Texas 2013 - 83rd Regular

Texas House Bill HB620 Compare Versions

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1	1	83R12799 SCL-F
2	2	By: Eiland, Bonnen of Galveston H.B. No. 620
3	3	Substitute the following for H.B. No. 620:
4	4	By: Eiland C.S.H.B. No. 620
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the regulation of certain health care provider network
10	10	contract arrangements; providing an administrative penalty;
11	11	authorizing a fee.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
14	14	by adding Chapter 1458 to read as follows:
15	15	CHAPTER 1458. PROVIDER NETWORK CONTRACT ARRANGEMENTS
16	16	SUBCHAPTER A. GENERAL PROVISIONS
17	17	Sec. 1458.001. GENERAL DEFINITIONS. In this chapter:
18	18	(1) "Affiliate" means a person who, directly or
19	19	indirectly through one or more intermediaries, controls, is
20	20	controlled by, or is under common control with another person.
21	21	(2) "Contracting entity" means a person who:
22	22	(A) enters into a direct contract with a provider
23	23	for the delivery of health care services to covered individuals;
24	24	and
25	25	(B) in the ordinary course of business
26	26	establishes a provider network or networks for access by another
27	27	party.
28	28	(3) "Covered individual" means an individual who is
29	29	covered under a health benefit plan.
30	30	(4) "Express authority" means a provider's consent
31	31	that is obtained through separate signature lines for each line of
32	32	business.
33	33	(5) "Health care services" means services provided for
34	34	the diagnosis, prevention, treatment, or cure of a health
35	35	condition, illness, injury, or disease.
36	36	(6) "Person" has the meaning assigned by Section
37	37	823.002.
38	38	(7)(A) "Provider" means:
39	39	(i) an advanced practice nurse;
40	40	(ii) an optometrist;
41	41	(iii) a therapeutic optometrist;
42	42	(iv) a physician;
43	43	(v) a professional association composed
44	44	solely of physicians, optometrists, or therapeutic optometrists;
45	45	(vi) a single legal entity authorized to
46	46	practice medicine owned by two or more physicians;
47	47	(vii) a nonprofit health corporation
48	48	certified by the Texas Medical Board under Chapter 162, Occupations
49	49	Code;
50	50	(viii) a partnership composed solely of
51	51	physicians, optometrists, or therapeutic optometrists;
52	52	(ix) a physician-hospital organization
53	53	that acts exclusively as an administrator for a provider to
54	54	facilitate the provider's participation in health care contracts;
55	55	or
56	56	(x) an institution that is licensed under
57	57	Chapter 241, Health and Safety Code.
58	58	(B) "Provider" does not include a
59	59	physician-hospital organization that leases or rents the
60	60	physician-hospital organization's network to another party.
61	61	(8) "Provider network contract" means a contract
62	62	between a contracting entity and a provider for the delivery of, and
63	63	payment for, health care services to a covered individual.
64	64	Sec. 1458.002. DEFINITION OF HEALTH BENEFIT PLAN. (a) In
65	65	this chapter, "health benefit plan" means:
66	66	(1) a hospital and medical expense incurred policy;
67	67	(2) a nonprofit health care service plan contract;
68	68	(3) a health maintenance organization subscriber
69	69	contract; or
70	70	(4) any other health care plan or arrangement that
71	71	pays for or furnishes medical or health care services.
72	72	(b) "Health benefit plan" does not include one or more or
73	73	any combination of the following:
74	74	(1) coverage only for accident or disability income
75	75	insurance or any combination of those coverages;
76	76	(2) credit-only insurance;
77	77	(3) coverage issued as a supplement to liability
78	78	insurance;
79	79	(4) liability insurance, including general liability
80	80	insurance and automobile liability insurance;
81	81	(5) workers' compensation or similar insurance;
82	82	(6) a discount health care program, as defined by
83	83	Section 7001.001;
84	84	(7) coverage for on-site medical clinics;
85	85	(8) automobile medical payment insurance;
86	86	(9) a multiple employer welfare arrangement that holds
87	87	a certificate of authority under Chapter 846; or
88	88	(10) other similar insurance coverage, as specified by
89	89	federal regulations issued under the Health Insurance Portability
90	90	and Accountability Act of 1996 (Pub. L. No. 104-191), under which
91	91	benefits for medical care are secondary or incidental to other
92	92	insurance benefits.
93	93	(c) "Health benefit plan" does not include the following
94	94	benefits if they are provided under a separate policy, certificate,
95	95	or contract of insurance, or are otherwise not an integral part of
96	96	the coverage:
97	97	(1) dental or vision benefits;
98	98	(2) benefits for long-term care, nursing home care,
99	99	home health care, community-based care, or any combination of these
100	100	benefits;
101	101	(3) other similar, limited benefits, including
102	102	benefits specified by federal regulations issued under the Health
103	103	Insurance Portability and Accountability Act of 1996 (Pub. L. No.
104	104	104-191); or
105	105	(4) a Medicare supplement benefit plan described by
106	106	Section 1652.002.
107	107	(d) "Health benefit plan" does not include coverage limited
108	108	to a specified disease or illness or hospital indemnity coverage or
109	109	other fixed indemnity insurance coverage if:
110	110	(1) the coverage is provided under a separate policy,
111	111	certificate, or contract of insurance;
112	112	(2) there is no coordination between the provision of
113	113	the coverage and any exclusion of benefits under any group health
114	114	benefit plan maintained by the same plan sponsor; and
115	115	(3) the coverage is paid with respect to an event
116	116	without regard to whether benefits are provided with respect to
117	117	such an event under any group health benefit plan maintained by the
118	118	same plan sponsor.
119	119	Sec. 1458.003. EXEMPTIONS. This chapter does not apply:
120	120	(1) under circumstances in which access to the
121	121	provider network is granted to an entity that operates under the
122	122	same brand licensee program as the contracting entity; or
123	123	(2) to a contract between a contracting entity and a
124	124	discount health care program operator, as defined by Section
125	125	7001.001.
126	126	Sec. 1458.004. RULEMAKING AUTHORITY. The commissioner may
127	127	adopt rules to implement this chapter.
128	128	SUBCHAPTER B. REGISTRATION REQUIREMENTS
129	129	Sec. 1458.051. REGISTRATION REQUIRED. (a) Unless the
130	130	person holds a certificate of authority issued by the department to
131	131	engage in the business of insurance in this state or operates a
132	132	health maintenance organization under Chapter 843, a person must
133	133	register with the department not later than the 30th day after the
134	134	date on which the person begins acting as a contracting entity in
135	135	this state.
136	136	(b) Notwithstanding Subsection (a), under Section 1458.055
137	137	a contracting entity that holds a certificate of authority issued
138	138	by the department to engage in the business of insurance in this
139	139	state or is a health maintenance organization shall file with the
140	140	commissioner an application for exemption from registration under
141	141	which the affiliates may access the contracting entity's network.
142	142	(c) An application for an exemption filed under Subsection
143	143	(b) must be accompanied by a list of the contracting entity's
144	144	affiliates. The contracting entity shall update the list with the
145	145	commissioner on an annual basis.
146	146	(d) A list of affiliates filed with the commissioner under
147	147	Subsection (c) is public information and is not exempt from
148	148	disclosure under Chapter 552, Government Code.
149	149	Sec. 1458.052. DISCLOSURE OF INFORMATION. (a) A person
150	150	required to register under Section 1458.051 must disclose:
151	151	(1) all names used by the contracting entity,
152	152	including any name under which the contracting entity intends to
153	153	engage or has engaged in business in this state;
154	154	(2) the mailing address and main telephone number of
155	155	the contracting entity's headquarters;
156	156	(3) the name and telephone number of the contracting
157	157	entity's primary contact for the department; and
158	158	(4) any other information required by the commissioner
159	159	by rule.
160	160	(b) The disclosure made under Subsection (a) must include a
161	161	description or a copy of the applicant's basic organizational
162	162	structure documents and a copy of organizational charts and lists
163	163	that show:
164	164	(1) the relationships between the contracting entity
165	165	and any affiliates of the contracting entity, including subsidiary
166	166	networks or other networks; and
167	167	(2) the internal organizational structure of the
168	168	contracting entity's management.
169	169	Sec. 1458.053. SUBMISSION OF INFORMATION. Information
170	170	required under this subchapter must be submitted in a written or
171	171	electronic format adopted by the commissioner by rule.
172	172	Sec. 1458.054. FEES. The department may collect a
173	173	reasonable fee set by the commissioner as necessary to administer
174	174	the registration process. Fees collected under this chapter shall
175	175	be deposited in the Texas Department of Insurance operating fund.
176	176	Sec. 1458.055. EXEMPTION FOR AFFILIATES. (a) The
177	177	commissioner shall grant an exemption for affiliates of a
178	178	contracting entity if the contracting entity holds a certificate of
179	179	authority issued by the department to engage in the business of
180	180	insurance in this state or is a health maintenance organization if
181	181	the commissioner determines that:
182	182	(1) the affiliate is not subject to a disclaimer of
183	183	affiliation under Chapter 823; and
184	184	(2) the relationships between the person who holds a
185	185	certificate of authority and all affiliates of the person,
186	186	including subsidiary networks or other networks, are disclosed and
187	187	clearly defined.
188	188	(b) An exemption granted under this section applies only to
189	189	registration. An entity granted an exemption is otherwise subject
190	190	to this chapter.
191	191	SUBCHAPTER C. RIGHTS AND RESPONSIBILITIES OF A CONTRACTING ENTITY
192	192	Sec. 1458.101. CONTRACT REQUIREMENTS. (a) In this
193	193	section, the following are each considered a single separate line
194	194	of business:
195	195	(1) preferred provider benefit plans covering
196	196	individuals and groups;
197	197	(2) exclusive provider benefit plans covering
198	198	individuals and groups;
199	199	(3) health maintenance organization plans covering
200	200	individuals and groups;
201	201	(4) Medicare Advantage or similar plans issued in
202	202	connection with a contract with the Centers for Medicare and
203	203	Medicaid Services;
204	204	(5) Medicaid managed care; and
205	205	(6) the state child health plan established under
206	206	Chapter 62, Health and Safety Code, or the comparable plan under
207	207	Chapter 63, Health and Safety Code.
208	208	(b) A contracting entity may not sell, lease, or otherwise
209	209	transfer information regarding the payment or reimbursement terms
210	210	of the provider network contract without the express authority of
211	211	and prior adequate notification of the provider.
212	212	(c) The provider network contract must require that on the
213	213	request of the provider, the contracting entity will provide
214	214	information necessary to determine whether a particular person has
215	215	been authorized to access the provider's health care services and
216	216	contractual discounts.
217	217	(d) To be enforceable against a provider, a provider network
218	218	contract, including the lines of business described by Subsections
219	219	(a) and (e), must also specify a separate fee schedule for each such
220	220	line of business. The separate fee schedule may describe specific
221	221	services or procedures that the provider will deliver along with a
222	222	corresponding payment, may describe a methodology for calculating
223	223	payment based on a published fee schedule, or may describe payment
224	224	in any other reasonable manner that specifies a definite payment
225	225	for services. The fee information may be provided by any reasonable
226	226	method, including electronically.
227	227	(e) The commissioner may, by rule, add additional lines of
228	228	business for which express authority is required.
229	229	Sec. 1458.102. CONTRACT ACCESS. (a) A contracting entity
230	230	may not provide a person access to health care services or
231	231	contractual discounts under a provider network contract unless the
232	232	provider network contract specifically states that the person must
233	233	comply with all applicable terms, limitations, and conditions of
234	234	the provider network contract.
235	235	(b) For the purposes of this section, a contracting entity
236	236	shall permit reasonable access, including electronic access, to the
237	237	provider during business hours for the review of the provider
238	238	network contract. The information may be used or disclosed only for
239	239	the purposes of complying with the terms of the contract or state
240	240	law.
241	241	Sec. 1458.103. ENFORCEMENT. The commissioner may impose a
242	242	sanction under Chapter 82 or assess an administrative penalty under
243	243	Chapter 84 on a contracting entity that violates this chapter or a
244	244	rule adopted to implement this chapter.
245	245	SECTION 2. (a) The change in law made by this Act applies
246	246	only to a provider network contract entered into or renewed on or
247	247	after September 1, 2013. A provider network contract entered into
248	248	or renewed before September 1, 2013, is governed by the law as it
249	249	existed immediately before the effective date of this Act, and that
250	250	law is continued in effect for that purpose.
251	251	(b) For the purposes of compliance with Section 1458.101,
252	252	Insurance Code, as added by this Act, a provider's express
253	253	authority is presumed if:
254	254	(1) the provider network contract is in existence
255	255	before September 1, 2013;
256	256	(2) on the first renewal after September 1, 2013, the
257	257	contracting entity sends a written renewal notice by United States
258	258	mail to the provider;
259	259	(3) the notice described by Subdivision (2) of this
260	260	subsection:
261	261	(A) contains a statement that failure to timely
262	262	respond serves as assent to the renewal;
263	263	(B) contains separate signature lines for each
264	264	line of business applicable to the contract; and
265	265	(C) specifies the separate fee schedule for each
266	266	line of business applicable to the contract, described in any
267	267	reasonable manner and which may be provided electronically; and
268	268	(4) the provider fails to respond within 60 days of
269	269	receipt of the notice and has not objected to the renewal.
270	270	SECTION 3. This Act takes effect September 1, 2013.