bill defining emergency care by what a prudent layperson believes

The text as introduced · 611 words

89R1176 RDS-F

By: Oliverson
H.B. No. 1635

A BILL TO BE ENTITLED

AN ACT

relating to the definition of emergency care for purposes of

certain health benefit plans.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 843.002(7), Insurance Code, is amended

to read as follows:

(7) "Emergency care" means health care services

provided in a hospital emergency facility, freestanding emergency

medical care facility, or comparable emergency facility to evaluate

and stabilize medical conditions of a recent onset and severity,

including severe pain, regardless of the final diagnosis of the

conditions, that would lead a prudent layperson possessing an

average knowledge of medicine and health to believe that the

individual's condition, sickness, or injury is of such a nature

that failure to get immediate medical care could:

(A) place the individual's health in serious

jeopardy;

(B) result in serious impairment to bodily

functions;

(C) result in serious dysfunction of a bodily

organ or part;

(D) result in serious disfigurement; or

(E) for a pregnant woman, result in serious

jeopardy to the health of the fetus.

SECTION 2. Section 1301.155(a), Insurance Code, is amended

to read as follows:

(a) In this section, "emergency care" means health care

services provided in a hospital emergency facility, freestanding

emergency medical care facility, or comparable emergency facility

to evaluate and stabilize a medical condition of a recent onset and

severity, including severe pain, regardless of the final diagnosis

of the condition, that would lead a prudent layperson possessing an

average knowledge of medicine and health to believe that the

person's condition, sickness, or injury is of such a nature that

failure to get immediate medical care could result in:

(1) placing the person's health in serious jeopardy;

(2) serious impairment to bodily functions;

(3) serious dysfunction of a bodily organ or part;

(4) serious disfigurement; or

(5) in the case of a pregnant woman, serious jeopardy

to the health of the fetus.

SECTION 3. Sections 4201.002(2) and (13), Insurance Code,

are amended to read as follows:

(2) "Emergency care" means health care services

provided in a hospital emergency facility or comparable facility to

evaluate and stabilize medical conditions of a recent onset and

severity, including severe pain, regardless of the final diagnosis

of the conditions, that would lead a prudent layperson possessing

an average knowledge of medicine and health to believe that the

individual's condition, sickness, or injury is of such a nature

that failure to get immediate medical care could:

(A) place the individual's health in serious

jeopardy;

(B) result in serious impairment to bodily

functions;

(C) result in serious dysfunction of a bodily

organ or part;

(D) result in serious disfigurement; or

(E) for a pregnant woman, result in serious

jeopardy to the health of the fetus.

(13) "Utilization review" includes a system for

prospective, concurrent, or retrospective review of the medical

necessity and appropriateness of health care services , including a

determination that the services do not meet the definition of

emergency care, and a system for prospective, concurrent, or

retrospective review to determine the experimental or

investigational nature of health care services. The term does not

include a review in response to an elective request for

clarification of coverage.

SECTION 4. 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 5. This Act takes effect September 1, 2025.