bill making insurers pay for the full anesthesia time

The text as introduced · 942 words

89R13049 DNC-D

By: Vo
H.B. No. 4037

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.