HB4037 - Relating to anesthesia coverage and patient assessment requirements for certain health benefit plans.

  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.