By: Oliverson, Raymond H.B. No. 1236
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the definition of and certain determinations regarding
  emergency care for purposes of certain health benefit plan
  coverage.
         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.  Subchapter A, Chapter 843, Insurance Code, is
  amended by adding Section 843.011 to read as follows:
         Sec. 843.011.  EMERGENCY SERVICE DETERMINATIONS. Nothing in
  this subchapter prohibits a health maintenance organization from
  considering diagnosis codes to detect fraud or abuse.
         SECTION 3.  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 4.  Subchapter D, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.166 to read as follows:
         Sec. 1301.166.  EMERGENCY SERVICE DETERMINATIONS. Nothing
  in this subchapter prohibits a preferred provider benefit plan from
  considering diagnosis codes to detect fraud or abuse.
         SECTION 5.  Section 4201.002(2), Insurance Code, is 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.
         SECTION 6.  Subchapter A, Chapter 4201, Insurance Code, is
  amended by adding Section 4201.005 to read as follows:
         Sec. 4201.005.  EMERGENCY SERVICE DETERMINATIONS. Nothing
  in this subchapter prohibits a payor from considering diagnosis
  codes to detect fraud or abuse.
         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, 2024. A health benefit plan delivered, issued
  for delivery, or renewed before January 1, 2024, 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, 2023.