89R15058 SCL-D
By: González of El Paso H.B. No. 4046
A BILL TO BE ENTITLED
AN ACT
relating to an enrollee's cost-sharing liability for emergency care
under a health benefit plan.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle A, Title 8, Insurance Code, is amended
by adding Chapter 1224 to read as follows:
CHAPTER 1224. COST-SHARING LIABILITY
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1224.001. DEFINITIONS. In this chapter:
(1) "Cost-sharing liability" means the amount an
enrollee is responsible for paying for a covered health care
service or supply under the terms of a health benefit plan. The
term includes deductibles, coinsurance, and copayments but does not
include premiums, balance billing amounts by out-of-network
providers, or the cost of health care services or supplies that are
not covered under a health benefit plan.
(2) "Emergency care" has the meaning assigned by
Section 1301.155.
(3) "Enrollee" means an individual, including a
dependent, entitled to coverage under a health benefit plan.
(4) "Health care provider" means a practitioner,
institutional provider, or other person or organization that
furnishes health care services and that is licensed or otherwise
authorized to practice in this state. The term includes a
pharmacist and a pharmacy.
Sec. 1224.002. APPLICABILITY OF CHAPTER. This chapter
applies only to a health benefit plan that provides benefits for
medical or surgical expenses incurred as a result of a health
condition, accident, or sickness, including an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an individual or group evidence
of coverage or similar coverage document that is issued by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885;
(8) a Lloyd's plan operating under Chapter 941; or
(9) an exchange operating under Chapter 942.
Sec. 1224.003. EXCEPTION. This chapter does not apply to
the state Medicaid program, including the Medicaid managed care
program operated under Chapter 540, Government Code.
Sec. 1224.004. RULES. The commissioner may adopt rules to
implement this chapter.
SUBCHAPTER B. REGULATION OF COST-SHARING LIABILITY FOR EMERGENCY
CARE
Sec. 1224.051. ISSUER REQUIREMENTS. Notwithstanding any
other law, a health benefit plan issuer:
(1) shall pay a health care provider the full amount
payable to the provider under the terms of the enrollee's health
benefit plan, including the enrollee's cost-sharing liability, for
covered emergency care;
(2) has the sole responsibility for collecting the
amount due for an enrollee's cost-sharing liability under the
enrollee's health benefit plan for emergency care; and
(3) on an enrollee's request, shall collect the amount
due for the enrollee's cost-sharing liability for emergency care
throughout the plan year in increments determined by the issuer.
Sec. 1224.052. ISSUER PROHIBITIONS. A health benefit plan
issuer may not:
(1) withhold any amount for an enrollee's cost-sharing
liability from a payment to a health care provider for covered
emergency care;
(2) require a health care provider to offer additional
discounts for emergency care to enrollees outside the terms of a
contract between the issuer and the provider;
(3) cancel an enrollee's health benefit plan for
failure to collect amounts due under the enrollee's cost-sharing
liability for emergency care; or
(4) use additional expenses incurred by complying with
this chapter as a basis for increasing an enrollee's premiums or
decreasing payments to a health care provider.
Sec. 1224.053. ENFORCEMENT OF SUBCHAPTER. (a) A violation
of this chapter is an unfair method of competition or an unfair or
deceptive act or practice in the business of insurance under
Chapter 541 and is subject to enforcement under that chapter.
(b) Notwithstanding Section 541.002, a health benefit plan
issuer is considered a person for purposes of enforcing this
subchapter under Chapter 541.
SECTION 2. Section 1271.008(a), Insurance Code, as
effective September 1, 2025, is amended to read as follows:
(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 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, as applicable;
(2) a statement of:
(A) with respect to emergency care subject to
Section 1271.155, the total amount payable to the physician or
provider under the enrollee's health benefit plan, the total amount
the physician or provider may bill the enrollee, if applicable, the
total amount of the enrollee's cost-sharing liability owed to the
health maintenance organization, and an itemization of copayments,
coinsurance, deductibles, and other amounts included in that
cost-sharing liability; and
(B) with respect to a health care service or
supply subject to Section 1271.157 or 1271.158, 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.
SECTION 3. Section 1271.155(g), Insurance Code, is amended
to read as follows:
(g) For emergency care subject to this section or a supply
related to that care, [a non-network physician or provider or a
person asserting a claim as an agent or assignee of the physician or
provider may not bill] an enrollee [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 physician or provider under Chapter 1467.
SECTION 4. Section 1301.0053(b), Insurance Code, is amended
to read as follows:
(b) For emergency care or post-emergency stabilization care
subject to this section or a supply related to that care, [an
out-of-network provider or a person asserting a claim as an agent or
assignee of the provider may not bill] an insured [in, and the
insured] does not have financial responsibility for[,] an amount
greater than an applicable copayment, coinsurance, and deductible
under the insured's exclusive provider benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) if applicable, a 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.
SECTION 5. Section 1301.010(a), Insurance Code, as
effective September 1, 2025, is amended to read as follows:
(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 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, as applicable;
(2) a statement of:
(A) with respect to emergency care subject to
Section 1301.0053 or 1301.155, the total amount payable to the
physician or provider under the insured's preferred provider
benefit plan, the total amount the physician or provider may bill
the insured, if applicable, the total amount of the insured's
cost-sharing liability owed to the insurer, and an itemization of
copayments, coinsurance, deductibles, and other amounts included
in that cost-sharing liability; and
(B) with respect to a health care service or
supply subject to Section 1301.164 or 1301.165, 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.
SECTION 6. Section 1301.155(d), Insurance Code, is amended
to read as follows:
(d) For emergency care subject to this section or a supply
related to that care, [an out-of-network provider or a person
asserting a claim as an agent or assignee of the provider may not
bill] an insured [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, a 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.
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, 2026. A health benefit plan delivered, issued
for delivery, or renewed before January 1, 2026, 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, 2025.