Texas 2023 - 88th Regular

Texas Senate Bill SB2476 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New	Differences
1	1	S.B. No. 2476
2	2
3	3
4	4	AN ACT
5	5	relating to consumer protections against certain medical and health
6	6	care billing by emergency medical services providers.
7	7	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
8	8	SECTION 1. Subchapter A, Chapter 38, Insurance Code, is
9	9	amended by adding Section 38.006 to read as follows:
10	10	Sec. 38.006. EMERGENCY MEDICAL SERVICES PROVIDER BALANCE
11	11	BILLING RATE DATABASE. (a) A political subdivision may submit to
12	12	the department, in the form and manner prescribed by the
13	13	commissioner, a rate set, controlled, or regulated by the political
14	14	subdivision for purposes of Section 1271.159, 1275.054, 1301.166,
15	15	1551.231, 1575.174, or 1579.112. The department shall establish
16	16	and maintain on the department's Internet website a publicly
17	17	accessible database for the rates.
18	18	(b) This section expires September 1, 2025.
19	19	SECTION 2. (a) Section 1271.008, Insurance Code, is
20	20	amended to read as follows:
21	21	Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A
22	22	health maintenance organization shall provide written notice in
23	23	accordance with this section in an explanation of benefits provided
24	24	to the enrollee and the physician or provider in connection with a
25	25	health care service or supply or transport provided by a
26	26	non-network physician or provider. The notice must include:
27	27	(1) a statement of the billing prohibition under
28	28	Section 1271.155, 1271.157, [or] 1271.158, or 1271.159, as
29	29	applicable;
30	30	(2) the total amount the physician or provider may
31	31	bill the enrollee under the enrollee's health benefit plan and an
32	32	itemization of copayments, coinsurance, deductibles, and other
33	33	amounts included in that total; and
34	34	(3) for an explanation of benefits provided to the
35	35	physician or provider, information required by commissioner rule
36	36	advising the physician or provider of the availability of mediation
37	37	or arbitration, as applicable, under Chapter 1467.
38	38	(b) A health maintenance organization shall provide the
39	39	explanation of benefits with the notice required by this section to
40	40	a physician or health care provider not later than the date the
41	41	health maintenance organization makes a payment under Section
42	42	1271.155, 1271.157, [or] 1271.158, or 1271.159, as applicable.
43	43	(b) Effective September 1, 2025, Section 1271.008,
44	44	Insurance Code, is amended to read as follows:
45	45	Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (a) A
46	46	health maintenance organization shall provide written notice in
47	47	accordance with this section in an explanation of benefits provided
48	48	to the enrollee and the physician or provider in connection with a
49	49	health care service or supply provided by a non-network physician
50	50	or provider. The notice must include:
51	51	(1) a statement of the billing prohibition under
52	52	Section 1271.155, 1271.157, or 1271.158, as applicable;
53	53	(2) the total amount the physician or provider may
54	54	bill the enrollee under the enrollee's health benefit plan and an
55	55	itemization of copayments, coinsurance, deductibles, and other
56	56	amounts included in that total; and
57	57	(3) for an explanation of benefits provided to the
58	58	physician or provider, information required by commissioner rule
59	59	advising the physician or provider of the availability of mediation
60	60	or arbitration, as applicable, under Chapter 1467.
61	61	(b) A health maintenance organization shall provide the
62	62	explanation of benefits with the notice required by this section to
63	63	a physician or health care provider not later than the date the
64	64	health maintenance organization makes a payment under Section
65	65	1271.155, 1271.157, or 1271.158, as applicable.
66	66	SECTION 3. Subchapter D, Chapter 1271, Insurance Code, is
67	67	amended by adding Section 1271.159 to read as follows:
68	68	Sec. 1271.159. NON-NETWORK EMERGENCY MEDICAL SERVICES
69	69	PROVIDER. (a) In this section, "emergency medical services
70	70	provider" has the meaning assigned by Section 773.003, Health and
71	71	Safety Code, except that the term does not include an air ambulance.
72	72	(b) Except as provided by Subsection (c), a health
73	73	maintenance organization shall pay for a covered health care
74	74	service performed for, or a covered supply or covered transport
75	75	related to that service provided to, an enrollee by a non-network
76	76	emergency medical services provider at:
77	77	(1) if the political subdivision has submitted the
78	78	rate to the department under Section 38.006, the rate set,
79	79	controlled, or regulated by the political subdivision in which:
80	80	(A) the service originated; or
81	81	(B) the transport originated if transport is
82	82	provided; or
83	83	(2) if the political subdivision has not submitted the
84	84	rate to the department, the lesser of:
85	85	(A) the provider's billed charge; or
86	86	(B) 325 percent of the current Medicare rate,
87	87	including any applicable extenders and modifiers.
88	88	(c) A health maintenance organization shall adjust a
89	89	payment required by Subsection (b)(1) each plan year by increasing
90	90	the payment by the lesser of the Medicare Inflation Index or 10
91	91	percent of the provider's previous calendar year rates.
92	92	(d) The health maintenance organization shall make a
93	93	payment required by this section directly to the provider not later
94	94	than, as applicable:
95	95	(1) the 30th day after the date the health maintenance
96	96	organization receives an electronic clean claim as defined by
97	97	Section 843.336 for those services that includes all information
98	98	necessary for the health maintenance organization to pay the claim;
99	99	or
100	100	(2) the 45th day after the date the health maintenance
101	101	organization receives a nonelectronic clean claim as defined by
102	102	Section 843.336 for those services that includes all information
103	103	necessary for the health maintenance organization to pay the claim.
104	104	(e) A non-network emergency medical services provider or a
105	105	person asserting a claim as an agent or assignee of the provider may
106	106	not bill an enrollee receiving a health care service or supply or
107	107	transport described by Subsection (b) in, and the enrollee does not
108	108	have financial responsibility for, an amount greater than an
109	109	applicable copayment, coinsurance, and deductible under the
110	110	enrollee's health care plan that is based on:
111	111	(1) the amount initially determined payable by the
112	112	health maintenance organization; or
113	113	(2) if applicable, a modified amount as determined
114	114	under the health maintenance organization's internal appeal
115	115	process.
116	116	(f) This section may not be construed to require the
117	117	imposition of a penalty under Section 843.342.
118	118	(g) This section expires September 1, 2025.
119	119	SECTION 4. (a) Section 1275.003, Insurance Code, is
120	120	amended to read as follows:
121	121	Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a)
122	122	The administrator of a health benefit plan to which this chapter
123	123	applies shall provide written notice in accordance with this
124	124	section in an explanation of benefits provided to the enrollee and
125	125	the physician or health care provider in connection with a health
126	126	care or medical service or supply or transport provided by an
127	127	out-of-network provider. The notice must include:
128	128	(1) a statement of the billing prohibition under
129	129	Section 1275.051, 1275.052, [or] 1275.053, or 1275.054, as
130	130	applicable;
131	131	(2) the total amount the physician or provider may
132	132	bill the enrollee under the enrollee's health benefit plan and an
133	133	itemization of copayments, coinsurance, deductibles, and other
134	134	amounts included in that total; and
135	135	(3) for an explanation of benefits provided to the
136	136	physician or provider, information required by commissioner rule
137	137	advising the physician or provider of the availability of mediation
138	138	or arbitration, as applicable, under Chapter 1467.
139	139	(b) The administrator shall provide the explanation of
140	140	benefits with the notice required by this section to a physician or
141	141	health care provider not later than the date the administrator
142	142	makes a payment under Section 1275.051, 1275.052, [or] 1275.053, or
143	143	1275.054, as applicable.
144	144	(b) Effective September 1, 2025, Section 1275.003,
145	145	Insurance Code, is amended to read as follows:
146	146	Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a)
147	147	The administrator of a health benefit plan to which this chapter
148	148	applies shall provide written notice in accordance with this
149	149	section in an explanation of benefits provided to the enrollee and
150	150	the physician or health care provider in connection with a health
151	151	care or medical service or supply provided by an out-of-network
152	152	provider. The notice must include:
153	153	(1) a statement of the billing prohibition under
154	154	Section 1275.051, 1275.052, or 1275.053, as applicable;
155	155	(2) the total amount the physician or provider may
156	156	bill the enrollee under the enrollee's health benefit plan and an
157	157	itemization of copayments, coinsurance, deductibles, and other
158	158	amounts included in that total; and
159	159	(3) for an explanation of benefits provided to the
160	160	physician or provider, information required by commissioner rule
161	161	advising the physician or provider of the availability of mediation
162	162	or arbitration, as applicable, under Chapter 1467.
163	163	(b) The administrator shall provide the explanation of
164	164	benefits with the notice required by this section to a physician or
165	165	health care provider not later than the date the administrator
166	166	makes a payment under Section 1275.051, 1275.052, or 1275.053, as
167	167	applicable.
168	168	SECTION 5. Subchapter B, Chapter 1275, Insurance Code, is
169	169	amended by adding Section 1275.054 to read as follows:
170	170	Sec. 1275.054. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
171	171	PROVIDER PAYMENTS. (a) In this section, "emergency medical
172	172	services provider" has the meaning assigned by Section 773.003,
173	173	Health and Safety Code, except that the term does not include an air
174	174	ambulance.
175	175	(b) Except as provided by Subsection (c), the administrator
176	176	of a health benefit plan to which this chapter applies shall pay for
177	177	a covered health care or medical service performed for, or a covered
178	178	supply or covered transport related to that service provided to, an
179	179	enrollee by an out-of-network provider who is an emergency medical
180	180	services provider at:
181	181	(1) if the political subdivision has submitted the
182	182	rate to the department under Section 38.006, the rate set,
183	183	controlled, or regulated by the political subdivision in which:
184	184	(A) the service originated; or
185	185	(B) the transport originated if transport is
186	186	provided; or
187	187	(2) if the political subdivision has not submitted the
188	188	rate to the department, the lesser of:
189	189	(A) the provider's billed charge; or
190	190	(B) 325 percent of the current Medicare rate,
191	191	including any applicable extenders and modifiers.
192	192	(c) The administrator shall adjust a payment required by
193	193	Subsection (b)(1) each plan year by increasing the payment by the
194	194	lesser of the Medicare Inflation Index or 10 percent of the
195	195	provider's previous calendar year rates.
196	196	(d) The administrator shall make a payment required by this
197	197	section directly to the provider not later than, as applicable:
198	198	(1) the 30th day after the date the administrator
199	199	receives an electronic claim for those services that includes all
200	200	information necessary for the administrator to pay the claim; or
201	201	(2) the 45th day after the date the administrator
202	202	receives a nonelectronic claim for those services that includes all
203	203	information necessary for the administrator to pay the claim.
204	204	(e) An out-of-network provider who is an emergency medical
205	205	services provider or a person asserting a claim as an agent or
206	206	assignee of the provider may not bill an enrollee receiving a health
207	207	care or medical service or supply or transport described by
208	208	Subsection (b) in, and the enrollee does not have financial
209	209	responsibility for, an amount greater than an applicable copayment,
210	210	coinsurance, and deductible under the enrollee's health benefit
211	211	plan that is based on:
212	212	(1) the amount initially determined payable by the
213	213	administrator; or
214	214	(2) if applicable, the modified amount as determined
215	215	under the administrator's internal appeal process.
216	216	(f) This section expires September 1, 2025.
217	217	SECTION 6. (a) Section 1301.0045(b), Insurance Code, is
218	218	amended to read as follows:
219	219	(b) Except as provided by Sections 1301.0052, 1301.0053,
220	220	1301.155, 1301.164, [and] 1301.165, and 1301.166, this chapter may
221	221	not be construed to require an exclusive provider benefit plan to
222	222	compensate a nonpreferred provider for services provided to an
223	223	insured.
224	224	(b) Effective September 1, 2025, Section 1301.0045(b),
225	225	Insurance Code, is amended to read as follows:
226	226	(b) Except as provided by Sections 1301.0052, 1301.0053,
227	227	1301.155, 1301.164, and 1301.165, this chapter may not be construed
228	228	to require an exclusive provider benefit plan to compensate a
229	229	nonpreferred provider for services provided to an insured.
230	230	SECTION 7. (a) Section 1301.010, Insurance Code, is
231	231	amended to read as follows:
232	232	Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An
233	233	insurer shall provide written notice in accordance with this
234	234	section in an explanation of benefits provided to the insured and
235	235	the physician or health care provider in connection with a medical
236	236	care or health care service or supply or transport provided by an
237	237	out-of-network provider. The notice must include:
238	238	(1) a statement of the billing prohibition under
239	239	Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or 1301.166,
240	240	as applicable;
241	241	(2) the total amount the physician or provider may
242	242	bill the insured under the insured's preferred provider benefit
243	243	plan and an itemization of copayments, coinsurance, deductibles,
244	244	and other amounts included in that total; and
245	245	(3) for an explanation of benefits provided to the
246	246	physician or provider, information required by commissioner rule
247	247	advising the physician or provider of the availability of mediation
248	248	or arbitration, as applicable, under Chapter 1467.
249	249	(b) An insurer shall provide the explanation of benefits
250	250	with the notice required by this section to a physician or health
251	251	care provider not later than the date the insurer makes a payment
252	252	under Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or
253	253	1301.166, as applicable.
254	254	(b) Effective September 1, 2025, Section 1301.010,
255	255	Insurance Code, is amended to read as follows:
256	256	Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (a) An
257	257	insurer shall provide written notice in accordance with this
258	258	section in an explanation of benefits provided to the insured and
259	259	the physician or health care provider in connection with a medical
260	260	care or health care service or supply provided by an out-of-network
261	261	provider. The notice must include:
262	262	(1) a statement of the billing prohibition under
263	263	Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;
264	264	(2) the total amount the physician or provider may
265	265	bill the insured under the insured's preferred provider benefit
266	266	plan and an itemization of copayments, coinsurance, deductibles,
267	267	and other amounts included in that total; and
268	268	(3) for an explanation of benefits provided to the
269	269	physician or provider, information required by commissioner rule
270	270	advising the physician or provider of the availability of mediation
271	271	or arbitration, as applicable, under Chapter 1467.
272	272	(b) An insurer shall provide the explanation of benefits
273	273	with the notice required by this section to a physician or health
274	274	care provider not later than the date the insurer makes a payment
275	275	under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as
276	276	applicable.
277	277	SECTION 8. Subchapter D, Chapter 1301, Insurance Code, is
278	278	amended by adding Section 1301.166 to read as follows:
279	279	Sec. 1301.166. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
280	280	PROVIDER. (a) In this section, "emergency medical services
281	281	provider" has the meaning assigned by Section 773.003, Health and
282	282	Safety Code, except that the term does not include an air ambulance.
283	283	(b) Except as provided by Subsection (c), an insurer shall
284	284	pay for a covered medical care or health care service performed for,
285	285	or a covered supply or covered transport related to that service
286	286	provided to, an insured by an out-of-network provider who is an
287	287	emergency medical services provider at:
288	288	(1) if the political subdivision has submitted the
289	289	rate to the department under Section 38.006, the rate set,
290	290	controlled, or regulated by the political subdivision in which:
291	291	(A) the service originated; or
292	292	(B) the transport originated if transport is
293	293	provided; or
294	294	(2) if the political subdivision has not submitted the
295	295	rate to the department, the lesser of:
296	296	(A) the provider's billed charge; or
297	297	(B) 325 percent of the current Medicare rate,
298	298	including any applicable extenders and modifiers.
299	299	(c) An insurer shall adjust a payment required by Subsection
300	300	(b)(1) each plan year by increasing the payment by the lesser of the
301	301	Medicare Inflation Index or 10 percent of the provider's previous
302	302	calendar year rates.
303	303	(d) The insurer shall make a payment required by this
304	304	section directly to the provider not later than, as applicable:
305	305	(1) the 30th day after the date the insurer receives an
306	306	electronic clean claim as defined by Section 1301.101 for those
307	307	services that includes all information necessary for the insurer to
308	308	pay the claim; or
309	309	(2) the 45th day after the date the insurer receives a
310	310	nonelectronic clean claim as defined by Section 1301.101 for those
311	311	services that includes all information necessary for the insurer to
312	312	pay the claim.
313	313	(e) An out-of-network provider who is an emergency medical
314	314	services provider or a person asserting a claim as an agent or
315	315	assignee of the provider may not bill an insured receiving a medical
316	316	care or health care service or supply or transport described by
317	317	Subsection (b) in, and the insured does not have financial
318	318	responsibility for, an amount greater than an applicable copayment,
319	319	coinsurance, and deductible under the insured's preferred provider
320	320	benefit plan that is based on:
321	321	(1) the amount initially determined payable by the
322	322	insurer; or
323	323	(2) if applicable, the modified amount as determined
324	324	under the insurer's internal appeal process.
325	325	(f) This section may not be construed to require the
326	326	imposition of a penalty under Section 1301.137.
327	327	(g) This section expires September 1, 2025.
328	328	SECTION 9. (a) Section 1551.015, Insurance Code, is
329	329	amended to read as follows:
330	330	Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a)
331	331	The administrator of a managed care plan provided under the group
332	332	benefits program shall provide written notice in accordance with
333	333	this section in an explanation of benefits provided to the
334	334	participant and the physician or health care provider in connection
335	335	with a health care or medical service or supply or transport
336	336	provided by an out-of-network provider. The notice must include:
337	337	(1) a statement of the billing prohibition under
338	338	Section 1551.228, 1551.229, [or] 1551.230, or 1551.231, as
339	339	applicable;
340	340	(2) the total amount the physician or provider may
341	341	bill the participant under the participant's managed care plan and
342	342	an itemization of copayments, coinsurance, deductibles, and other
343	343	amounts included in that total; and
344	344	(3) for an explanation of benefits provided to the
345	345	physician or provider, information required by commissioner rule
346	346	advising the physician or provider of the availability of mediation
347	347	or arbitration, as applicable, under Chapter 1467.
348	348	(b) The administrator shall provide the explanation of
349	349	benefits with the notice required by this section to a physician or
350	350	health care provider not later than the date the administrator
351	351	makes a payment under Section 1551.228, 1551.229, [or] 1551.230, or
352	352	1551.231, as applicable.
353	353	(b) Effective September 1, 2025, Section 1551.015,
354	354	Insurance Code, is amended to read as follows:
355	355	Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a)
356	356	The administrator of a managed care plan provided under the group
357	357	benefits program shall provide written notice in accordance with
358	358	this section in an explanation of benefits provided to the
359	359	participant and the physician or health care provider in connection
360	360	with a health care or medical service or supply provided by an
361	361	out-of-network provider. The notice must include:
362	362	(1) a statement of the billing prohibition under
363	363	Section 1551.228, 1551.229, or 1551.230, as applicable;
364	364	(2) the total amount the physician or provider may
365	365	bill the participant under the participant's managed care plan and
366	366	an itemization of copayments, coinsurance, deductibles, and other
367	367	amounts included in that total; and
368	368	(3) for an explanation of benefits provided to the
369	369	physician or provider, information required by commissioner rule
370	370	advising the physician or provider of the availability of mediation
371	371	or arbitration, as applicable, under Chapter 1467.
372	372	(b) The administrator shall provide the explanation of
373	373	benefits with the notice required by this section to a physician or
374	374	health care provider not later than the date the administrator
375	375	makes a payment under Section 1551.228, 1551.229, or 1551.230, as
376	376	applicable.
377	377	SECTION 10. Subchapter E, Chapter 1551, Insurance Code, is
378	378	amended by adding Section 1551.231 to read as follows:
379	379	Sec. 1551.231. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
380	380	PROVIDER PAYMENTS. (a) In this section, "emergency medical
381	381	services provider" has the meaning assigned by Section 773.003,
382	382	Health and Safety Code, except that the term does not include an air
383	383	ambulance.
384	384	(b) Except as provided by Subsection (c), the administrator
385	385	of a managed care plan provided under the group benefits program
386	386	shall pay for a covered health care or medical service performed
387	387	for, or a covered supply or covered transport related to that
388	388	service provided to, a participant by an out-of-network provider
389	389	who is an emergency medical services provider at:
390	390	(1) if the political subdivision has submitted the
391	391	rate to the department under Section 38.006, the rate set,
392	392	controlled, or regulated by the political subdivision in which:
393	393	(A) the service originated; or
394	394	(B) the transport originated if transport is
395	395	provided; or
396	396	(2) if the political subdivision has not submitted the
397	397	rate to the department, the lesser of:
398	398	(A) the provider's billed charge; or
399	399	(B) 325 percent of the current Medicare rate,
400	400	including any applicable extenders and modifiers.
401	401	(c) The administrator shall adjust a payment required by
402	402	Subsection (b)(1) each plan year by increasing the payment by the
403	403	lesser of the Medicare Inflation Index or 10 percent of the
404	404	provider's previous calendar year rates.
405	405	(d) The administrator shall make a payment required by this
406	406	section directly to the provider not later than, as applicable:
407	407	(1) the 30th day after the date the administrator
408	408	receives an electronic claim for those services that includes all
409	409	information necessary for the administrator to pay the claim; or
410	410	(2) the 45th day after the date the administrator
411	411	receives a nonelectronic claim for those services that includes all
412	412	information necessary for the administrator to pay the claim.
413	413	(e) An out-of-network provider who is an emergency medical
414	414	services provider or a person asserting a claim as an agent or
415	415	assignee of the provider may not bill a participant receiving a
416	416	health care or medical service or supply or transport described by
417	417	Subsection (b) in, and the participant does not have financial
418	418	responsibility for, an amount greater than an applicable copayment,
419	419	coinsurance, and deductible under the participant's managed care
420	420	plan that is based on:
421	421	(1) the amount initially determined payable by the
422	422	administrator; or
423	423	(2) if applicable, the modified amount as determined
424	424	under the administrator's internal appeal process.
425	425	(f) This section expires September 1, 2025.
426	426	SECTION 11. (a) Section 1575.009, Insurance Code, is
427	427	amended to read as follows:
428	428	Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a)
429	429	The administrator of a managed care plan provided under the group
430	430	program shall provide written notice in accordance with this
431	431	section in an explanation of benefits provided to the enrollee and
432	432	the physician or health care provider in connection with a health
433	433	care or medical service or supply or transport provided by an
434	434	out-of-network provider. The notice must include:
435	435	(1) a statement of the billing prohibition under
436	436	Section 1575.171, 1575.172, [or] 1575.173, or 1575.174, as
437	437	applicable;
438	438	(2) the total amount the physician or provider may
439	439	bill the enrollee under the enrollee's managed care plan and an
440	440	itemization of copayments, coinsurance, deductibles, and other
441	441	amounts included in that total; and
442	442	(3) for an explanation of benefits provided to the
443	443	physician or provider, information required by commissioner rule
444	444	advising the physician or provider of the availability of mediation
445	445	or arbitration, as applicable, under Chapter 1467.
446	446	(b) The administrator shall provide the explanation of
447	447	benefits with the notice required by this section to a physician or
448	448	health care provider not later than the date the administrator
449	449	makes a payment under Section 1575.171, 1575.172, [or] 1575.173, or
450	450	1575.174, as applicable.
451	451	(b) Effective September 1, 2025, Section 1575.009,
452	452	Insurance Code, is amended to read as follows:
453	453	Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a)
454	454	The administrator of a managed care plan provided under the group
455	455	program shall provide written notice in accordance with this
456	456	section in an explanation of benefits provided to the enrollee and
457	457	the physician or health care provider in connection with a health
458	458	care or medical service or supply provided by an out-of-network
459	459	provider. The notice must include:
460	460	(1) a statement of the billing prohibition under
461	461	Section 1575.171, 1575.172, or 1575.173, as applicable;
462	462	(2) the total amount the physician or provider may
463	463	bill the enrollee under the enrollee's managed care plan and an
464	464	itemization of copayments, coinsurance, deductibles, and other
465	465	amounts included in that total; and
466	466	(3) for an explanation of benefits provided to the
467	467	physician or provider, information required by commissioner rule
468	468	advising the physician or provider of the availability of mediation
469	469	or arbitration, as applicable, under Chapter 1467.
470	470	(b) The administrator shall provide the explanation of
471	471	benefits with the notice required by this section to a physician or
472	472	health care provider not later than the date the administrator
473	473	makes a payment under Section 1575.171, 1575.172, or 1575.173, as
474	474	applicable.
475	475	SECTION 12. Subchapter D, Chapter 1575, Insurance Code, is
476	476	amended by adding Section 1575.174 to read as follows:
477	477	Sec. 1575.174. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
478	478	PROVIDER PAYMENTS. (a) In this section, "emergency medical
479	479	services provider" has the meaning assigned by Section 773.003,
480	480	Health and Safety Code, except that the term does not include an air
481	481	ambulance.
482	482	(b) Except as provided by Subsection (c), the administrator
483	483	of a managed care plan provided under the group program shall pay
484	484	for a covered health care or medical service performed for, or a
485	485	covered supply or covered transport related to that service
486	486	provided to, an enrollee by an out-of-network provider who is an
487	487	emergency medical services provider at:
488	488	(1) if the political subdivision has submitted the
489	489	rate to the department under Section 38.006, the rate set,
490	490	controlled, or regulated by the political subdivision in which:
491	491	(A) the service originated; or
492	492	(B) the transport originated if transport is
493	493	provided; or
494	494	(2) if the political subdivision has not submitted the
495	495	rate to the department, the lesser of:
496	496	(A) the provider's billed charge; or
497	497	(B) 325 percent of the current Medicare rate,
498	498	including any applicable extenders and modifiers.
499	499	(c) The administrator shall adjust a payment required by
500	500	Subsection (b)(1) each plan year by increasing the payment by the
501	501	lesser of the Medicare Inflation Index or 10 percent of the
502	502	provider's previous calendar year rates.
503	503	(d) The administrator shall make a payment required by this
504	504	section directly to the provider not later than, as applicable:
505	505	(1) the 30th day after the date the administrator
506	506	receives an electronic claim for those services that includes all
507	507	information necessary for the administrator to pay the claim; or
508	508	(2) the 45th day after the date the administrator
509	509	receives a nonelectronic claim for those services that includes all
510	510	information necessary for the administrator to pay the claim.
511	511	(e) An out-of-network provider who is an emergency medical
512	512	services provider or a person asserting a claim as an agent or
513	513	assignee of the provider may not bill an enrollee receiving a health
514	514	care or medical service or supply or transport described by
515	515	Subsection (b) in, and the enrollee does not have financial
516	516	responsibility for, an amount greater than an applicable copayment,
517	517	coinsurance, and deductible under the enrollee's managed care plan
518	518	that is based on:
519	519	(1) the amount initially determined payable by the
520	520	administrator; or
521	521	(2) if applicable, the modified amount as determined
522	522	under the administrator's internal appeal process.
523	523	(f) This section expires September 1, 2025.
524	524	SECTION 13. (a) Section 1579.009, Insurance Code, is
525	525	amended to read as follows:
526	526	Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a)
527	527	The administrator of a managed care plan provided under this
528	528	chapter shall provide written notice in accordance with this
529	529	section in an explanation of benefits provided to the enrollee and
530	530	the physician or health care provider in connection with a health
531	531	care or medical service or supply or transport provided by an
532	532	out-of-network provider. The notice must include:
533	533	(1) a statement of the billing prohibition under
534	534	Section 1579.109, 1579.110, [or] 1579.111, or 1579.112, as
535	535	applicable;
536	536	(2) the total amount the physician or provider may
537	537	bill the enrollee under the enrollee's managed care plan and an
538	538	itemization of copayments, coinsurance, deductibles, and other
539	539	amounts included in that total; and
540	540	(3) for an explanation of benefits provided to the
541	541	physician or provider, information required by commissioner rule
542	542	advising the physician or provider of the availability of mediation
543	543	or arbitration, as applicable, under Chapter 1467.
544	544	(b) The administrator shall provide the explanation of
545	545	benefits with the notice required by this section to a physician or
546	546	health care provider not later than the date the administrator
547	547	makes a payment under Section 1579.109, 1579.110, [or] 1579.111, or
548	548	1579.112, as applicable.
549	549	(b) Effective September 1, 2025, Section 1579.009,
550	550	Insurance Code, is amended to read as follows:
551	551	Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a)
552	552	The administrator of a managed care plan provided under this
553	553	chapter shall provide written notice in accordance with this
554	554	section in an explanation of benefits provided to the enrollee and
555	555	the physician or health care provider in connection with a health
556	556	care or medical service or supply provided by an out-of-network
557	557	provider. The notice must include:
558	558	(1) a statement of the billing prohibition under
559	559	Section 1579.109, 1579.110, or 1579.111, as applicable;
560	560	(2) the total amount the physician or provider may
561	561	bill the enrollee under the enrollee's managed care plan and an
562	562	itemization of copayments, coinsurance, deductibles, and other
563	563	amounts included in that total; and
564	564	(3) for an explanation of benefits provided to the
565	565	physician or provider, information required by commissioner rule
566	566	advising the physician or provider of the availability of mediation
567	567	or arbitration, as applicable, under Chapter 1467.
568	568	(b) The administrator shall provide the explanation of
569	569	benefits with the notice required by this section to a physician or
570	570	health care provider not later than the date the administrator
571	571	makes a payment under Section 1579.109, 1579.110, or 1579.111, as
572	572	applicable.
573	573	SECTION 14. Subchapter C, Chapter 1579, Insurance Code, is
574	574	amended by adding Section 1579.112 to read as follows:
575	575	Sec. 1579.112. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
576	576	PROVIDER PAYMENTS. (a) In this section, "emergency medical
577	577	services provider" has the meaning assigned by Section 773.003,
578	578	Health and Safety Code, except that the term does not include an air
579	579	ambulance.
580	580	(b) Except as provided by Subsection (c), the administrator
581	581	of a managed care plan provided under this chapter shall pay for a
582	582	covered health care or medical service performed for, or a covered
583	583	supply or covered transport related to that service provided to, an
584	584	enrollee by an out-of-network provider who is an emergency medical
585	585	services provider at:
586	586	(1) if the political subdivision has submitted the
587	587	rate to the department under Section 38.006, the rate set,
588	588	controlled, or regulated by the political subdivision in which:
589	589	(A) the service originated; or
590	590	(B) the transport originated if transport is
591	591	provided; or
592	592	(2) if the political subdivision has not submitted the
593	593	rate to the department, the lesser of:
594	594	(A) the provider's billed charge; or
595	595	(B) 325 percent of the current Medicare rate,
596	596	including any applicable extenders and modifiers.
597	597	(c) The administrator shall adjust a payment required by
598	598	Subsection (b)(1) each plan year by increasing the payment by the
599	599	lesser of the Medicare Inflation Index or 10 percent of the
600	600	provider's previous calendar year rates.
601	601	(d) The administrator shall make a payment required by this
602	602	section directly to the provider not later than, as applicable:
603	603	(1) the 30th day after the date the administrator
604	604	receives an electronic claim for those services that includes all
605	605	information necessary for the administrator to pay the claim; or
606	606	(2) the 45th day after the date the administrator
607	607	receives a nonelectronic claim for those services that includes all
608	608	information necessary for the administrator to pay the claim.
609	609	(e) An out-of-network provider who is an emergency medical
610	610	services provider or a person asserting a claim as an agent or
611	611	assignee of the provider may not bill an enrollee receiving a health
612	612	care or medical service or supply or transport described by
613	613	Subsection (b) in, and the enrollee does not have financial
614	614	responsibility for, an amount greater than an applicable copayment,
615	615	coinsurance, and deductible under the enrollee's managed care plan
616	616	that is based on:
617	617	(1) the amount initially determined payable by the
618	618	administrator; or
619	619	(2) if applicable, a modified amount as determined
620	620	under the administrator's internal appeal process.
621	621	(f) This section expires September 1, 2025.
622	622	SECTION 15. The changes in law made by this Act apply only
623	623	to emergency medical services provided on or after January 1, 2024.
624	624	Emergency medical services provided before January 1, 2024, are
625	625	governed by the law in effect immediately before the effective date
626	626	of this Act, and that law is continued in effect for that purpose.
627	627	SECTION 16. The Texas Department of Insurance is not
628	628	required to establish the database described by Section 38.006,
629	629	Insurance Code, as added by this Act, before January 1, 2024.
630	630	SECTION 17. Except as otherwise provided by this Act, this
631	631	Act takes effect September 1, 2023.
632	632	______________________________ ______________________________
633	633	President of the Senate Speaker of the House
634	634	I hereby certify that S.B. No. 2476 passed the Senate on
635	635	May 2, 2023, by the following vote: Yeas 31, Nays 0; and that the
636	636	Senate concurred in House amendment on May 25, 2023, by the
637	637	following vote: Yeas 31, Nays 0.
638	638	______________________________
639	639	Secretary of the Senate
640	640	I hereby certify that S.B. No. 2476 passed the House, with
641	641	amendment, on May 19, 2023, by the following vote: Yeas 139,
642	642	Nays 4, two present not voting.
643	643	______________________________
644	644	Chief Clerk of the House
645	645	Approved:
646	646	______________________________
647	647	Date
648	648	______________________________
649	649	Governor