Texas 2025 - 89th Regular

Texas House Bill HB4046 Compare Versions

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

Old	New	Differences
1	1	89R15058 SCL-D
2	2	By: González of El Paso H.B. No. 4046
3	3
4	4
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to an enrollee's cost-sharing liability for emergency care
10	10	under a health benefit plan.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subtitle A, Title 8, Insurance Code, is amended
13	13	by adding Chapter 1224 to read as follows:
14	14	CHAPTER 1224. COST-SHARING LIABILITY
15	15	SUBCHAPTER A. GENERAL PROVISIONS
16	16	Sec. 1224.001. DEFINITIONS. In this chapter:
17	17	(1) "Cost-sharing liability" means the amount an
18	18	enrollee is responsible for paying for a covered health care
19	19	service or supply under the terms of a health benefit plan. The
20	20	term includes deductibles, coinsurance, and copayments but does not
21	21	include premiums, balance billing amounts by out-of-network
22	22	providers, or the cost of health care services or supplies that are
23	23	not covered under a health benefit plan.
24	24	(2) "Emergency care" has the meaning assigned by
25	25	Section 1301.155.
26	26	(3) "Enrollee" means an individual, including a
27	27	dependent, entitled to coverage under a health benefit plan.
28	28	(4) "Health care provider" means a practitioner,
29	29	institutional provider, or other person or organization that
30	30	furnishes health care services and that is licensed or otherwise
31	31	authorized to practice in this state. The term includes a
32	32	pharmacist and a pharmacy.
33	33	Sec. 1224.002. APPLICABILITY OF CHAPTER. This chapter
34	34	applies only to a health benefit plan that provides benefits for
35	35	medical or surgical expenses incurred as a result of a health
36	36	condition, accident, or sickness, including an individual, group,
37	37	blanket, or franchise insurance policy or insurance agreement, a
38	38	group hospital service contract, or an individual or group evidence
39	39	of coverage or similar coverage document that is issued by:
40	40	(1) an insurance company;
41	41	(2) a group hospital service corporation operating
42	42	under Chapter 842;
43	43	(3) a health maintenance organization operating under
44	44	Chapter 843;
45	45	(4) an approved nonprofit health corporation that
46	46	holds a certificate of authority under Chapter 844;
47	47	(5) a multiple employer welfare arrangement that holds
48	48	a certificate of authority under Chapter 846;
49	49	(6) a stipulated premium company operating under
50	50	Chapter 884;
51	51	(7) a fraternal benefit society operating under
52	52	Chapter 885;
53	53	(8) a Lloyd's plan operating under Chapter 941; or
54	54	(9) an exchange operating under Chapter 942.
55	55	Sec. 1224.003. EXCEPTION. This chapter does not apply to
56	56	the state Medicaid program, including the Medicaid managed care
57	57	program operated under Chapter 540, Government Code.
58	58	Sec. 1224.004. RULES. The commissioner may adopt rules to
59	59	implement this chapter.
60	60	SUBCHAPTER B. REGULATION OF COST-SHARING LIABILITY FOR EMERGENCY
61	61	CARE
62	62	Sec. 1224.051. ISSUER REQUIREMENTS. Notwithstanding any
63	63	other law, a health benefit plan issuer:
64	64	(1) shall pay a health care provider the full amount
65	65	payable to the provider under the terms of the enrollee's health
66	66	benefit plan, including the enrollee's cost-sharing liability, for
67	67	covered emergency care;
68	68	(2) has the sole responsibility for collecting the
69	69	amount due for an enrollee's cost-sharing liability under the
70	70	enrollee's health benefit plan for emergency care; and
71	71	(3) on an enrollee's request, shall collect the amount
72	72	due for the enrollee's cost-sharing liability for emergency care
73	73	throughout the plan year in increments determined by the issuer.
74	74	Sec. 1224.052. ISSUER PROHIBITIONS. A health benefit plan
75	75	issuer may not:
76	76	(1) withhold any amount for an enrollee's cost-sharing
77	77	liability from a payment to a health care provider for covered
78	78	emergency care;
79	79	(2) require a health care provider to offer additional
80	80	discounts for emergency care to enrollees outside the terms of a
81	81	contract between the issuer and the provider;
82	82	(3) cancel an enrollee's health benefit plan for
83	83	failure to collect amounts due under the enrollee's cost-sharing
84	84	liability for emergency care; or
85	85	(4) use additional expenses incurred by complying with
86	86	this chapter as a basis for increasing an enrollee's premiums or
87	87	decreasing payments to a health care provider.
88	88	Sec. 1224.053. ENFORCEMENT OF SUBCHAPTER. (a) A violation
89	89	of this chapter is an unfair method of competition or an unfair or
90	90	deceptive act or practice in the business of insurance under
91	91	Chapter 541 and is subject to enforcement under that chapter.
92	92	(b) Notwithstanding Section 541.002, a health benefit plan
93	93	issuer is considered a person for purposes of enforcing this
94	94	subchapter under Chapter 541.
95	95	SECTION 2. Section 1271.008(a), Insurance Code, as
96	96	effective September 1, 2025, is amended to read as follows:
97	97	(a) A health maintenance organization shall provide written
98	98	notice in accordance with this section in an explanation of
99	99	benefits provided to the enrollee and the physician or provider in
100	100	connection with a health care service or supply provided by a
101	101	non-network physician or provider. The notice must include:
102	102	(1) a statement of the billing prohibition under
103	103	Section 1271.155, 1271.157, or 1271.158, as applicable;
104	104	(2) a statement of:
105	105	(A) with respect to emergency care subject to
106	106	Section 1271.155, the total amount payable to the physician or
107	107	provider under the enrollee's health benefit plan, the total amount
108	108	the physician or provider may bill the enrollee, if applicable, the
109	109	total amount of the enrollee's cost-sharing liability owed to the
110	110	health maintenance organization, and an itemization of copayments,
111	111	coinsurance, deductibles, and other amounts included in that
112	112	cost-sharing liability; and
113	113	(B) with respect to a health care service or
114	114	supply subject to Section 1271.157 or 1271.158, the total amount
115	115	the physician or provider may bill the enrollee under the
116	116	enrollee's health benefit plan and an itemization of copayments,
117	117	coinsurance, deductibles, and other amounts included in that total;
118	118	and
119	119	(3) for an explanation of benefits provided to the
120	120	physician or provider, information required by commissioner rule
121	121	advising the physician or provider of the availability of mediation
122	122	or arbitration, as applicable, under Chapter 1467.
123	123	SECTION 3. Section 1271.155(g), Insurance Code, is amended
124	124	to read as follows:
125	125	(g) For emergency care subject to this section or a supply
126	126	related to that care, [a non-network physician or provider or a
127	127	person asserting a claim as an agent or assignee of the physician or
128	128	provider may not bill] an enrollee [in, and the enrollee] does not
129	129	have financial responsibility for[,] an amount greater than an
130	130	applicable copayment, coinsurance, and deductible under the
131	131	enrollee's health care plan that:
132	132	(1) is based on:
133	133	(A) the amount initially determined payable by
134	134	the health maintenance organization; or
135	135	(B) if applicable, a modified amount as
136	136	determined under the health maintenance organization's internal
137	137	appeal process; and
138	138	(2) is not based on any additional amount determined
139	139	to be owed to the physician or provider under Chapter 1467.
140	140	SECTION 4. Section 1301.0053(b), Insurance Code, is amended
141	141	to read as follows:
142	142	(b) For emergency care or post-emergency stabilization care
143	143	subject to this section or a supply related to that care, [an
144	144	out-of-network provider or a person asserting a claim as an agent or
145	145	assignee of the provider may not bill] an insured [in, and the
146	146	insured] does not have financial responsibility for[,] an amount
147	147	greater than an applicable copayment, coinsurance, and deductible
148	148	under the insured's exclusive provider benefit plan that:
149	149	(1) is based on:
150	150	(A) the amount initially determined payable by
151	151	the insurer; or
152	152	(B) if applicable, a modified amount as
153	153	determined under the insurer's internal appeal process; and
154	154	(2) is not based on any additional amount determined
155	155	to be owed to the provider under Chapter 1467.
156	156	SECTION 5. Section 1301.010(a), Insurance Code, as
157	157	effective September 1, 2025, is amended to read as follows:
158	158	(a) An insurer shall provide written notice in accordance
159	159	with this section in an explanation of benefits provided to the
160	160	insured and the physician or health care provider in connection
161	161	with a medical care or health care service or supply provided by an
162	162	out-of-network provider. The notice must include:
163	163	(1) a statement of the billing prohibition under
164	164	Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;
165	165	(2) a statement of:
166	166	(A) with respect to emergency care subject to
167	167	Section 1301.0053 or 1301.155, the total amount payable to the
168	168	physician or provider under the insured's preferred provider
169	169	benefit plan, the total amount the physician or provider may bill
170	170	the insured, if applicable, the total amount of the insured's
171	171	cost-sharing liability owed to the insurer, and an itemization of
172	172	copayments, coinsurance, deductibles, and other amounts included
173	173	in that cost-sharing liability; and
174	174	(B) with respect to a health care service or
175	175	supply subject to Section 1301.164 or 1301.165, the total amount
176	176	the physician or provider may bill the insured under the insured's
177	177	preferred provider benefit plan and an itemization of copayments,
178	178	coinsurance, deductibles, and other amounts included in that total;
179	179	and
180	180	(3) for an explanation of benefits provided to the
181	181	physician or provider, information required by commissioner rule
182	182	advising the physician or provider of the availability of mediation
183	183	or arbitration, as applicable, under Chapter 1467.
184	184	SECTION 6. Section 1301.155(d), Insurance Code, is amended
185	185	to read as follows:
186	186	(d) For emergency care subject to this section or a supply
187	187	related to that care, [an out-of-network provider or a person
188	188	asserting a claim as an agent or assignee of the provider may not
189	189	bill] an insured [in, and the insured] does not have financial
190	190	responsibility for[,] an amount greater than an applicable
191	191	copayment, coinsurance, and deductible under the insured's
192	192	preferred provider benefit plan that:
193	193	(1) is based on:
194	194	(A) the amount initially determined payable by
195	195	the insurer; or
196	196	(B) if applicable, a modified amount as
197	197	determined under the insurer's internal appeal process; and
198	198	(2) is not based on any additional amount determined
199	199	to be owed to the provider under Chapter 1467.
200	200	SECTION 7. The changes in law made by this Act apply only to
201	201	a health benefit plan delivered, issued for delivery, or renewed on
202	202	or after January 1, 2026. A health benefit plan delivered, issued
203	203	for delivery, or renewed before January 1, 2026, is governed by the
204	204	law as it existed immediately before the effective date of this Act,
205	205	and that law is continued in effect for that purpose.
206	206	SECTION 8. This Act takes effect September 1, 2025.