Texas 2025 - 89th Regular

Texas House Bill HB4037 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R13049 DNC-D
2	2	By: Vo H.B. No. 4037
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to anesthesia coverage and patient assessment
10	10	requirements for certain health benefit plans.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
13	13	by adding Chapter 1381 to read as follows:
14	14	CHAPTER 1381. ANESTHESIA
15	15	Sec. 1381.001. APPLICABILITY OF CHAPTER. (a) Except as
16	16	otherwise provided by this chapter, this chapter applies only to a
17	17	health benefit plan that provides benefits for medical or surgical
18	18	expenses incurred as a result of a health condition, accident, or
19	19	sickness, including an individual, group, blanket, or franchise
20	20	insurance policy or insurance agreement, a group hospital service
21	21	contract, or an individual or group evidence of coverage or similar
22	22	coverage document that is issued by:
23	23	(1) an insurance company;
24	24	(2) a group hospital service corporation operating
25	25	under Chapter 842;
26	26	(3) a health maintenance organization operating under
27	27	Chapter 843;
28	28	(4) an approved nonprofit health corporation that
29	29	holds a certificate of authority under Chapter 844;
30	30	(5) a multiple employer welfare arrangement that holds
31	31	a certificate of authority under Chapter 846;
32	32	(6) a stipulated premium company operating under
33	33	Chapter 884;
34	34	(7) a fraternal benefit society operating under
35	35	Chapter 885;
36	36	(8) a Lloyd's plan operating under Chapter 941; or
37	37	(9) an exchange operating under Chapter 942.
38	38	(b) Notwithstanding any other law, this chapter applies to:
39	39	(1) a small employer health benefit plan subject to
40	40	Chapter 1501, including coverage provided through a health group
41	41	cooperative under Subchapter B of that chapter;
42	42	(2) a standard health benefit plan issued under
43	43	Chapter 1507;
44	44	(3) a basic coverage plan under Chapter 1551;
45	45	(4) a basic plan under Chapter 1575; and
46	46	(5) a primary care coverage plan under Chapter 1579.
47	47	Sec. 1381.002. COVERAGE REQUIRED. A health benefit plan
48	48	that provides coverage for medically necessary anesthesia must
49	49	provide coverage for the full time that the anesthesia services are
50	50	performed.
51	51	SECTION 2. Subchapter B, Chapter 1551, Insurance Code, is
52	52	amended by adding Section 1551.0551 to read as follows:
53	53	Sec. 1551.0551. NETWORK ADEQUACY. The board of trustees
54	54	shall ensure that a managed care plan provided under the group
55	55	benefits program has an adequate network of health care providers
56	56	by requiring continued coverage and payment calculations that
57	57	account for:
58	58	(1) the assessment of patient physical status, as
59	59	determined by a participant's treating physician or health care
60	60	provider; and
61	61	(2) the complexity and urgency of care, as determined
62	62	by a participant's treating physician or health care provider.
63	63	SECTION 3. Section 1551.219, Insurance Code, is amended by
64	64	adding Subsection (c) to read as follows:
65	65	(c) Disease management services provided or covered under
66	66	Subsection (b) must take into account patient physical status and
67	67	complexity of care as identified by a clinician for patient care.
68	68	SECTION 4. Subchapter E, Chapter 1551, Insurance Code, is
69	69	amended by adding Section 1551.2195 to read as follows:
70	70	Sec. 1551.2195. FACTORS FOR NECESSITY AND BENEFIT PAYMENT
71	71	AMOUNT DETERMINATIONS. A group health benefit plan offered under
72	72	the group benefits program must provide for the following factors
73	73	to be taken into account in determining necessity of services and
74	74	calculation of benefits payment amounts:
75	75	(1) the assessment of patient physical status, as
76	76	determined by the patient's treating physician or health care
77	77	provider; and
78	78	(2) the complexity and urgency of care, as determined
79	79	by the patient's treating physician or health care provider.
80	80	SECTION 5. Section 1575.164, Insurance Code, is amended by
81	81	adding Subsection (c) to read as follows:
82	82	(c) Disease management services provided or covered under
83	83	Subsection (b) must take into account patient physical status and
84	84	complexity of care as identified by a clinician for patient care.
85	85	SECTION 6. Subchapter D, Chapter 1575, Insurance Code, is
86	86	amended by adding Section 1575.1645 to read as follows:
87	87	Sec. 1575.1645. FACTORS FOR NECESSITY AND BENEFIT PAYMENT
88	88	AMOUNT DETERMINATIONS. A health benefit plan provided under this
89	89	chapter must provide for the following factors to be taken into
90	90	account in determining necessity of services and calculation of
91	91	benefits payment amounts:
92	92	(1) the assessment of patient physical status, as
93	93	determined by the patient's treating physician or health care
94	94	provider; and
95	95	(2) the complexity and urgency of care, as determined
96	96	by the patient's treating physician or health care provider.
97	97	SECTION 7. Section 1579.107, Insurance Code, is amended by
98	98	adding Subsection (c) to read as follows:
99	99	(c) Disease management services provided or covered under
100	100	Subsection (b) must take into account patient physical status and
101	101	complexity of care as identified by a clinician for patient care.
102	102	SECTION 8. Subchapter C, Chapter 1579, Insurance Code, is
103	103	amended by adding Section 1579.1075 to read as follows:
104	104	Sec. 1579.1075. FACTORS FOR NECESSITY AND BENEFIT PAYMENT
105	105	AMOUNT DETERMINATIONS. A health coverage plan provided under this
106	106	chapter must provide for the following factors to be taken into
107	107	account in determining necessity of services and calculation of
108	108	benefits payment amounts:
109	109	(1) the assessment of patient physical status, as
110	110	determined by the patient's treating physician or health care
111	111	provider; and
112	112	(2) the complexity and urgency of care, as determined
113	113	by the patient's treating physician or health care provider.
114	114	SECTION 9. Chapter 1381, Insurance Code, as added by this
115	115	Act, applies only to a health benefit plan that is delivered, issued
116	116	for delivery, or renewed on or after January 1, 2026.
117	117	SECTION 10. The changes in law made by this Act to Chapters
118	118	1551, 1575, and 1579, Insurance Code, apply only to a plan year that
119	119	commences on or after January 1, 2026. A plan year that commenced
120	120	before January 1, 2026, is governed by the law as it existed
121	121	immediately before the effective date of this Act, and that law is
122	122	continued in effect for that purpose.
123	123	SECTION 11. This Act takes effect September 1, 2025.