By: Bailey H.B. No. 915
73R3271 PB-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the regulation of certain managed health care firms;
1-3 providing a civil penalty.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter A, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.07-6A to read as follows:
1-7 Art. 21.07-6A. MANAGED HEALTH CARE FIRMS
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Administrator" has the meaning assigned by
1-10 Article 21.07-6 of this code.
1-11 (2) "Health care facility" means a hospital, emergency
1-12 clinic, outpatient clinic, or other facility providing health care.
1-13 (3) "Health care practitioner" means an individual who
1-14 is licensed in this state to provide health care.
1-15 (4) "Health care program" means a plan of benefits
1-16 that supplies health care services, provides accommodations that
1-17 are clinically necessary, and directs care to the most appropriate
1-18 setting to provide quality health care in the most cost-efficient
1-19 manner.
1-20 (5) "Health care provider" means a health care
1-21 facility or health care practitioner.
1-22 (6) "Managed health care firm" means an administrator
1-23 that manages, in a specific geographical service area, a health
1-24 care program offered through a policy of health insurance or
2-1 through a health maintenance organization on behalf of the
2-2 insurance company or health maintenance organization.
2-3 (7) "Participating provider" means a health care
2-4 provider that provides health care services through a managed
2-5 health care firm.
2-6 Sec. 2. REGISTRATION REQUIREMENT; ELIGIBILITY; APPLICATION.
2-7 (a) A person may not operate as a managed health care firm in this
2-8 state unless the person holds a certificate of registration issued
2-9 under this article.
2-10 (b) To be eligible to apply for registration under this
2-11 article, an applicant must hold a certificate of authority issued
2-12 under Article 21.07-6 of this code to conduct business as an
2-13 administrator.
2-14 (c) An applicant for registration shall apply to the
2-15 commissioner in the form prescribed by the commissioner. The
2-16 applicant shall include with the application:
2-17 (1) a copy of the certificate of authority issued to
2-18 the applicant under Article 21.07-6 of this code; and
2-19 (2) any other information reasonably required by the
2-20 commissioner.
2-21 Sec. 3. PROVIDER PARTICIPATION OPTION. (a) Each managed
2-22 health care firm shall establish a 20-day period during each
2-23 calendar year during which any health care provider located in the
2-24 geographic service area of the firm may apply to the firm for
2-25 designation as a participating provider under the terms and
2-26 conditions established by the managed health care firm for the
2-27 provision of health care services and the designation of
3-1 participating providers.
3-2 (b) A managed health care firm shall provide to a health
3-3 care provider, on request, the practice standards and
3-4 qualifications for the provision of health services and any other
3-5 requirements to qualify for designation as a participating
3-6 provider.
3-7 (c) This section may not be construed to require that a
3-8 managed health care firm use a particular type of health care
3-9 provider in its operations or accept a provider of a category or
3-10 type that does not meet the practice standards and qualifications
3-11 established by the managed health care firm.
3-12 Sec. 4. PROVIDER NOTIFICATION. If the application of a
3-13 health care provider to participate in the provision of health care
3-14 through a managed health care firm is rejected by the firm, the
3-15 firm shall notify the health care provider in writing of the reason
3-16 for the rejection of the application and shall specify in what
3-17 manner the applicant fails to meet the practice standards or other
3-18 qualifications for participation.
3-19 Sec. 5. PROHIBITED ACTS; RESTRAINT OF TRADE. (a) A managed
3-20 health care firm may not require a health care provider to have a
3-21 previous association with the firm as a condition for acceptance as
3-22 a participating provider.
3-23 (b) A managed health care firm may not employ or use one of
3-24 its participating providers to select or determine who shall
3-25 qualify as a participating provider. A violation of this
3-26 subsection constitutes restraint of trade and is an unlawful
3-27 practice under Section 15.05, Business & Commerce Code.
4-1 Sec. 6. CIVIL PENALTY. (a) A managed health care firm that
4-2 violates this article commits an offense punishable by a civil
4-3 penalty. Each violation constitutes a separate offense. A civil
4-4 penalty assessed under this section may not exceed:
4-5 (1) $1,000 for a first or second offense; and
4-6 (2) $10,000 for a third or subsequent offense.
4-7 (b) The attorney general shall recover a penalty imposed by
4-8 this section in an action brought in the name of the state.
4-9 SECTION 2. (a) Except as provided by Subsection (b) of this
4-10 section, this Act takes effect September 1, 1993.
4-11 (b) A person is not required to hold a certificate of
4-12 registration issued under Section 2, Article 21.07-6A, Insurance
4-13 Code, as added by this Act, to operate as a managed health care
4-14 firm until January 1, 1994.
4-15 SECTION 3. The importance of this legislation and the
4-16 crowded condition of the calendars in both houses create an
4-17 emergency and an imperative public necessity that the
4-18 constitutional rule requiring bills to be read on three several
4-19 days in each house be suspended, and this rule is hereby suspended.