Texas Passes Law for Consumer Protections Against Surprise Billing

September 2019 ~

Effective September 1, Texas enacted Senate Bill 1264 which provides consumer protections against certain medical and health care billing by certain out-of-network (OON) providers.

SB 1264, or Consumer Protections Against Billing, revises provisions relating to consumer protections against medical and health care billing by out of network providers, provides the procedure for an injunction for balance billing, provides for enforcement by regulatory agencies, and expands the mandatory coverage of emergency care.

Under the bill, out-of-network providers are prohibited from sending patients bills for an amount greater than the applicable copayment, coinsurance, or deductible under the allowed amount by the health plan. This applies to out-of-network providers for emergency services, facility-based services at a network hospital, and lab and diagnostic services from a network service.

SB 1264 mandates health plans to pay out-of-network claims for emergency care at an agreed rate or a usual and customary rate under the Texas Employees Group Benefits Act, the Texas Public School Retired Employees Group Benefits Act, or the Texas School Employees Uniform Group Health Coverage Act.

The Consumer Protections Against Billing bill also requires written notice by a health plan in the explanation of benefits given to the patient and provider and prohibits billing the health plan enrollee for an amount greater than the required copayment, coinsurance, or deductible, which must be based on the amount allowed and payable by the health benefit plan or a modified amount as agreed to with the provider, and not based on any additional amount owed to the provider under an out-of-network claim dispute resolution. Under the bill, enrollees are held harmless for financial responsibility for the dispute resolution amount.

Additionally, the bill provides for certain mediation options between the provider and health benefit plan and also includes provisions for mandatory binding arbitration for certain providers and health benefit plans to determine the amount owed by the plan to the provider when in dispute, but without involving the patient/enrollee.

The new protections under SB 1264 will apply to bills for medical services received on or after January 1, 2020.

Source(s): TrackBill; JD Supra; MedData; Inside Health Policy; National Law Review;