89R6051 MPF-D
By: Oliverson H.B. No. 3321
A BILL TO BE ENTITLED
AN ACT
relating to certain health care entity or system transaction fees
and payment claims; providing administrative and civil penalties.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle G, Title 4, Health and Safety Code, is
amended by adding Chapter 328 to read as follows:
CHAPTER 328. HEALTH CARE ENTITY AND HEALTH CARE SYSTEM TRANSACTION
FEES AND PAYMENT CLAIMS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 328.001. DEFINITIONS. In this chapter:
(1) "Affiliate" means a person who is:
(A) employed by a hospital or health care system;
or
(B) under a professional services agreement,
faculty agreement, or management agreement with a hospital or
health care system that authorizes the hospital or health care
system to bill on behalf of the person.
(2) "Campus" means, with respect to a health care
entity:
(A) the entity's main buildings for providing
health care services;
(B) the physical area immediately adjacent to the
main buildings and other areas or structures not contiguous to the
main buildings but located not more than 250 yards from the main
buildings; and
(C) another area the Centers for Medicare and
Medicaid Services determines is a campus of a health care entity.
(3) "Commission" means the Health and Human Services
Commission.
(4) "Enrollee" means an individual who is covered
under a health benefit plan, including a multiple employer welfare
arrangement. The term does not include an individual who is covered
under a limited benefit plan, accident plan, indemnity plan,
limited scope dental or vision plan, or short-term limited-duration
insurance policy governed by Chapter 1509, Insurance Code.
(5) "Executive commissioner" means the executive
commissioner of the commission.
(6) "Facility fee" means a fee a health care entity or
health care system charges for outpatient health care services that
is:
(A) intended to compensate the entity or system
for operational expenses; and
(B) separate from a fee the entity or system
charges for professional health care services.
(7) "Freestanding emergency medical care facility"
has the meaning assigned by Section 254.001.
(8) "Health benefit plan issuer" means an insurer,
health maintenance organization, or other entity authorized to
provide health benefits coverage under the laws of this state.
(9) "Health care entity" means a group, professional
corporation, or other entity that provides health care services.
The term includes a hospital, medical clinic, medical group, home
health care agency, health infusion clinic, urgent care clinic, and
freestanding emergency medical care facility.
(10) "Health care system" means a system of health
care entities in this state that are under the common governance or
control of a corporate parent.
(11) "Hospital" means a health care facility licensed
under Chapter 241. The term includes a general hospital and special
hospital.
(12) "National provider identifier" means the
national provider identifier described by 45 C.F.R. Section
162.406.
Sec. 328.002. RULES. The executive commissioner shall
adopt rules to implement this chapter.
SUBCHAPTER B. FACILITY FEES FOR CERTAIN HEALTH CARE SERVICES
Sec. 328.051. PROHIBITED FACILITY FEES. A health care
entity or health care system may not charge a facility fee for:
(1) health care services provided at a location
outside of a campus associated with the entity or system; and
(2) outpatient health care services classified by a
Current Procedural Terminology code as performance of an evaluation
and management procedure, regardless of whether the services are
provided at a campus.
Sec. 328.052. FACILITY FEE NOTICE FOR EXISTING AFFILIATES.
(a) This section applies only to a health care entity that is an
affiliate of or owned by a hospital or health care system and that
charges a facility fee.
(b) A health care entity subject to this section shall:
(1) provide to a patient written notice:
(A) at the time a health care service appointment
is scheduled and before delivering the service:
(i) that the entity may charge a facility
fee; and
(ii) of the cost range of a potential
facility fee; and
(B) at the time a health care service appointment
is scheduled regarding:
(i) available complaint procedures for
improper billing;
(ii) available programs for eligible
patients to receive free or reduced cost health care services; and
(iii) the facility fee waiver process
authorized by Section 328.054; and
(2) post a sign that states:
(A) the entity may charge a facility fee in
addition to the cost for the health care service;
(B) the location within the entity's facility at
which the health care services are provided where a patient may
inquire about the entity's facility fees;
(C) the address of the entity's Internet webpage
that provides information about the entity's facility fees; and
(D) a toll-free telephone number available to the
patient that provides information about the entity's facility fees.
(c) The sign required by Subsection (b)(2) must be:
(1) posted prominently and conspicuously at each
location in the health care entity's facility where health care
services are provided and for which a facility fee is charged and at
the location where an individual registers or checks in for the
services;
(2) posted in English and the 15 other foreign
languages most commonly spoken in this state; and
(3) available in an alternative format for individuals
with a disability who require an auxiliary aid for communication.
(d) A health care entity that requests payment from a
patient after providing a health care service for which a facility
fee is charged shall submit with the payment request the written,
itemized bill required by Section 185.002 that also includes:
(1) a specific notation of the facility fee charge;
and
(2) contact information for the entity representative
through which the patient may appeal the facility fee charge.
(e) A health care entity shall, to the extent practicable,
provide the notice required by Subsection (b)(1) and the itemized
billing information required by Subsection (d) to the patient in
the patient's preferred language and in plain language.
Sec. 328.053. FACILITY FEE NOTICE FOR AFFILIATES. (a) A
health care entity shall, on becoming an affiliate of a hospital or
health care system, provide written notice to any patient who
received health care services from the entity in the 12 months
preceding the date the facility became an affiliate of:
(1) the name, address, and telephone number of the
affiliated hospital or system;
(2) the date on which the entity may begin charging a
facility fee for the affiliated hospital or system;
(3) the prohibition on the entity charging a patient a
facility fee for the affiliated hospital or system before the date
described by Subdivision (2); and
(4) the patient's opportunity to contact the patient's
health benefit plan issuer for additional information regarding a
facility fee, including the patient's financial responsibility for
the facility fee.
(b) A health care entity and the affiliated hospital or
health care system may not charge a patient a facility fee for a
health care service provided before the 30th day after the date the
entity provides the notice required by Subsection (a).
Sec. 328.054. FACILITY FEE WAIVER PROCESS. (a) Each health
care entity and health care system that charges a facility fee shall
develop a process by which a patient may apply for a waiver to
wholly or partly reduce the costs of the facility fee. The process
must provide a patient:
(1) a period of not less than 30 days for the patient
to apply for the waiver that begins the day after the date the
patient receives the notice described by Section 328.052(b)(1); and
(2) information on the waiver process in the patient's
preferred language and with any auxiliary aid necessary for the
patient to complete the process.
(b) Each health care entity and health care system that
charges facility fees shall provide waivers described by Subsection
(a) to patients in accordance with rules adopted by the executive
commissioner.
Sec. 328.055. FACILITY FEE ANNUAL REPORT. (a) Each health
care entity and health care system shall annually submit a written
report to the commission on the facility fees charged by the entity
or system during the preceding year. The report must include:
(1) the name and mailing address of the entity or
system;
(2) the number of patient visits for which the entity
or system charged a facility fee;
(3) regarding the facility fee waiver process
established under Section 328.054:
(A) the number of waiver requests the entity or
system received;
(B) the number of waiver requests the entity or
system approved and denied; and
(C) the average dollar amount of an approved
waiver request and the percentage of the fee compared to the total
cost for the provided health care service;
(4) the number of appeals described by Section
328.052(d)(2) the entity or system received, approved, and denied;
(5) the total number of, total dollar amount of, and
cost range of facility fees paid by:
(A) Medicare or Medicaid;
(B) any private insurance plan; and
(C) a patient;
(6) the total amount billed and total revenue received
from facility fees;
(7) the 10 health care services, identified by Current
Procedural Terminology code, that generated the greatest amount of
facility fee gross revenue for the entity or system, including
information for each service on:
(A) the total number the entity or system
provided;
(B) the total net and gross revenue the entity or
system received; and
(C) the amount of gross revenue derived from
facility fees;
(8) the 10 health care services, identified by Current
Procedural Terminology code, for which facility fees were charged
that provided the greatest total number of patients for the entity
or system and the total net and gross revenue the entity or system
received for each service; and
(9) any other information related to facility fees the
commission determines necessary.
(b) The commission shall publish the information reported
under Subsection (a) on a publicly accessible web page on the
commission's Internet website.
SUBCHAPTER C. HEALTH CARE TRANSACTION TRANSPARENCY
Sec. 328.101. REQUIRED NATIONAL PROVIDER IDENTIFIER. (a)
Each health care entity or health care system shall apply for,
obtain, and use a unique national provider identifier for:
(1) each campus; and
(2) each location owned or operated by the entity or
system that is outside of the entity's or system's campus.
(b) A health care entity must demonstrate the entity has
complied with Subsection (a) as a condition for renewal of a license
required under this title.
Sec. 328.102. INCLUSION OF NATIONAL PROVIDER IDENTIFIER ON
PAYMENT CLAIMS. A health care entity shall include the national
provider identifier of the campus or location where the health care
services were provided on each bill or claim for reimbursement for
the health care services provided to a patient.
Sec. 328.103. PROHIBITED BILLING AND REIMBURSEMENT. (a) A
health care entity may not bill a patient or submit a claim for
reimbursement to the patient's health benefit plan issuer for
health care services provided to the patient at a location outside
of an entity campus unless the bill or claim:
(1) includes the national provider identifier of the
location where the services were provided; and
(2) uses the current version of the form CMS-1500 or
837P, as applicable.
(b) A patient and health benefit plan issuer are not
required to pay a health care entity's bill or claim for
reimbursement for health care services provided to the patient at a
location that is outside of the entity's campus unless the bill or
claim complies with Subsection (a).
(c) An enrollee is only financially responsible for cost
sharing required under the enrollee's health benefit plan for a
health care service provided at a location outside of the campus of
a health care entity.
SUBCHAPTER D. ENFORCEMENT
Sec. 328.151. AUDIT. (a) The commission may audit a health
care entity to verify compliance with this chapter.
(b) Each health care entity shall make available, on written
request of the commission, copies of any books, documents, records,
or other data that are necessary to complete the audit.
(c) Each health care entity shall retain copies of
information described by Subsection (b) until the fourth
anniversary of the date the health care services were provided.
(d) The commission shall publish the audit report on the
commission's Internet website.
Sec. 328.152. DECEPTIVE TRADE PRACTICE. A violation of
this chapter or a rule adopted under this chapter is a deceptive
trade practice under Chapter 17, Business & Commerce Code, and is
actionable under that chapter.
Sec. 328.153. DISCIPLINARY ACTION. (a) The commission,
after notice and hearing, may take disciplinary action against a
health care entity that violates this chapter or a rule adopted
under this chapter, including:
(1) assessing an administrative penalty in an amount
not less than $1,000;
(2) revocation, suspension, or denial of issuance of a
license required under this title;
(3) conditional or probationary issuance of or renewal
of a license required under this title; and
(4) referral of the matter to the attorney general for
imposition of a civil penalty against the entity.
(b) If, following an investigation and hearing conducted
under Subsection (a), the commission determines the health care
entity violated this chapter, the commission may recover from the
entity reasonable investigative costs the commission incurred in
conducting the investigation.
(c) If a health care entity is determined to have violated
this chapter or a rule adopted under this chapter, the entity shall
publish on the main page of the entity's Internet website
information on the violation, including the amount of any civil or
administrative penalty, conditions on licensure, and the actions
taken by the entity to remedy the violation.
SECTION 2. (a) As soon as practicable after the effective
date of this Act but not later than January 1, 2026, the executive
commissioner of the Health and Human Services Commission shall
adopt rules as required by Chapter 328, Health and Safety Code, as
added by this Act.
(b) Notwithstanding Chapter 328, Health and Safety Code, as
added by this Act, a health care entity, as defined by Section
328.001, Health and Safety Code, as added by this Act, is not
required to comply with that chapter until January 1, 2026.
SECTION 3. This Act takes effect September 1, 2025.