81R8948 PMO-D
By: Hancock H.B. No. 2256
A BILL TO BE ENTITLED
AN ACT
relating to requirements for contracts between physicians,
hospitals, and health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1461 to read as follows:
CHAPTER 1461. IN-NETWORK PROVIDER REQUIREMENTS
Sec. 1461.001. DEFINITIONS. In this chapter:
(1) "Enrollee" has the meaning assigned by Section
1456.001.
(2) "Health care facility" has the meaning assigned by
Section 1456.001.
(3) "Health care practitioner" has the meaning
assigned by Section 1456.001.
(4) "Medical specialty" means a medical specialty
offered by the American Board of Medical Specialties.
(5) "Physician" means a person licensed to practice
medicine in this state.
(6) "Provider network" has the meaning assigned by
Section 1456.001.
Sec. 1461.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies to:
(1) each health benefit plan or person described by
Subsection (b) or (c);
(2) a health care facility; and
(3) a provider network.
(b) This chapter applies to any health benefit plan that:
(1) provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884;
(E) a health maintenance organization operating
under Chapter 843;
(F) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; or
(H) an entity not authorized under this code or
another insurance law of this state that contracts directly for
health care services on a risk-sharing basis, including a
capitation basis; or
(2) provides health and accident coverage through a
risk pool created under Chapter 172, Local Government Code,
notwithstanding Section 172.014, Local Government Code, or any
other law.
(c) This chapter applies to a person to whom a health
benefit plan contracts to:
(1) process or pay claims;
(2) obtain the services of physicians or other
providers to provide health care services to enrollees; or
(3) issue verifications or preauthorizations.
(d) This chapter does not apply to:
(1) Medicaid managed care programs operated under
Chapter 533, Government Code;
(2) Medicaid programs operated under Chapter 32, Human
Resources Code; or
(3) the state child health plan operated under Chapter
62 or 63, Health and Safety Code.
Sec. 1461.003. GENERAL REQUIREMENTS. (a) A health benefit
plan must make available in its provider network at least one
physician for each medical specialty.
(b) A health care facility must make available to an
enrollee at least one health care provider in the provider network
of an enrollee's health benefit plan for each medical specialty.
Sec. 1461.004. EXCLUSIVE CONTRACTS PROHIBITED; EXCEPTION.
(a) A hospital may not enter into an exclusive contract or grant
exclusive privileges to a specific physician group, including a
professional association of physicians authorized under Chapter
162, Occupations Code.
(b) A health benefit plan may not enter into exclusive
contracts with specific hospitals. A health benefit plan may not
enter into an exclusive contract with a specific physician group,
including a professional association of physicians authorized
under Chapter 162, Occupations Code.
(c) Notwithstanding Subsection (a), a hospital may enter
into an exclusive contract or grant exclusive privileges to a
specific physician group that is a member of the provider network of
each health benefit plan that has contracted with the hospital.
Sec. 1461.005. NETWORK ADEQUACY STANDARDS. The
commissioner shall by rule adopt network adequacy standards that
are adapted to local markets in which the health benefit plan
operates. The rules must include standards that ensure
availability of, and accessibility to, a full range of health care
practitioners to provide health care services to enrollees.
Sec. 1461.006. REIMBURSEMENT REPORTING. (a) A health
benefit plan must submit to the department, as prescribed by the
commissioner, information regarding:
(1) the methods used by the health benefit plan to
compute out-of-network reimbursements, such as a maximum allowable
amount; and
(2) the effect of the computation described by
Subdivision (1) on the out-of-pocket expenses of an enrollee.
(b) The commissioner shall establish by rule the
information required under Subsection (a).
SECTION 2. This Act applies only to an insurance policy or
contract or evidence of coverage that is delivered, issued for
delivery, or renewed on or after January 1, 2010. An insurance
policy or contract or evidence of coverage delivered, issued for
delivery, or renewed before January 1, 2010, is governed by the law
as it existed immediately before the effective date of this Act, and
that law is continued in effect for that purpose.
SECTION 3. This Act takes effect September 1, 2009.