Texas 2011 - 82nd Regular

Texas House Bill HB1772 Compare Versions

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1	1	By: Taylor of Galveston (Senate Sponsor - Duncan) H.B. No. 1772
2	2	(In the Senate - Received from the House May 6, 2011;
3	3	May 9, 2011, read first time and referred to Committee on State
4	4	Affairs; May 13, 2011, reported favorably by the following vote:
5	5	Yeas 9, Nays 0; May 13, 2011, sent to printer.)
6	6
7	7
8	8	A BILL TO BE ENTITLED
9	9	AN ACT
10	10	relating to the regulation of certain benefit plans.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Section 1273.001(4), Insurance Code, is amended
13	13	to read as follows:
14	14	(4) "Point-of-service plan" means an arrangement
15	15	under which:
16	16	(A) an enrollee chooses to obtain benefits or
17	17	services through:
18	18	(i) a health maintenance organization
19	19	delivery network, including a limited provider network; or
20	20	(ii) a non-network delivery system outside
21	21	the health maintenance organization delivery network, including an
22	22	exclusive provider benefit plan under Chapter 1301 or a limited
23	23	provider network, that is administered under an indemnity benefit
24	24	arrangement for the cost of health care services; or
25	25	(B) indemnity benefits for the cost of health
26	26	care services are provided by an insurer or group hospital service
27	27	corporation in conjunction with network benefits arranged or
28	28	provided by a health maintenance organization.
29	29	SECTION 2. Section 1301.001, Insurance Code, is amended by
30	30	amending Subdivision (1) and adding Subdivision (1-a) to read as
31	31	follows:
32	32	(1) "Exclusive provider benefit plan" means a benefit
33	33	plan in which an insurer excludes benefits to an insured for some or
34	34	all services, other than emergency care services required under
35	35	Section 1301.155, provided by a physician or health care provider
36	36	who is not a preferred provider.
37	37	(1-a) "Health care provider" means a practitioner,
38	38	institutional provider, or other person or organization that
39	39	furnishes health care services and that is licensed or otherwise
40	40	authorized to practice in this state. The term does not include a
41	41	physician.
42	42	SECTION 3. Section 1301.003, Insurance Code, is amended to
43	43	read as follows:
44	44	Sec. 1301.003. PREFERRED PROVIDER BENEFIT PLANS AND
45	45	EXCLUSIVE PROVIDER BENEFIT PLANS PERMITTED. A preferred provider
46	46	benefit plan or an exclusive provider benefit plan [health
47	47	insurance policy that provides different benefits from the basic
48	48	level of coverage for the use of preferred providers and] that meets
49	49	the requirements of this chapter is not:
50	50	(1) unjust under Chapter 1701;
51	51	(2) unfair discrimination under Subchapter A or B,
52	52	Chapter 544; or
53	53	(3) a violation of Subchapter B or C, Chapter 1451.
54	54	SECTION 4. Section 1301.0041, Insurance Code, is amended to
55	55	read as follows:
56	56	Sec. 1301.0041. APPLICABILITY. (a) Except as otherwise
57	57	specifically provided by this chapter, this [This] chapter applies
58	58	to each [any] preferred provider benefit plan in which an insurer
59	59	provides, through the insurer's health insurance policy, for the
60	60	payment of a level of coverage that is different depending on
61	61	whether an [from the basic level of coverage provided by the health
62	62	insurance policy if the] insured uses a preferred provider or a
63	63	nonpreferred provider.
64	64	(b) Unless otherwise specified, an exclusive provider
65	65	benefit plan is subject to this chapter in the same manner as a
66	66	preferred provider benefit plan.
67	67	(c) This chapter does not apply to:
68	68	(1) the child health plan program under Chapter 62,
69	69	Health and Safety Code; or
70	70	(2) a Medicaid managed care program under Chapter 533,
71	71	Government Code.
72	72	SECTION 5. Subchapter A, Chapter 1301, Insurance Code, is
73	73	amended by adding Section 1301.0042 to read follows:
74	74	Sec. 1301.0042. APPLICABILITY OF INSURANCE LAW. (a)
75	75	Except as provided by Subsection (b), a provision of this code or
76	76	another insurance law of this state that applies to a preferred
77	77	provider benefit plan applies to an exclusive provider benefit plan
78	78	except to the extent that the commissioner determines the provision
79	79	to be inconsistent with the function and purpose of an exclusive
80	80	provider benefit plan.
81	81	(b) An exclusive provider benefit plan may not provide
82	82	dental care benefits.
83	83	SECTION 6. Section 1301.0045, Insurance Code, is amended to
84	84	read as follows:
85	85	Sec. 1301.0045. CONSTRUCTION OF CHAPTER. (a) Except as
86	86	provided by Section 1301.0046, this chapter may not be construed to
87	87	limit the level of reimbursement or the level of coverage,
88	88	including deductibles, copayments, coinsurance, or other
89	89	cost-sharing provisions, that are applicable to preferred
90	90	providers or, for plans other than exclusive provider benefit
91	91	plans, nonpreferred providers.
92	92	(b) Except as provided by Sections 1301.0052 and 1301.155,
93	93	this chapter may not be construed to require an exclusive provider
94	94	benefit plan to compensate a nonpreferred provider for services
95	95	provided to an insured.
96	96	SECTION 7. Section 1301.0046, Insurance Code, is amended to
97	97	read as follows:
98	98	Sec. 1301.0046. COINSURANCE REQUIREMENTS FOR SERVICES OF
99	99	NONPREFERRED PROVIDERS. The insured's coinsurance applicable to
100	100	payment to nonpreferred providers may not exceed 50 percent of the
101	101	total covered amount applicable to the medical or health care
102	102	services. This section does not apply to an exclusive provider
103	103	benefit plan.
104	104	SECTION 8. Sections 1301.005(a) and (b), Insurance Code,
105	105	are amended to read as follows:
106	106	(a) An insurer offering a preferred provider benefit plan
107	107	shall ensure that both preferred provider benefits and basic level
108	108	benefits are reasonably available to all insureds within a
109	109	designated service area. This subsection does not apply to an
110	110	exclusive provider benefit plan.
111	111	(b) If services are not available through a preferred
112	112	provider within a designated [the] service area under a preferred
113	113	provider benefit plan or an exclusive provider benefit plan, an
114	114	insurer shall reimburse a physician or health care provider who is
115	115	not a preferred provider at the same percentage level of
116	116	reimbursement as a preferred provider would have been reimbursed
117	117	had the insured been treated by a preferred provider.
118	118	SECTION 9. Subchapter A, Chapter 1301, Insurance Code, is
119	119	amended by adding Sections 1301.0051, 1301.0052, 1301.0053, and
120	120	1301.0056 to read as follows:
121	121	Sec. 1301.0051. EXCLUSIVE PROVIDER BENEFIT PLANS: QUALITY
122	122	IMPROVEMENT AND UTILIZATION MANAGEMENT. (a) An insurer that offers
123	123	an exclusive provider benefit plan shall establish procedures to
124	124	ensure that health care services are provided to insureds under
125	125	reasonable standards of quality of care that are consistent with
126	126	prevailing professionally recognized standards of care or
127	127	practice. The procedures must include:
128	128	(1) mechanisms to ensure availability, accessibility,
129	129	quality, and continuity of care;
130	130	(2) subject to Section 1301.059, a continuing quality
131	131	improvement program to monitor and evaluate services provided under
132	132	the plan, including primary and specialist physician services and
133	133	ancillary and preventive health care services, provided in
134	134	institutional or noninstitutional settings;
135	135	(3) a method of recording formal proceedings of
136	136	quality improvement program activities and maintaining quality
137	137	improvement program documentation in a confidential manner;
138	138	(4) subject to Section 1301.059, a physician review
139	139	panel to assist the insurer in reviewing medical guidelines or
140	140	criteria;
141	141	(5) a patient record system that facilitates
142	142	documentation and retrieval of clinical information for the
143	143	insurer's evaluation of continuity and coordination of services and
144	144	assessment of the quality of services provided to insureds under
145	145	the plan;
146	146	(6) a mechanism for making available to the
147	147	commissioner the clinical records of insureds for examination and
148	148	review by the commissioner on request of the commissioner; and
149	149	(7) a specific procedure for the periodic reporting of
150	150	quality improvement program activities to:
151	151	(A) the governing body and appropriate staff of
152	152	the insurer; and
153	153	(B) physicians and health care providers that
154	154	provide health care services under the plan.
155	155	(b) Minutes of a formal proceeding of the quality
156	156	improvement program established under Subsection (a) shall be made
157	157	available to the commissioner on request of the commissioner.
158	158	(c) Insured records made available to the commissioner
159	159	under Subsection (a)(6) are confidential and privileged, and are
160	160	not subject to Chapter 552, Government Code, or to subpoena, except
161	161	to the extent necessary for the commissioner to enforce this
162	162	chapter.
163	163	Sec. 1301.0052. EXCLUSIVE PROVIDER BENEFIT PLANS:
164	164	REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered
165	165	service is medically necessary and is not available through a
166	166	preferred provider, the issuer of an exclusive provider benefit
167	167	plan, on the request of a preferred provider, shall:
168	168	(1) approve the referral of an insured to a
169	169	nonpreferred provider within a reasonable period; and
170	170	(2) fully reimburse the nonpreferred provider at the
171	171	usual and customary rate or at a rate agreed to by the issuer and the
172	172	nonpreferred provider.
173	173	(b) An exclusive provider benefit plan must provide for a
174	174	review by a health care provider with expertise in the same
175	175	specialty as or a specialty similar to the type of health care
176	176	provider to whom a referral is requested under Subsection (a)
177	177	before the issuer of the plan may deny the referral.
178	178	Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS:
179	179	EMERGENCY CARE. If a nonpreferred provider provides emergency care
180	180	as defined by Section 1301.155 to an enrollee in an exclusive
181	181	provider benefit plan, the issuer of the plan shall reimburse the
182	182	nonpreferred provider at the usual and customary rate or at a rate
183	183	agreed to by the issuer and the nonpreferred provider for the
184	184	provision of the services.
185	185	Sec. 1301.0056. EXAMINATIONS AND FEES. (a) The
186	186	commissioner may examine an insurer to determine the quality and
187	187	adequacy of a network used by an exclusive provider benefit plan
188	188	offered by the insurer under this chapter. An insurer is subject to
189	189	a qualifying examination of the insurer's exclusive provider
190	190	benefit plans and subsequent quality of care examinations by the
191	191	commissioner at least once every five years. Documentation
192	192	provided to the commissioner during an examination conducted under
193	193	this section is confidential and is not subject to disclosure as
194	194	public information under Chapter 552, Government Code.
195	195	(b) An insurer examined under this section shall pay the
196	196	cost of the examination in an amount determined by the
197	197	commissioner.
198	198	(c) The department shall collect an assessment in an amount
199	199	determined by the commissioner from the insurer at the time of the
200	200	examination to cover all expenses attributable directly to the
201	201	examination, including the salaries and expenses of department
202	202	employees and all reasonable expenses of the department necessary
203	203	for the administration of this chapter.
204	204	(d) The department shall deposit an assessment collected
205	205	under this section to the credit of the Texas Department of
206	206	Insurance operating account. Money deposited under this subsection
207	207	shall be used to pay the salaries and expenses of examiners and all
208	208	other expenses relating to the examination of insurers under this
209	209	section.
210	210	SECTION 10. Subchapter D, Chapter 1301, Insurance Code, is
211	211	amended by adding Section 1301.1581 to read as follows:
212	212	Sec. 1301.1581. INFORMATION CONCERNING EXCLUSIVE PROVIDER
213	213	BENEFIT PLANS. (a) In this section, "prospective insured" has the
214	214	meaning assigned by Section 1301.158.
215	215	(b) In addition to the information required to be provided
216	216	under Section 1301.158, an insurer that offers an exclusive
217	217	provider benefit plan shall provide to a current or prospective
218	218	group contract holder or current or prospective insured notice that
219	219	the benefit plan includes limited coverage for services provided by
220	220	a physician or health care provider that is not a preferred
221	221	provider.
222	222	(c) An identification card or similar document issued by an
223	223	insurer to an insured in an exclusive provider benefit plan must
224	224	display:
225	225	(1) the first date on which the insured became insured
226	226	under the plan;
227	227	(2) a toll-free number that a physician or health care
228	228	provider may use to obtain the date on which the insured became
229	229	insured under the plan; and
230	230	(3) the acronym "EPO" or the phrase "Exclusive
231	231	Provider Organization" on the card in a location of the insurer's
232	232	choice.
233	233	SECTION 11. The change in law made by this Act applies only
234	234	to an exclusive provider benefit plan that is delivered, issued for
235	235	delivery, or renewed on or after January 1, 2012. An exclusive
236	236	provider benefit plan that is delivered, issued for delivery, or
237	237	renewed before January 1, 2012, is governed by the law as it existed
238	238	immediately before the effective date of this Act, and that law is
239	239	continued in effect for that purpose.
240	240	SECTION 12. This Act takes effect September 1, 2011.
241	241	* * * * *