H.B. No. 5036 amends the Texas Insurance Code to clarify the definition of "out-of-network provider" and to establish new procedures for arbitration related to out-of-network health benefit claims. The bill specifies that an out-of-network provider includes diagnostic imaging providers, emergency care providers, facility-based providers, or laboratory service providers that do not participate in a health benefit plan. Additionally, it introduces criteria for identifying a group of out-of-network providers based on their National Provider Identification Number, group National Provider Identification Number, or Employer Identification Number.

The bill also modifies the arbitration process by stating that the losing party shall pay the arbitrator's fees and expenses within 30 days of receiving the written decision from the arbitrator, rather than splitting the costs between the parties. These changes will apply to health care or medical services provided on or after January 1, 2026, with the existing law remaining in effect for services provided before that date. The act is set to take effect on September 1, 2025.

Statutes affected:
Introduced: Insurance Code 1467.087 (Insurance Code 1467)