81R2819 KCR-D
By: Davis of Harris H.B. No. 1889
A BILL TO BE ENTITLED
AN ACT
relating to the electronic transmission of certain information by
and to health benefit plan issuers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1213.002, Insurance Code, is amended to
read as follows:
Sec. 1213.002. ELECTRONIC SUBMISSION OF CLAIMS AND OTHER
INFORMATION. (a) The issuer of a health benefit plan by contract
may require that a health care professional licensed or registered
under the Occupations Code or a health care facility licensed under
the Health and Safety Code:
(1) electronically submit a health care claim or
equivalent encounter information, a referral certification, or an
authorization or eligibility transaction; and
(2) communicate electronically with the health
benefit plan issuer concerning information not otherwise described
by Subdivision (1).
(a-1) The health benefit plan issuer shall comply with the
standards for electronic transactions required by this section and
established by the commissioner by rule.
(b) The issuer of a health benefit plan by contract shall
establish a default method to submit claims and other information
in a nonelectronic format if there is a system failure or failures
or a catastrophic event substantially interferes with the normal
business operations of the physician, provider, or health benefit
plan or its agents. The health benefit plan issuer shall comply
with the standards for nonelectronic transactions established by
the commissioner by rule.
SECTION 2. Chapter 1274, Insurance Code, is amended to read
as follows:
CHAPTER 1274. ELECTRONIC TRANSMISSION OF CERTAIN HEALTH BENEFIT
PLAN INFORMATION [ELIGIBILITY AND PAYMENT STATUS]
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1274.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible for
coverage under a health benefit plan, including a covered
dependent.
(2) "Health benefit plan" means a group, blanket, or
franchise insurance policy, a certificate issued under a group
policy, a group hospital service contract, or a group subscriber
contract or evidence of coverage issued by a health maintenance
organization that provides benefits for health care services. The
term does not include:
(A) accident-only or disability income insurance
coverage or a combination of accident-only and disability income
insurance coverage;
(B) credit-only insurance coverage;
(C) disability insurance coverage;
(D) coverage only for a specified disease or
illness;
(E) Medicare services under a federal contract;
(F) Medicare supplement and Medicare Select
policies regulated in accordance with federal law;
(G) long-term care coverage or benefits, nursing
home care coverage or benefits, home health care coverage or
benefits, community-based care coverage or benefits, or any
combination of those coverages or benefits;
(H) coverage that provides limited-scope dental
or vision benefits;
(I) coverage provided by a single service health
maintenance organization;
(J) coverage issued as a supplement to liability
insurance;
(K) workers' compensation insurance coverage or
similar insurance coverage;
(L) automobile medical payment insurance
coverage;
(M) a jointly managed trust authorized under 29
U.S.C. Section 141 et seq. that contains a plan of benefits for
employees that is negotiated in a collective bargaining agreement
governing wages, hours, and working conditions of the employees
that is authorized under 29 U.S.C. Section 157;
(N) hospital indemnity or other fixed indemnity
insurance coverage;
(O) reinsurance contracts issued on a stop-loss,
quota-share, or similar basis;
(P) liability insurance coverage, including
general liability insurance and automobile liability insurance
coverage; or
(Q) coverage that provides other limited
benefits specified by federal regulations.
(3) "Health benefit plan issuer" means a health
maintenance organization operating under Chapter 843, a preferred
provider organization operating under Chapter 1301, an approved
nonprofit health corporation that holds a certificate of authority
under Chapter 844, and any other entity that issues a health benefit
plan, including:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885; or
(D) a stipulated premium company operating under
Chapter 884.
(4) "Health care provider" means:
(A) a person, other than a physician, who is
licensed or otherwise authorized to provide a health care service
in this state, including:
(i) a pharmacist or dentist; or
(ii) a pharmacy, hospital, or other
institution or organization;
(B) a person who is wholly owned or controlled by
a provider or by a group of providers who are licensed or otherwise
authorized to provide the same health care service; or
(C) a person who is wholly owned or controlled by
one or more hospitals and physicians, including a
physician-hospital organization.
(5) "Participating provider" means:
(A) a physician or health care provider who
contracts with a health benefit plan issuer to provide medical care
or health care to enrollees in a health benefit plan; or
(B) a physician or health care provider who
accepts and treats a patient on a referral from a physician or
provider described by Paragraph (A).
(6) "Physician" means:
(A) an individual licensed to practice medicine
in this state under Subtitle B, Title 3, Occupations Code;
(B) a professional association organized under
the Texas Professional Association Act (Article 1528f, Vernon's
Texas Civil Statutes);
(C) a nonprofit health corporation certified
under Chapter 162, Occupations Code;
(D) a medical school or medical and dental unit,
as defined or described by Section 61.003, 61.501, or 74.601,
Education Code, that employs or contracts with physicians to teach
or provide medical services or employs physicians and contracts
with physicians in a practice plan; or
(E) another entity wholly owned by physicians.
Sec. 1274.002. RULES. (a) The commissioner shall adopt
rules as necessary to implement this chapter.
(b) Before adopting rules under this section, the
commissioner shall consult and receive advice from the technical
advisory committee on claims processing established under Chapter
1212.
SUBCHAPTER B. ELIGIBILITY AND PAYMENT STATUS INFORMATION FOR HEALTH
CARE PROVIDERS
Sec. 1274.051 [1274.0015]. EXEMPTION. This subchapter
[chapter] does not apply to a single-service health maintenance
organization that provides coverage only for dental or vision
benefits.
Sec. 1274.052 [1274.002]. TRANSMISSION OF ENROLLEE
ELIGIBILITY AND PAYMENT STATUS. (a) Each health benefit plan
issuer shall, upon the participating provider's submission of the
patient's name, relationship to the primary enrollee, and birth
date, make available telephonically, electronically, or by an
Internet website portal to each participating provider information
maintained in the ordinary course of business and sufficient for
the provider to determine at the time of the enrollee's visit
information concerning:
(1) the enrollee, including:
(A) the enrollee's identification number
assigned by the health benefit plan issuer;
(B) the name of the enrollee and all covered
dependents, if appropriate;
(C) the birth date of the enrollee and the birth
dates of all covered dependents, if appropriate;
(D) the gender of the enrollee and the gender of
each covered dependent, if appropriate; and
(E) the current enrollment and eligibility
status of the enrollee under the health benefit plan;
(2) the enrollee's benefits, including:
(A) whether a specific type or category of
service is a covered benefit; and
(B) excluded benefits or limitations, both group
and individual; and
(3) the enrollee's financial information, including:
(A) copayment requirements, if any; and
(B) the unmet amount of the enrollee's deductible
or enrollee financial responsibility.
(b) Information required to be made available under this
section may be made available only to a participating provider who
is authorized under state and federal law to receive personally
identifiable information on an enrollee or dependent.
Sec. 1274.053 [1274.003]. CERTAIN CHARGES PROHIBITED. A
health benefit plan issuer may not directly or indirectly charge or
hold a physician, health care provider, or enrollee responsible for
a fee for making available or accessing information under this
subchapter [chapter].
Sec. 1274.054 [1274.004. RULES. (a) The commissioner
shall adopt rules as necessary to implement this chapter.
[(b) Before adopting rules under this section, the
commissioner shall consult and receive advice from the technical
advisory committee on claims processing established under Chapter
1212.
[Sec. 1274.005]. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN
FEDERAL PLANS. If the commissioner, in consultation with the
executive commissioner of health and human services, determines
that a provision of Section 1274.052 [1274.002] will cause a
negative fiscal impact on the state with respect to providing
benefits or services under Subchapter XIX, Social Security Act (42
U.S.C. Section 1396 et seq.), or Subchapter XXI, Social Security
Act (42 U.S.C. Section 1397aa et seq.), the commissioner [of
insurance] by rule shall waive the application of that provision to
the providing of those benefits or services.
SUBCHAPTER C. COMMUNICATIONS WITH ENROLLEES
Sec. 1274.101. ELECTRONIC TRANSMISSION OF ENROLLEE
DOCUMENTS AUTHORIZED. (a) Except as provided by Subsection (b), a
health benefit plan issuer may electronically provide an enrollee
with any document to which the enrollee is entitled.
(b) A health benefit plan issuer must provide an enrollee
with a paper copy of any document to which the enrollee is entitled,
if the enrollee requests in writing that documents be provided to
the enrollee in paper form.
SECTION 3. Section 1213.003, Insurance Code, is repealed.
SECTION 4. The change in law made by this Act applies only
to a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2010. A health benefit plan that is
delivered, issued for delivery, or renewed before January 1, 2010,
is covered by the law in effect at the time the health benefit plan
was delivered, issued for delivery, or renewed, and that law is
continued in effect for that purpose.
SECTION 5. This Act takes effect September 1, 2009.