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 through National Provider Identification Numbers or Employer Identification Numbers.

The bill also modifies the arbitration process by stating that the losing party will be responsible for paying the arbitrator's fees and expenses within 30 days of receiving the written decision, rather than splitting the costs between parties. These changes will take effect for health care services provided on or after January 1, 2026, while services provided before this date will continue to be governed by the previous law. The act is set to take effect on September 1, 2025.

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