are limited to the same administrator
or health benefit plan issuer.
(b) A mediation of a settlement of a health benefit claim
for an out-of-network municipal ground ambulance service must be
completed not later than the 90th day after the date of the request
for mediation.
ARTICLE 3. TRANSITION AND EFFECTIVE DATE
SECTION 3.01. The changes in law made by this Act apply only
to a ground ambulance service provided on or after January 1, 2024.
A ground ambulance service provided before January 1, 2024, 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 3.02. This Act takes effect September 1, 2023.