89R13049 DNC-D
By: Hughes S.B. No. 1118
A BILL TO BE ENTITLED
AN ACT
relating to anesthesia coverage and patient assessment
requirements for certain health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle E, Title 8, Insurance Code, is amended
by adding Chapter 1381 to read as follows:
CHAPTER 1381. ANESTHESIA
Sec. 1381.001. APPLICABILITY OF CHAPTER. (a) Except as
otherwise provided by this 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.
(b) Notwithstanding any other law, this chapter applies to:
(1) a small employer health benefit plan subject to
Chapter 1501, including coverage provided through a health group
cooperative under Subchapter B of that chapter;
(2) a standard health benefit plan issued under
Chapter 1507;
(3) a basic coverage plan under Chapter 1551;
(4) a basic plan under Chapter 1575; and
(5) a primary care coverage plan under Chapter 1579.
Sec. 1381.002. COVERAGE REQUIRED. A health benefit plan
that provides coverage for medically necessary anesthesia must
provide coverage for the full time that the anesthesia services are
performed.
SECTION 2. Subchapter B, Chapter 1551, Insurance Code, is
amended by adding Section 1551.0551 to read as follows:
Sec. 1551.0551. NETWORK ADEQUACY. The board of trustees
shall ensure that a managed care plan provided under the group
benefits program has an adequate network of health care providers
by requiring continued coverage and payment calculations that
account for:
(1) the assessment of patient physical status, as
determined by a participant's treating physician or health care
provider; and
(2) the complexity and urgency of care, as determined
by a participant's treating physician or health care provider.
SECTION 3. Section 1551.219, Insurance Code, is amended by
adding Subsection (c) to read as follows:
(c) Disease management services provided or covered under
Subsection (b) must take into account patient physical status and
complexity of care as identified by a clinician for patient care.
SECTION 4. Subchapter E, Chapter 1551, Insurance Code, is
amended by adding Section 1551.2195 to read as follows:
Sec. 1551.2195. FACTORS FOR NECESSITY AND BENEFIT PAYMENT
AMOUNT DETERMINATIONS. A group health benefit plan offered under
the group benefits program must provide for the following factors
to be taken into account in determining necessity of services and
calculation of benefits payment amounts:
(1) the assessment of patient physical status, as
determined by the patient's treating physician or health care
provider; and
(2) the complexity and urgency of care, as determined
by the patient's treating physician or health care provider.
SECTION 5. Section 1575.164, Insurance Code, is amended by
adding Subsection (c) to read as follows:
(c) Disease management services provided or covered under
Subsection (b) must take into account patient physical status and
complexity of care as identified by a clinician for patient care.
SECTION 6. Subchapter D, Chapter 1575, Insurance Code, is
amended by adding Section 1575.1645 to read as follows:
Sec. 1575.1645. FACTORS FOR NECESSITY AND BENEFIT PAYMENT
AMOUNT DETERMINATIONS. A health benefit plan provided under this
chapter must provide for the following factors to be taken into
account in determining necessity of services and calculation of
benefits payment amounts:
(1) the assessment of patient physical status, as
determined by the patient's treating physician or health care
provider; and
(2) the complexity and urgency of care, as determined
by the patient's treating physician or health care provider.
SECTION 7. Section 1579.107, Insurance Code, is amended by
adding Subsection (c) to read as follows:
(c) Disease management services provided or covered under
Subsection (b) must take into account patient physical status and
complexity of care as identified by a clinician for patient care.
SECTION 8. Subchapter C, Chapter 1579, Insurance Code, is
amended by adding Section 1579.1075 to read as follows:
Sec. 1579.1075. FACTORS FOR NECESSITY AND BENEFIT PAYMENT
AMOUNT DETERMINATIONS. A health coverage plan provided under this
chapter must provide for the following factors to be taken into
account in determining necessity of services and calculation of
benefits payment amounts:
(1) the assessment of patient physical status, as
determined by the patient's treating physician or health care
provider; and
(2) the complexity and urgency of care, as determined
by the patient's treating physician or health care provider.
SECTION 9. Chapter 1381, Insurance Code, as added by this
Act, applies only to a health benefit plan that is delivered, issued
for delivery, or renewed on or after January 1, 2026.
SECTION 10. The changes in law made by this Act to Chapters
1551, 1575, and 1579, Insurance Code, apply only to a plan year that
commences on or after January 1, 2026. A plan year that commenced
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 11. This Act takes effect September 1, 2025.