Bill Text: TX SB2476 | 2023-2024 | 88th Legislature | Comm Sub

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Relating to consumer protections against certain medical and health care billing by emergency medical services providers.

Spectrum: Bipartisan Bill

Status: (Passed) 2023-06-18 - See remarks for effective date [SB2476 Detail]

Download: Texas-2023-SB2476-Comm_Sub.html

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By: Zaffirini, Hancock S.B. No. 2476
(In the Senate - Filed March 10, 2023; March 23, 2023, read
first time and referred to Committee on Health & Human Services;
April 26, 2023, reported adversely, with favorable Committee
Substitute by the following vote: Yeas 6, Nays 0; April 26, 2023,
sent to printer.)
Click here to see the committee vote
COMMITTEE SUBSTITUTE FOR S.B. No. 2476 By: Perry

A BILL TO BE ENTITLED
AN ACT
relating to consumer protections against certain medical and health
care billing by emergency medical services providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subchapter A, Chapter 38, Insurance Code, is
amended by adding Section 38.006 to read as follows:
Sec. 38.006. EMERGENCY MEDICAL SERVICES PROVIDER BALANCE
BILLING RATE DATABASE. (a) A political subdivision may submit to
the department a rate set, controlled, or regulated by the
political subdivision for purposes of Section 1271.159, 1275.054,
1301.166, 1551.231, 1575.174, or 1579.112. The department shall
establish and maintain on the department's Internet website a
publicly accessible database for the rates.
(b) This section expires September 1, 2025.
SECTION 2. (a) Section 1271.008, Insurance Code, is
amended to read as follows:
Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (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 or transport 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, or 1271.159, as
applicable;
(2) 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.
(b) A health maintenance organization shall provide the
explanation of benefits with the notice required by this section to
a physician or health care provider not later than the date the
health maintenance organization makes a payment under Section
1271.155, 1271.157, [or] 1271.158, or 1271.159, as applicable.
(b) Effective September 1, 2025, Section 1271.008,
Insurance Code, is amended to read as follows:
Sec. 1271.008. BALANCE BILLING PROHIBITION NOTICE. (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) 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.
(b) A health maintenance organization shall provide the
explanation of benefits with the notice required by this section to
a physician or health care provider not later than the date the
health maintenance organization makes a payment under Section
1271.155, 1271.157, or 1271.158, as applicable.
SECTION 3. Subchapter D, Chapter 1271, Insurance Code, is
amended by adding Section 1271.159 to read as follows:
Sec. 1271.159. NON-NETWORK EMERGENCY MEDICAL SERVICES
PROVIDER. (a) In this section, "emergency medical services
provider" has the meaning assigned by Section 773.003, Health and
Safety Code, except that the term does not include an air ambulance.
(b) Except as provided by Subsection (c), a health
maintenance organization shall pay for a covered health care
service performed for, or a covered supply or covered transport
related to that service provided to, an enrollee by a non-network
emergency medical services provider at:
(1) if the political subdivision has submitted the
rate to the department under Section 38.006, the rate set,
controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is
provided; or
(2) if the political subdivision has not submitted the
rate to the department or does not have set, controlled, or
regulated rates, the lesser of:
(A) the provider's billed charge; or
(B) 325 percent of the current Medicare rate,
including any applicable extenders and modifiers.
(c) A health maintenance organization shall adjust a
payment required by Subsection (b)(1) each plan year by increasing
the payment by the lesser of the Medicare Inflation Index or 10
percent of the provider's previous calendar year rates.
(d) The health maintenance organization shall make a
payment required by this section directly to the provider not later
than, as applicable:
(1) the 30th day after the date the health maintenance
organization receives an electronic clean claim as defined by
Section 843.336 for those services that includes all information
necessary for the health maintenance organization to pay the claim;
or
(2) the 45th day after the date the health maintenance
organization receives a nonelectronic clean claim as defined by
Section 843.336 for those services that includes all information
necessary for the health maintenance organization to pay the claim.
(e) A non-network emergency medical services provider or a
person asserting a claim as an agent or assignee of the provider may
not bill an enrollee receiving a health care service or supply or
transport described by Subsection (b) 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 is based on:
(1) the amount initially determined payable by the
health maintenance organization; or
(2) if applicable, a modified amount as determined
under the health maintenance organization's internal appeal
process.
(f) This section may not be construed to require the
imposition of a penalty under Section 843.342.
(g) This section expires September 1, 2025.
SECTION 4. (a) Section 1275.003, Insurance Code, is
amended to read as follows:
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a health benefit plan to which this chapter
applies shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply or transport provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1275.051, 1275.052, [or] 1275.053, or 1275.054, as
applicable;
(2) 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1275.051, 1275.052, [or] 1275.053, or
1275.054, as applicable.
(b) Effective September 1, 2025, Section 1275.003,
Insurance Code, is amended to read as follows:
Sec. 1275.003. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a health benefit plan to which this chapter
applies shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply provided by an out-of-network
provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1275.051, 1275.052, or 1275.053, as applicable;
(2) 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1275.051, 1275.052, or 1275.053, as
applicable.
SECTION 5. Subchapter B, Chapter 1275, Insurance Code, is
amended by adding Section 1275.054 to read as follows:
Sec. 1275.054. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
PROVIDER PAYMENTS. (a) In this section, "emergency medical
services provider" has the meaning assigned by Section 773.003,
Health and Safety Code, except that the term does not include an air
ambulance.
(b) Except as provided by Subsection (c), the administrator
of a health benefit plan to which this chapter applies shall pay for
a covered health care or medical service performed for, or a covered
supply or covered transport related to that service provided to, an
enrollee by an out-of-network provider who is an emergency medical
services provider at:
(1) if the political subdivision has submitted the
rate to the department under Section 38.006, the rate set,
controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is
provided; or
(2) if the political subdivision has not submitted the
rate to the department or does not have set, controlled, or
regulated rates, the lesser of:
(A) the provider's billed charge; or
(B) 325 percent of the current Medicare rate,
including any applicable extenders and modifiers.
(c) The administrator shall adjust a payment required by
Subsection (b)(1) each plan year by increasing the payment by the
lesser of the Medicare Inflation Index or 10 percent of the
provider's previous calendar year rates.
(d) The administrator shall make a payment required by this
section directly to the provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(e) An out-of-network provider who is an emergency medical
services provider or a person asserting a claim as an agent or
assignee of the provider may not bill an enrollee receiving a health
care or medical service or supply or transport described by
Subsection (b) 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 benefit
plan that is based on:
(1) the amount initially determined payable by the
administrator; or
(2) if applicable, the modified amount as determined
under the administrator's internal appeal process.
(f) This section expires September 1, 2025.
SECTION 6. (a) Section 1301.0045(b), Insurance Code, is
amended to read as follows:
(b) Except as provided by Sections 1301.0052, 1301.0053,
1301.155, 1301.164, [and] 1301.165, and 1301.166, this chapter may
not be construed to require an exclusive provider benefit plan to
compensate a nonpreferred provider for services provided to an
insured.
(b) Effective September 1, 2025, Section 1301.0045(b),
Insurance Code, is amended to read as follows:
(b) Except as provided by Sections 1301.0052, 1301.0053,
1301.155, 1301.164, and 1301.165, this chapter may not be construed
to require an exclusive provider benefit plan to compensate a
nonpreferred provider for services provided to an insured.
SECTION 7. (a) Section 1301.010, Insurance Code, is
amended to read as follows:
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (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 or transport 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, or 1301.166,
as applicable;
(2) 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.
(b) An insurer shall provide the explanation of benefits
with the notice required by this section to a physician or health
care provider not later than the date the insurer makes a payment
under Section 1301.0053, 1301.155, 1301.164, [or] 1301.165, or
1301.166, as applicable.
(b) Effective September 1, 2025, Section 1301.010,
Insurance Code, is amended to read as follows:
Sec. 1301.010. BALANCE BILLING PROHIBITION NOTICE. (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) 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.
(b) An insurer shall provide the explanation of benefits
with the notice required by this section to a physician or health
care provider not later than the date the insurer makes a payment
under Section 1301.0053, 1301.155, 1301.164, or 1301.165, as
applicable.
SECTION 8. Subchapter D, Chapter 1301, Insurance Code, is
amended by adding Section 1301.166 to read as follows:
Sec. 1301.166. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
PROVIDER. (a) In this section, "emergency medical services
provider" has the meaning assigned by Section 773.003, Health and
Safety Code, except that the term does not include an air ambulance.
(b) Except as provided by Subsection (c), an insurer shall
pay for a covered medical care or health care service performed for,
or a covered supply or covered transport related to that service
provided to, an insured by an out-of-network provider who is an
emergency medical services provider at:
(1) if the political subdivision has submitted the
rate to the department under Section 38.006, the rate set,
controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is
provided; or
(2) if the political subdivision has not submitted the
rate to the department or does not have set, controlled, or
regulated rates, the lesser of:
(A) the provider's billed charge; or
(B) 325 percent of the current Medicare rate,
including any applicable extenders and modifiers.
(c) An insurer shall adjust a payment required by Subsection
(b)(1) each plan year by increasing the payment by the lesser of the
Medicare Inflation Index or 10 percent of the provider's previous
calendar year rates.
(d) The insurer shall make a payment required by this
section directly to the provider not later than, as applicable:
(1) the 30th day after the date the insurer receives an
electronic clean claim as defined by Section 1301.101 for those
services that includes all information necessary for the insurer to
pay the claim; or
(2) the 45th day after the date the insurer receives a
nonelectronic clean claim as defined by Section 1301.101 for those
services that includes all information necessary for the insurer to
pay the claim.
(e) An out-of-network provider who is an emergency medical
services provider or a person asserting a claim as an agent or
assignee of the provider may not bill an insured receiving a medical
care or health care service or supply or transport described by
Subsection (b) 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 is based on:
(1) the amount initially determined payable by the
insurer; or
(2) if applicable, the modified amount as determined
under the insurer's internal appeal process.
(f) This section may not be construed to require the
imposition of a penalty under Section 1301.137.
(g) This section expires September 1, 2025.
SECTION 9. (a) Section 1551.015, Insurance Code, is
amended to read as follows:
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under the group
benefits program shall provide written notice in accordance with
this section in an explanation of benefits provided to the
participant and the physician or health care provider in connection
with a health care or medical service or supply or transport
provided by an out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1551.228, 1551.229, [or] 1551.230, or 1551.231, as
applicable;
(2) the total amount the physician or provider may
bill the participant under the participant's managed care 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1551.228, 1551.229, [or] 1551.230, or
1551.231, as applicable.
(b) Effective September 1, 2025, Section 1551.015,
Insurance Code, is amended to read as follows:
Sec. 1551.015. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under the group
benefits program shall provide written notice in accordance with
this section in an explanation of benefits provided to the
participant and the physician or health care provider in connection
with a health care or medical service or supply provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1551.228, 1551.229, or 1551.230, as applicable;
(2) the total amount the physician or provider may
bill the participant under the participant's managed care 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1551.228, 1551.229, or 1551.230, as
applicable.
SECTION 10. Subchapter E, Chapter 1551, Insurance Code, is
amended by adding Section 1551.231 to read as follows:
Sec. 1551.231. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
PROVIDER PAYMENTS. (a) In this section, "emergency medical
services provider" has the meaning assigned by Section 773.003,
Health and Safety Code, except that the term does not include an air
ambulance.
(b) Except as provided by Subsection (c), the administrator
of a managed care plan provided under the group benefits program
shall pay for a covered health care or medical service performed
for, or a covered supply or covered transport related to that
service provided to, a participant by an out-of-network provider
who is an emergency medical services provider at:
(1) if the political subdivision has submitted the
rate to the department under Section 38.006, the rate set,
controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is
provided; or
(2) if the political subdivision has not submitted the
rate to the department or does not have set, controlled, or
regulated rates, the lesser of:
(A) the provider's billed charge; or
(B) 325 percent of the current Medicare rate,
including any applicable extenders and modifiers.
(c) The administrator shall adjust a payment required by
Subsection (b)(1) each plan year by increasing the payment by the
lesser of the Medicare Inflation Index or 10 percent of the
provider's previous calendar year rates.
(d) The administrator shall make a payment required by this
section directly to the provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(e) An out-of-network provider who is an emergency medical
services provider or a person asserting a claim as an agent or
assignee of the provider may not bill a participant receiving a
health care or medical service or supply or transport described by
Subsection (b) in, and the participant does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, and deductible under the participant's managed care
plan that is based on:
(1) the amount initially determined payable by the
administrator; or
(2) if applicable, the modified amount as determined
under the administrator's internal appeal process.
(f) This section expires September 1, 2025.
SECTION 11. (a) Section 1575.009, Insurance Code, is
amended to read as follows:
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under the group
program shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply or transport provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1575.171, 1575.172, [or] 1575.173, or 1575.174, as
applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's managed care 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1575.171, 1575.172, [or] 1575.173, or
1575.174, as applicable.
(b) Effective September 1, 2025, Section 1575.009,
Insurance Code, is amended to read as follows:
Sec. 1575.009. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under the group
program shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply provided by an out-of-network
provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1575.171, 1575.172, or 1575.173, as applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's managed care 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1575.171, 1575.172, or 1575.173, as
applicable.
SECTION 12. Subchapter D, Chapter 1575, Insurance Code, is
amended by adding Section 1575.174 to read as follows:
Sec. 1575.174. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
PROVIDER PAYMENTS. (a) In this section, "emergency medical
services provider" has the meaning assigned by Section 773.003,
Health and Safety Code, except that the term does not include an air
ambulance.
(b) Except as provided by Subsection (c), the administrator
of a managed care plan provided under the group program shall pay
for a covered health care or medical service performed for, or a
covered supply or covered transport related to that service
provided to, an enrollee by an out-of-network provider who is an
emergency medical services provider at:
(1) if the political subdivision has submitted the
rate to the department under Section 38.006, the rate set,
controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is
provided; or
(2) if the political subdivision has not submitted the
rate to the department or does not have set, controlled, or
regulated rates, the lesser of:
(A) the provider's billed charge; or
(B) 325 percent of the current Medicare rate,
including any applicable extenders and modifiers.
(c) The administrator shall adjust a payment required by
Subsection (b)(1) each plan year by increasing the payment by the
lesser of the Medicare Inflation Index or 10 percent of the
provider's previous calendar year rates.
(d) The administrator shall make a payment required by this
section directly to the provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(e) An out-of-network provider who is an emergency medical
services provider or a person asserting a claim as an agent or
assignee of the provider may not bill an enrollee receiving a health
care or medical service or supply or transport described by
Subsection (b) in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, and deductible under the enrollee's managed care plan
that is based on:
(1) the amount initially determined payable by the
administrator; or
(2) if applicable, the modified amount as determined
under the administrator's internal appeal process.
(f) This section expires September 1, 2025.
SECTION 13. (a) Section 1579.009, Insurance Code, is
amended to read as follows:
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under this
chapter shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply or transport provided by an
out-of-network provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1579.109, 1579.110, [or] 1579.111, or 1579.112, as
applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's managed care 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1579.109, 1579.110, [or] 1579.111, or
1579.112, as applicable.
(b) Effective September 1, 2025, Section 1579.009,
Insurance Code, is amended to read as follows:
Sec. 1579.009. BALANCE BILLING PROHIBITION NOTICE. (a)
The administrator of a managed care plan provided under this
chapter shall provide written notice in accordance with this
section in an explanation of benefits provided to the enrollee and
the physician or health care provider in connection with a health
care or medical service or supply provided by an out-of-network
provider. The notice must include:
(1) a statement of the billing prohibition under
Section 1579.109, 1579.110, or 1579.111, as applicable;
(2) the total amount the physician or provider may
bill the enrollee under the enrollee's managed care 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.
(b) The administrator shall provide the explanation of
benefits with the notice required by this section to a physician or
health care provider not later than the date the administrator
makes a payment under Section 1579.109, 1579.110, or 1579.111, as
applicable.
SECTION 14. Subchapter C, Chapter 1579, Insurance Code, is
amended by adding Section 1579.112 to read as follows:
Sec. 1579.112. OUT-OF-NETWORK EMERGENCY MEDICAL SERVICES
PROVIDER PAYMENTS. (a) In this section, "emergency medical
services provider" has the meaning assigned by Section 773.003,
Health and Safety Code, except that the term does not include an air
ambulance.
(b) Except as provided by Subsection (c), the administrator
of a managed care plan provided under this chapter shall pay for a
covered health care or medical service performed for, or a covered
supply or covered transport related to that service provided to, an
enrollee by an out-of-network provider who is an emergency medical
services provider at:
(1) if the political subdivision has submitted the
rate to the department under Section 38.006, the rate set,
controlled, or regulated by the political subdivision in which:
(A) the service originated; or
(B) the transport originated if transport is
provided; or
(2) if the political subdivision has not submitted the
rate to the department or does not have set, controlled, or
regulated rates, the lesser of:
(A) the provider's billed charge; or
(B) 325 percent of the current Medicare rate,
including any applicable extenders and modifiers.
(c) The administrator shall adjust a payment required by
Subsection (b)(1) each plan year by increasing the payment by the
lesser of the Medicare Inflation Index or 10 percent of the
provider's previous calendar year rates.
(d) The administrator shall make a payment required by this
section directly to the provider not later than, as applicable:
(1) the 30th day after the date the administrator
receives an electronic claim for those services that includes all
information necessary for the administrator to pay the claim; or
(2) the 45th day after the date the administrator
receives a nonelectronic claim for those services that includes all
information necessary for the administrator to pay the claim.
(e) An out-of-network provider who is an emergency medical
services provider or a person asserting a claim as an agent or
assignee of the provider may not bill an enrollee receiving a health
care or medical service or supply or transport described by
Subsection (b) in, and the enrollee does not have financial
responsibility for, an amount greater than an applicable copayment,
coinsurance, and deductible under the enrollee's managed care plan
that is based on:
(1) the amount initially determined payable by the
administrator; or
(2) if applicable, a modified amount as determined
under the administrator's internal appeal process.
(f) This section expires September 1, 2025.
SECTION 15. The changes in law made by this Act apply only
to a ground ambulance service provided on or after January 1, 2024.
A ground ambulance service provided before January 1, 2024, is
governed by the law in effect immediately before the effective date
of this Act, and that law is continued in effect for that purpose.
SECTION 16. Except as otherwise provided by this Act, this
Act takes effect September 1, 2023.
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