Texas 2009 - 81st Regular

Texas House Bill HB4179 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	81R11292 PMO-D
2	2	By: Smithee H.B. No. 4179
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health insurance.
8	8	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
9	9	SECTION 1. Section 542.051, Insurance Code, is amended by
10	10	adding Subdivision (5) to read as follows:
11	11	(5) "Provider network" means a health benefit plan
12	12	under which health care services are provided to enrollees through
13	13	contracts with health care providers and that requires those
14	14	enrollees to use health care providers participating in the plan
15	15	and procedures covered by the plan. The term includes a network
16	16	operated by:
17	17	(A) a health maintenance organization;
18	18	(B) a preferred provider benefit plan issuer; or
19	19	(C) another entity that issues a health benefit
20	20	plan, including an insurance company.
21	21	SECTION 2. Section 542.052, Insurance Code, is amended to
22	22	read as follows:
23	23	Sec. 542.052. APPLICABILITY OF SUBCHAPTER. (a) This
24	24	subchapter applies to any insurer authorized to engage in business
25	25	as an insurance company or to provide insurance in this state,
26	26	including:
27	27	(1) a stock life, health, or accident insurance
28	28	company;
29	29	(2) a mutual life, health, or accident insurance
30	30	company;
31	31	(3) a stock fire or casualty insurance company;
32	32	(4) a mutual fire or casualty insurance company;
33	33	(5) a Mexican casualty insurance company;
34	34	(6) a Lloyd's plan;
35	35	(7) a reciprocal or interinsurance exchange;
36	36	(8) a fraternal benefit society;
37	37	(9) a stipulated premium company;
38	38	(10) a nonprofit legal services corporation;
39	39	(11) a statewide mutual assessment company;
40	40	(12) a local mutual aid association;
41	41	(13) a local mutual burial association;
42	42	(14) an association exempt under Section 887.102;
43	43	(15) a nonprofit hospital, medical, or dental service
44	44	corporation, including a corporation subject to Chapter 842;
45	45	(16) a county mutual insurance company;
46	46	(17) a farm mutual insurance company;
47	47	(18) a risk retention group;
48	48	(19) a purchasing group;
49	49	(20) an eligible surplus lines insurer; and
50	50	(21) except as provided by Section 542.053(b), a
51	51	guaranty association operating under Chapter 462 or 463.
52	52	(b) This subchapter applies to a claim of a health care
53	53	provider who:
54	54	(1) is in the provider network of an enrollee's
55	55	insurer; or
56	56	(2) is not in the provider network of an enrollee's
57	57	insurer.
58	58	SECTION 3. Chapter 1274, Insurance Code, is amended by
59	59	adding Section 1274.006 to read as follows:
60	60	Sec. 1274.006. A health benefit plan issuer shall establish
61	61	a secure website that provides an enrollee with real-time
62	62	information concerning:
63	63	(1) any applicable deductibles; and
64	64	(2) physician or health care provider network
65	65	participation.
66	66	SECTION 4. Section 1369.153(a), Insurance Code, is amended
67	67	to read as follows:
68	68	(a) An issuer of a health benefit plan that provides
69	69	pharmacy benefits to enrollees shall include on the identification
70	70	card of each enrollee:
71	71	(1) the name or logo of the entity administering the
72	72	pharmacy benefits if the entity is different from the health
73	73	benefit plan issuer;
74	74	(2) the group number applicable to the enrollee;
75	75	(3) the identification number of the enrollee;
76	76	(4) [(3)] the effective date and expected expiration
77	77	date of the coverage evidenced by the card;
78	78	(5) [(4)] a telephone number for contacting an
79	79	appropriate person to obtain information relating to the pharmacy
80	80	benefits provided under the plan; [and]
81	81	(6) [(5)] copayment and deductible information for
82	82	generic and brand-name prescription drugs; and
83	83	(7) any other information required by the commission
84	84	by rule.
85	85	SECTION 5. Chapter 1456, Insurance Code, is amended by
86	86	adding Section 1456.0066 to read as follows:
87	87	Sec. 1456.0066. NETWORK ADEQUACY STANDARDS. The
88	88	commissioner shall by rule adopt network adequacy standards that
89	89	are adapted to local markets in which the health benefit plan
90	90	operates. The rules must include standards that ensure
91	91	availability of, and accessibility to, a full range of health care
92	92	practitioners to provide health care services to enrollees.
93	93	SECTION 6. Subtitle F, Title 8, Insurance Code, is amended
94	94	by adding Chapter 1458 to read as follows:
95	95	CHAPTER 1458. PAYMENT OF OUT-OF-NETWORK PROVIDERS
96	96	Sec. 1458.001. DEFINITIONS. In this chapter:
97	97	(1) "Balance billing" has the meaning assigned by
98	98	Section 1456.001.
99	99	(2) "Enrollee" means an individual who is eligible to
100	100	receive health care services under a managed care plan.
101	101	(3) "Health care provider" means:
102	102	(A) an individual who is licensed to provide
103	103	health care services; or
104	104	(B) a hospital, emergency clinic, outpatient
105	105	clinic, or other facility providing health care services.
106	106	(4) "Managed care plan" means a health benefit plan
107	107	under which health care services are provided to enrollees through
108	108	contracts with health care providers and that requires those
109	109	enrollees to use health care providers participating in the plan
110	110	and procedures covered by the plan. The term includes a health
111	111	benefit plan issued by:
112	112	(A) a health maintenance organization;
113	113	(B) a preferred provider benefit plan issuer; or
114	114	(C) any other entity that issues a health benefit
115	115	plan, including an insurance company.
116	116	(5) "Out-of-network provider" means a health care
117	117	provider who is not a participating provider.
118	118	(6) "Participating provider" means a health care
119	119	provider who has contracted with a health benefit plan issuer to
120	120	provide services to enrollees.
121	121	Sec. 1458.002. PAYMENT AT IN-NETWORK RATE. A managed care
122	122	plan must pay an out-of-network health care provider that provides
123	123	a service to an enrollee at the rate the plan pays a participating
124	124	provider for the health care service.
125	125	Sec. 1458.003. NO BALANCE BILLING. An out-of-network
126	126	health care provider may not balance bill.
127	127	Sec. 1458.004. RULES. The commissioner shall adopt rules
128	128	necessary to implement this chapter.
129	129	SECTION 7. This Act applies only to an insurance policy or
130	130	contract or evidence of coverage that is delivered, issued for
131	131	delivery, or renewed on or after January 1, 2010. An insurance
132	132	policy or contract or evidence of coverage delivered, issued for
133	133	delivery, or renewed before January 1, 2010, is governed by the law
134	134	as it existed immediately before the effective date of this Act, and
135	135	that law is continued in effect for that purpose.
136	136	SECTION 8. This Act takes effect September 1, 2009.