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
(C) a hospital licensed under Chapter 241.
(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.
(c) The department shall include on the consumer guide to health
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;
(C) the Joint Commission on Accreditation of Healthcare
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;
(C) informs consumers that the consumer may receive a bill for
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.
(c) Each facility shall post in the general waiting area and in
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
(C) 25 cents for any remaining pages 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.