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Texas Department of Insurance
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Letter from Commissioner Sullivan to Texas health plans

To the health plans of Texas:

As Texas begins the implementation of Senate Bill 1264 to prohibit surprise billing, it is critically important that health plans continue to take the steps necessary to achieve the legislation’s key consumer protections.

As you know, the Texas Department of Insurance has already put rules in place, developed an online portal for mediation and arbitration requests, scheduled stakeholder meetings and webinars, and sent out numerous emails with information about the new law.

TDI also will be monitoring how health plans implement the legislation. In that regard, there are several areas where we want to remind you of your responsibilities:

  • State law requires health plans to cover medical screenings necessary to rule out that an emergency condition exists.
  • Claim denials based on a failure to meet the prudent layperson standard for emergency care must be based on a review of the patient’s presenting symptoms, not on the later diagnosis code.
  • Plans must meet statutory deadlines to promptly adjudicate clean claims.
  • Plans must be ready to provide accurate information about the new law. This includes required notices about mediation and arbitration on explanations of benefits (EOBs) and the ability to quickly respond to questions from policyholders and providers.

We expect you to be proactive to meet both the letter and spirit of SB 1264. Review your policies and procedures and address potential issues quickly. We’ve created a SB 1264 page on our website, and you can sign up on the page to get an email alert when new events and information are posted. If you have questions or need to elevate an issue, please email us at IDR@tdi.texas.gov.

As with any major, transformative piece of legislation, this will require significant effort on your part. We are prepared to work collaboratively to resolve any issues. We appreciate your help and support as we work together to protect consumers.

Very truly yours,

Kent C. Sullivan
Commissioner of Insurance