TEXAS

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The Texas SBL became effective January 1, 2020. Texas Insurance Code (TIC) Chapter 1467 and rules under 28 TAC Ch. 21, Subchapter PP. The relevant provisions of the Texas law include:

• A timeline for filing arbitration by medical practitioners between 20 and 90 days from the date of receipt of the original EOB.
• A process of mediation (non-binding) for facilities. If no agreement is reached, a civil judicial action can be instituted.
• Reimbursement for emergency and inadvertent treatment tied to UCR, and the arbitrator can consider numerous factors, including complexity of the case, the provider’s expertise, info from benchmark databases. These databases have included the 80th percentile of charge data as well as the 50th percentile of “allowed” data, which vary tremendously.

As for bifurcation, according to CMS,

Texas does not have an applicable All-Payer Model Agreement that would determine the [OON] rate. Based on the survey response and CMS communications with the Texas Department of Insurance staff, CMS understands that Texas Insurance Code (TIC) Chapter 1467and rules under 28 TAC Ch. 21, Subchapter PP, are a specified state law that will apply for purposes of determining the [OON] rate with respect to emergency care provided in a hospital emergency room or a licensed free-standing emergency room, services provided by an [OON] facility-based provider in an [INN] facility, and [OON] diagnostic imaging or laboratory services that were performed in connection with [INN] care, for individuals in an PPO, EPO, or HMO fully insured commercial health benefit plan regulated by the Texas Department of Insurance in Texas, as well as the Texas state employee and retiree plans for employees of Texas state agencies and active and retired teachers. Under TIC 1467, Texas has two different independent dispute resolution processes that apply separately to health care facilities and health care providers that are not facilities. Mediation, addressed under TIC Chapter 1467, Subchapter B and rules in Division 2 of 28 TAC Chapter 21, Subchapter PP, applies to an [OON] facility. Arbitration, addressed under TIC Chapter 1467, Subchapter B-1 and rules in Division 3 of 28 TAC Chapter 21, Subchapter PP, applies to an [OON] provider who is not a facility.4 The [Federal IDR] process under section 2799A-2(b) of the PHS Act and 45 CFR 149.520 will apply for purposes of determining the [OON] rate with respect to services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Texas by nonparticipating providers of air ambulance services.

Letter from CMS to Governor of Texas, dated January 25, 2022.