bill making insurers pay emergency care in full, then collect

The text as introduced · 1,623 words

89R15058 SCL-D

By: González of El Paso
H.B. No. 4046

A BILL TO BE ENTITLED

AN ACT

relating to an enrollee's cost-sharing liability for emergency care

under a health benefit plan.

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

SECTION 1. Subtitle A, Title 8, Insurance Code, is amended

by adding Chapter 1224 to read as follows:

CHAPTER 1224. COST-SHARING LIABILITY

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 1224.001. DEFINITIONS. In this chapter:

(1) "Cost-sharing liability" means the amount an

enrollee is responsible for paying for a covered health care

service or supply under the terms of a health benefit plan. The

term includes deductibles, coinsurance, and copayments but does not

include premiums, balance billing amounts by out-of-network

providers, or the cost of health care services or supplies that are

not covered under a health benefit plan.

(2) "Emergency care" has the meaning assigned by

Section 1301.155.

(3) "Enrollee" means an individual, including a

dependent, entitled to coverage under a health benefit plan.

(4) "Health care provider" means a practitioner,

institutional provider, or other person or organization that

furnishes health care services and that is licensed or otherwise

authorized to practice in this state. The term includes a

pharmacist and a pharmacy.

Sec. 1224.002. APPLICABILITY OF 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.

Sec. 1224.003. EXCEPTION. This chapter does not apply to

the state Medicaid program, including the Medicaid managed care

program operated under Chapter 540, Government Code.

Sec. 1224.004. RULES. The commissioner may adopt rules to

implement this chapter.

SUBCHAPTER B. REGULATION OF COST-SHARING LIABILITY FOR EMERGENCY

CARE

Sec. 1224.051. ISSUER REQUIREMENTS. Notwithstanding any

other law, a health benefit plan issuer:

(1) shall pay a health care provider the full amount

payable to the provider under the terms of the enrollee's health

benefit plan, including the enrollee's cost-sharing liability, for

covered emergency care;

(2) has the sole responsibility for collecting the

amount due for an enrollee's cost-sharing liability under the

enrollee's health benefit plan for emergency care; and

(3) on an enrollee's request, shall collect the amount

due for the enrollee's cost-sharing liability for emergency care

throughout the plan year in increments determined by the issuer.

Sec. 1224.052. ISSUER PROHIBITIONS. A health benefit plan

issuer may not:

(1) withhold any amount for an enrollee's cost-sharing

liability from a payment to a health care provider for covered

emergency care;

(2) require a health care provider to offer additional

discounts for emergency care to enrollees outside the terms of a

contract between the issuer and the provider;

(3) cancel an enrollee's health benefit plan for

failure to collect amounts due under the enrollee's cost-sharing

liability for emergency care; or

(4) use additional expenses incurred by complying with

this chapter as a basis for increasing an enrollee's premiums or

decreasing payments to a health care provider.

Sec. 1224.053. ENFORCEMENT OF SUBCHAPTER. (a) A violation

of this chapter is an unfair method of competition or an unfair or

deceptive act or practice in the business of insurance under

Chapter 541 and is subject to enforcement under that chapter.

(b) Notwithstanding Section 541.002, a health benefit plan

issuer is considered a person for purposes of enforcing this

subchapter under Chapter 541.

SECTION 2. Section 1271.008(a), Insurance Code, as

effective September 1, 2025, is amended to read as follows:

(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) a statement of:

(A) with respect to emergency care subject to

Section 1271.155, the total amount payable to the physician or

provider under the enrollee's health benefit plan, the total amount

the physician or provider may bill the enrollee, if applicable, the

total amount of the enrollee's cost-sharing liability owed to the

health maintenance organization, and an itemization of copayments,

coinsurance, deductibles, and other amounts included in that

cost-sharing liability; and

(B) with respect to a health care service or

supply subject to Section 1271.157 or 1271.158, 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.

SECTION 3. Section 1271.155(g), Insurance Code, is amended

to read as follows:

(g) For emergency care subject to this section or a supply

related to that care, [ a non-network physician or provider or a

person asserting a claim as an agent or assignee of the physician or

provider may not bill ] an enrollee [ 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:

(1) is based on:

(A) the amount initially determined payable by

the health maintenance organization; or

(B) if applicable, a modified amount as

determined under the health maintenance organization's internal

appeal process; and

(2) is not based on any additional amount determined

to be owed to the physician or provider under Chapter 1467.

SECTION 4. Section 1301.0053(b), Insurance Code, is amended

to read as follows:

(b) For emergency care or post-emergency stabilization care

subject to this section or a supply related to that care, [ an

out-of-network provider or a person asserting a claim as an agent or

assignee of the provider may not bill ] an insured [ in, and the

insured ] does not have financial responsibility for[ , ] an amount

greater than an applicable copayment, coinsurance, and deductible

under the insured's exclusive provider benefit plan that:

(1) is based on:

(A) the amount initially determined payable by

the insurer; or

(B) if applicable, a modified amount as

determined under the insurer's internal appeal process; and

(2) is not based on any additional amount determined

to be owed to the provider under Chapter 1467.

SECTION 5. Section 1301.010(a), Insurance Code, as

effective September 1, 2025, is amended to read as follows:

(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) a statement of:

(A) with respect to emergency care subject to

Section 1301.0053 or 1301.155, the total amount payable to the

physician or provider under the insured's preferred provider

benefit plan, the total amount the physician or provider may bill

the insured, if applicable, the total amount of the insured's

cost-sharing liability owed to the insurer, and an itemization of

copayments, coinsurance, deductibles, and other amounts included

in that cost-sharing liability; and

(B) with respect to a health care service or

supply subject to Section 1301.164 or 1301.165, 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.

SECTION 6. Section 1301.155(d), Insurance Code, is amended

to read as follows:

(d) For emergency care subject to this section or a supply

related to that care, [ an out-of-network provider or a person

asserting a claim as an agent or assignee of the provider may not

bill ] an insured [ 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:

(1) is based on:

(A) the amount initially determined payable by

the insurer; or

(B) if applicable, a modified amount as

determined under the insurer's internal appeal process; and

(2) is not based on any additional amount determined

to be owed to the provider under Chapter 1467.

SECTION 7. 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 8. This Act takes effect September 1, 2025.