CHAPTER 324. CONSUMER ACCESS TO HEALTH CARE INFORMATION

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Statutes > Texas > Health-and-safety-code > Title-4-health-facilities > Chapter-324-consumer-access-to-health-care-information

HEALTH AND SAFETY CODE

TITLE 4. HEALTH FACILITIES

SUBTITLE G. PROVISION OF SERVICES IN CERTAIN FACILITIES

CHAPTER 324. CONSUMER ACCESS TO HEALTH CARE INFORMATION

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 324.001. DEFINITIONS. In this chapter:

(1) "Average charge" means the mathematical average of facility

charges for an inpatient admission or outpatient surgical

procedure. The term does not include charges for a particular

inpatient admission or outpatient surgical procedure that exceed

the average by more than two standard deviations.

(2) "Billed charge" means the amount a facility charges for an

inpatient admission, outpatient surgical procedure, or health

care service or supply.

(3) "Costs" means the fixed and variable expenses incurred by a

facility in the provision of a health care service.

(4) "Consumer" means any person who is considering receiving, is

receiving, or has received a health care service or supply as a

patient from a facility. The term includes the personal

representative of the patient.

(5) "Department" means the Department of State Health Services.

(6) "Executive commissioner" means the executive commissioner of

the Health and Human Services Commission.

(7) "Facility" means:

(A) an ambulatory surgical center licensed under Chapter 243;

(B) a birthing center licensed under Chapter 244; or

(8) "Facility-based physician" means a radiologist, an

anesthesiologist, a pathologist, an emergency department

physician, or a neonatologist.

Added by Acts 2007, 80th Leg., R.S., Ch.

997, Sec. 1, eff. September 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 4, eff. June 19, 2009.

Sec. 324.002. RULES. The executive commissioner shall adopt and

enforce rules to further the purposes of this chapter.

Added by Acts 2007, 80th Leg., R.S., Ch.

997, Sec. 1, eff. September 1, 2007.

SUBCHAPTER B. CONSUMER GUIDE TO HEALTH CARE

Sec. 324.051. DEPARTMENT WEBSITE. (a) The department shall

make available on the department's Internet website a consumer

guide to health care. The department shall include information

in the guide concerning facility pricing practices and the

correlation between a facility's average charge for an inpatient

admission or outpatient surgical procedure and the actual, billed

charge for the admission or procedure, including notice that the

average charge for a particular inpatient admission or outpatient

surgical procedure will vary from the actual, billed charge for

the admission or procedure based on:

(1) the person's medical condition;

(2) any unknown medical conditions of the person;

(3) the person's diagnosis and recommended treatment protocols

ordered by the physician providing care to the person; and

(4) other factors associated with the inpatient admission or

outpatient surgical procedure.

(b) The department shall include information in the guide to

advise consumers that:

(1) the average charge for an inpatient admission or outpatient

surgical procedure may vary between facilities depending on a

facility's cost structure, the range and frequency of the

services provided, intensity of care, and payor mix;

(2) the average charge by a facility for an inpatient admission

or outpatient surgical procedure will vary from the facility's

costs or the amount that the facility may be reimbursed by a

health benefit plan for the admission or surgical procedure;

(3) the consumer may be personally liable for payment for an

inpatient admission, outpatient surgical procedure, or health

care service or supply depending on the consumer's health benefit

plan coverage;

(4) the consumer should contact the consumer's health benefit

plan for accurate information regarding the plan structure,

benefit coverage, deductibles, copayments, coinsurance, and other

plan provisions that may impact the consumer's liability for

payment for an inpatient admission, outpatient surgical

procedure, or health care service or supply; and

(5) the consumer, if uninsured, may be eligible for a discount

on facility charges based on a sliding fee scale or a written

charity care policy established by the facility.

care website:

(1) an Internet link for consumers to access quality of care

data, including:

(A) the Texas Health Care Information Collection website;

(B) the Hospital Compare website within the United States

Department of Health and Human Services website;

Organizations website; and

(D) the Texas Hospital Association's Texas PricePoint website;

and

(2) a disclaimer noting the websites that are not provided by

this state or an agency of this state.

(d) The department may accept gifts and grants to fund the

consumer guide to health care. On the department's Internet

website, the department may not identify, recognize, or

acknowledge in any format the donors or grantors to the consumer

guide to health care.

Added by Acts 2007, 80th Leg., R.S., Ch.

997, Sec. 1, eff. September 1, 2007.

SUBCHAPTER C. BILLING OF FACILITY SERVICES AND SUPPLIES

Sec. 324.101. FACILITY POLICIES. (a) Each facility shall

develop, implement, and enforce written policies for the billing

of facility health care services and supplies. The policies must

address:

(1) any discounting of facility charges to an uninsured

consumer, subject to Chapter 552, Insurance Code;

(2) any discounting of facility charges provided to a

financially or medically indigent consumer who qualifies for

indigent services based on a sliding fee scale or a written

charity care policy established by the facility and the

documented income and other resources of the consumer;

(3) the providing of an itemized statement required by

Subsection (e);

(4) whether interest will be applied to any billed service not

covered by a third-party payor and the rate of any interest

charged;

(5) the procedure for handling complaints;

(6) the providing of a conspicuous written disclosure to a

consumer at the time the consumer is first admitted to the

facility or first receives services at the facility that:

(A) provides confirmation whether the facility is a

participating provider under the consumer's third-party payor

coverage on the date services are to be rendered based on the

information received from the consumer at the time the

confirmation is provided;

(B) informs consumers that a facility-based physician who may

provide services to the consumer while the consumer is in the

facility may not be a participating provider with the same

third-party payors as the facility;

medical services from a facility-based physician for the amount

unpaid by the consumer's health benefit plan;

(D) informs consumers that the consumer may request a listing

of facility-based physicians who have been granted medical staff

privileges to provide medical services at the facility; and

(E) informs consumers that the consumer may request information

from a facility-based physician on whether the physician has a

contract with the consumer's health benefit plan and under what

circumstances the consumer may be responsible for payment of any

amounts not paid by the consumer's health benefit plan;

(7) the requirement that a facility provide a list, on request,

to a consumer to be admitted to, or who is expected to receive

services from, the facility, that contains the name and contact

information for each facility-based physician or facility-based

physician group that has been granted medical staff privileges to

provide medical services at the facility; and

(8) if the facility operates a website that includes a listing

of physicians who have been granted medical staff privileges to

provide medical services at the facility, the posting on the

facility's website of a list that contains the name and contact

information for each facility-based physician or facility-based

physician group that has been granted medical staff privileges to

provide medical services at the facility and the updating of the

list in any calendar quarter in which there are any changes to

the list.

(b) For services provided in an emergency department of a

hospital or as a result of an emergent direct admission, the

hospital shall provide the written disclosure required by

Subsection (a)(6) before discharging the patient from the

emergency department or hospital, as appropriate.

the waiting areas of any off-site or on-site registration,

admission, or business office a clear and conspicuous notice of

the availability of the policies required by Subsection (a).

(d) The facility shall provide an estimate of the facility's

charges for any elective inpatient admission or nonemergency

outpatient surgical procedure or other service on request and

before the scheduling of the admission or procedure or service.

The estimate must be provided not later than the 10th business

day after the date on which the estimate is requested. The

facility must advise the consumer that:

(1) the request for an estimate of charges may result in a delay

in the scheduling and provision of the inpatient admission,

outpatient surgical procedure, or other service;

(2) the actual charges for an inpatient admission, outpatient

surgical procedure, or other service will vary based on the

person's medical condition and other factors associated with

performance of the procedure or service;

(3) the actual charges for an inpatient admission, outpatient

surgical procedure, or other service may differ from the amount

to be paid by the consumer or the consumer's third-party payor;

(4) the consumer may be personally liable for payment for the

inpatient admission, outpatient surgical procedure, or other

service depending on the consumer's health benefit plan coverage;

and

(5) the consumer should contact the consumer's health benefit

plan for accurate information regarding the plan structure,

benefit coverage, deductibles, copayments, coinsurance, and other

plan provisions that may impact the consumer's liability for

payment for the inpatient admission, outpatient surgical

procedure, or other service.

(e) A facility shall provide to the consumer at the consumer's

request an itemized statement of the billed services if the

consumer requests the statement not later than the first

anniversary of the date the person is discharged from the

facility. The facility shall provide the statement to the

consumer not later than the 10th business day after the date on

which the statement is requested.

(f) A facility shall provide an itemized statement of billed

services to a third-party payor who is actually or potentially

responsible for paying all or part of the billed services

provided to a patient and who has received a claim for payment of

those services. To be entitled to receive a statement, the

third-party payor must request the statement from the facility

and must have received a claim for payment. The request must be

made not later than one year after the date on which the payor

received the claim for payment. The facility shall provide the

statement to the payor not later than the 30th day after the date

on which the payor requests the statement. If a third-party

payor receives a claim for payment of part but not all of the

billed services, the third-party payor may request an itemized

statement of only the billed services for which payment is

claimed or to which any deduction or copayment applies.

(g) A facility in violation of this section is subject to

enforcement action by the appropriate licensing agency.

(h) If a consumer or a third-party payor requests more than two

copies of the statement, the facility may charge a reasonable fee

for the third and subsequent copies provided. The fee may not

exceed the sum of:

(1) a basic retrieval or processing fee, which must include the

fee for providing the first 10 pages of the copies and which may

not exceed $30;

(2) a charge for each page of:

(A) $1 for the 11th through the 60th page of the provided

copies;

(B) 50 cents for the 61st through the 400th page of the provided

copies; and

(3) the actual cost of mailing, shipping, or otherwise

delivering the provided copies.

(i) If a consumer overpays a facility, the facility must refund

the amount of the overpayment not later than the 30th day after

the date the facility determines that an overpayment has been

made. This subsection does not apply to an overpayment subject

to Section 1301.132 or 843.350, Insurance Code.

Added by Acts 2007, 80th Leg., R.S., Ch.

997, Sec. 1, eff. September 1, 2007.

Amended by:

Acts 2009, 81st Leg., R.S., Ch.

1290, Sec. 5, eff. June 19, 2009.

Sec. 324.102. COMPLAINT PROCESS. A facility shall establish and

implement a procedure for handling consumer complaints, and must

make a good faith effort to resolve the complaint in an informal

manner based on its complaint procedures. If the complaint

cannot be resolved informally, the facility shall advise the

consumer that a complaint may be filed with the department and

shall provide the consumer with the mailing address and telephone

number of the department.

Added by Acts 2007, 80th Leg., R.S., Ch.

997, Sec. 1, eff. September 1, 2007.

Sec. 324.103. CONSUMER WAIVER PROHIBITED. The provisions of

this chapter may not be waived, voided, or nullified by a

contract or an agreement between a facility and a consumer.

Added by Acts 2007, 80th Leg., R.S., Ch.

997, Sec. 1, eff. September 1, 2007.

State Codes and Statutes

State Codes and Statutes

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State Codes and Statutes

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