By Berlanga, et al. H.B. No. 1520
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to health care, including powers and duties of the center
1-3 for rural health initiatives, continuing medical education, the
1-4 delegation of prescription drug orders, services and patient
1-5 protection in the Medicaid program, standards for utilization
1-6 review, medically under served areas, health facilities and
1-7 services for the elderly and disabled.
1-8 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-9 SECTION 1. The Act may be cited as the Omnibus Rural Health
1-10 Services Enhancement and Patient Protection Act.
1-11 SECTION 2. Title 2, Chapter 106, Subchapter B,
1-12 Sec. 106.025(a), Health and Safety Code, is amended to read as
1-13 follows:
1-14 Sec. 106.025. Duties and Powers.
1-15 (a) The center shall:
1-16 (1) educate the public and recommend appropriate
1-17 public policies regarding the continued viability of rural health
1-18 care delivery in this state;
1-19 (2) monitor and work with state and federal agencies
1-20 to assess the impact of proposed rules on rural areas;
1-21 (3) provide impact statements of proposed rules as
1-22 considered appropriate by the center;
1-23 (4) streamline regulations to assist in the
2-1 development of service diversification of health care facilities;
2-2 (5) target state and federal programs to rural areas;
2-3 (6) promote and develop community involvement and
2-4 community support in maintaining, rebuilding, or diversifying local
2-5 health services;
2-6 (7) promote and develop diverse and innovative health
2-7 care service models in rural areas;
2-8 (8) encourage the use of advanced communication
2-9 technology<;>:
2-10 (A) to ensure that rural areas receive the
2-11 maximum benefits of telemedicine and distance learning by promoting
2-12 a transmission rate structure which accommodates rural needs and by
2-13 improving the telecommunications infrastructure in rural areas; and
2-14 (B) to provide access to specialty expertise, clinical
2-15 consultation, and continuing education;
2-16 (9) assist rural health care providers, communities,
2-17 and individuals in applying for public and private grants and
2-18 programs;
2-19 (10) encourage the development of regional emergency
2-20 transportation networks;
2-21 (11) work with state agencies, universities, and
2-22 private interest groups to conduct and promote research on rural
2-23 health issues, maintain and collect a timely data case, and develop
2-24 and maintain a rural health resource library;
2-25 (12) solicit the assistance of other offices or
3-1 programs of rural health in this state that are university-based to
3-2 carry out the duties of this chapter;
3-3 (13) disseminate information and provide technical
3-4 assistance to communities, health care providers, and individual
3-5 consumers of health care services; and
3-6 (14) develop plans to implement a fee-for-service
3-7 health care professional recruitment service and a medical supplies
3-8 group purchasing program within the center.
3-9 (15)(A) develop and initiate a study of rural health
3-10 clinics to:
3-11 (i) determine the efficiency and
3-12 effectiveness of rural health clinics;
3-13 (ii) assess the impact on access to health
3-14 care;
3-15 (iii) identify and address efficiency
3-16 barriers for the professional clinical relationship of physicians,
3-17 nurses, and physician assistants;
3-18 (iv) assess the success of attracting
3-19 primary care physicians and allied health professionals to rural
3-20 areas; and
3-21 (v) assess the appropriateness of the
3-22 current clinic designation process; and
3-23 (B) develop and initiate a quality assessment
3-24 program to evaluate the health outcomes of rural patients treated
3-25 in rural health clinics and;
4-1 (16) encourage the active participation by physicians
4-2 and other health care providers in the Early Periodic Diagnosis and
4-3 Treatment Program.
4-4 (b) The center may:
4-5 (1) solicit, receive, and spend grants, gifts, and
4-6 donations from public and private sources; and
4-7 (2) contract with public and private entities in the
4-8 performance of its responsibilities.
4-9 SECTION 3. Title 2, Chapter 105, Health and Safety Code, is
4-10 amended by adding a new section 105.005 and renumbering subsequent
4-11 sections accordingly. The new subsection 105.005 reads as follows:
4-12 105.005(a) The health professions resource center shall
4-13 develop and establish a clearinghouse for health professionals
4-14 seeking collaborative practice in rural or medically under served
4-15 areas.
4-16 (b) The health professions resource center may:
4-17 (1) set and collect a reasonable fee to offset the
4-18 cost of complying with the requirements of this section;
4-19 (2) solicit, receive, and spend grants, gifts, and
4-20 donations from public and private sources, to comply with the
4-21 requirements of this section; and
4-22 (3) contract with public or private entities in the
4-23 performance of its responsibilities under this section.
4-24 SECTION 4. Title 8, Chapter 671, Subchapter A, Sections
4-25 671.001 and 671.002, Health & Safety Code are amended to read as
5-1 follows:
5-2 Sec. 671.001. Standard Used in Determining Death.
5-3 (a) A person is dead when, according to ordinary standards
5-4 of medical practice, there is irreversible cessation of the
5-5 person's spontaneous respiratory and circulatory functions.
5-6 (b) If artificial means of support preclude a determination
5-7 that a person's spontaneous respiratory and circulatory functions
5-8 have ceased, the person is dead when, in the announced opinion of a
5-9 physician, according to ordinary standards of medical practice,
5-10 there is irreversible cessation of all spontaneous brain function.
5-11 Death occurs when the relevant functions cease.
5-12 (c) Death must be pronounced before artificial means of
5-13 supporting a person's respiratory and circulatory functions are
5-14 terminated.
5-15 (d) A registered nurse or physicians assistant may determine
5-16 and pronounce a person dead in situations other than those
5-17 described by Subsection (b) if permitted by written policies of a
5-18 licensed health care facility, institution, or entity providing
5-19 services to that person. If the facility, institution, or entity
5-20 has an organized nursing staff or medical consultant, the nursing
5-21 staff and medical staff or consultant shall jointly develop and
5-22 approve those policies. For purposes of this section, such
5-23 policies shall take into account physician assistants who are
5-24 credentialed or otherwise permitted to practice at the facility,
5-25 institution or entity. The board shall adopt rules to govern
6-1 policies for facilities, institutions, or entities that do not have
6-2 organized nursing staffs and organized medical staffs or medical
6-3 consultants.
6-4 Sec. 671.002. Limitation of Liability.
6-5 (a) A physician who determines death in accordance with Sec.
6-6 671.001(b) <or>, a registered nurse, or a physician assistant, is
6-7 not liable for civil damages or subject to criminal prosecution for
6-8 the physician's <or>, registered nurse's, or physician assistant's
6-9 actions or the actions of others based on the determination of
6-10 death.
6-11 (b) A person who acts in good faith in reliance on a
6-12 physician's <or>, registered nurse's, or physician assistant's
6-13 determination of death is not liable for civil damages or subject
6-14 to criminal prosecution for the person's actions.
6-15 SECTION 5. Section 3.06(d)(5), Medical Practice Act, Article
6-16 4495b is amended to read as follows:
6-17 (5)(A) At a site serving a medically under served
6-18 population, a physician licensed by the board shall be authorized
6-19 to delegate to a registered nurse or physician assistant acting
6-20 under adequate physician supervision, the act or acts of
6-21 administering, providing, carrying out or signing a prescription
6-22 drug order as authorized by the physician through physician's
6-23 orders, standing medical orders, standing delegation orders, or
6-24 other orders or protocols as defined by the board.
6-25 (B)(i) The carrying out or signing of
7-1 prescription drug orders under this subsection shall comply with
7-2 other applicable laws.
7-3 (ii) The authority of a physician to
7-4 delegate the carrying out or signing of prescription drug orders is
7-5 limited to dangerous drugs and is limited to the practice locations
7-6 designated by the physician in physician's orders, standing medical
7-7 orders, standing delegation orders or other orders or protocols
7-8 approved by the board.
7-9 (C) Physician supervision shall be adequate if a
7-10 delegating physician:
7-11 (i) is responsible for the formulation or
7-12 approval of such physician's orders, standing medical orders,
7-13 standing delegation orders, or other orders or protocols and
7-14 periodically reviews such orders and the services provided patients
7-15 under such orders;
7-16 (ii) is on site at least once a week to
7-17 provide medical direction and consultation;
7-18 (iii) receives a daily status report from
7-19 the registered nurse or physician assistant on any problems or
7-20 complication encountered; and
7-21 (iv) is available through direct
7-22 telecommunication for consultation, assistance with medical
7-23 emergencies, or patient referral.
7-24 (D) In this subsection:
7-25 (i) "Registered nurse" means a registered
8-1 nurse recognized by the Board of Nurse Examiners as having the
8-2 specialized education and training required under Section 7,
8-3 Article 4514, Revised Statutes.
8-4 (ii) "Physician assistant" has the meaning
8-5 assigned to that term by Section 2(3), Physician Assistant
8-6 Licensing Act, and its subsequent amendments.
8-7 (iii) "Carrying out or signing a
8-8 prescription drug order" means either to complete a prescription
8-9 drug order pre-signed by the delegating physician or the signing of
8-10 a prescription by a registered nurse or physician assistant after
8-11 such person has been designated with the board by the delegating
8-12 physician as a person delegated to sign a prescription. The
8-13 following information shall be provided on each prescription <by
8-14 providing the following information>: the patient's name and
8-15 address; the drug to be dispensed; directions to the patient in
8-16 regard to the taking and dosage; the name, address, and telephone
8-17 number of the physician; the name, address, telephone and
8-18 identification number of the registered nurse or physician
8-19 assistant completing or signing the prescription drug order; the
8-20 date; and the number of refills permitted. The board may adopt
8-21 additional methods to carry into effect or put into force a
8-22 physician's prescription or delegation of a prescription under
8-23 physician's orders, standing medical orders, standing delegation
8-24 orders, or other orders or protocols.
8-25 (iv) "A site serving a medically under
9-1 served population" means:
9-2 (a) a site located in a medically
9-3 under served area;
9-4 (b) a site located in a health
9-5 manpower shortage area;
9-6 (c) a clinic designated as a rural
9-7 health clinic under the Rural Health Clinic Services Act of 1977
9-8 (Pub. L. No. 95-210);
9-9 (d) a public health clinic or a
9-10 family planning clinic under contract with the Texas Department of
9-11 Human Services or the Texas Department of Health;
9-12 (e) a site located in an area in
9-13 which the Texas Department of Health determines there exists an
9-14 insufficient number of physicians providing services to eligible
9-15 clinics of federal, state, or locally funded health care programs;
9-16 or
9-17 (f) a site that the Texas Department
9-18 of Health determines serves a disproportionate number of clients
9-19 eligible to participate in federal, state, or locally funded health
9-20 care programs.
9-21 (v) "Health manpower shortage area" means
9-22 (1) an area in an urban or rural area of Texas (which need not
9-23 conform to the geographic boundaries of a political subdivision and
9-24 which is a rational area for the delivery of health services) which
9-25 the secretary of health and human services determines has a health
10-1 manpower shortage and which is not reasonably accessible to an
10-2 adequately served area; (2) a population group which the secretary
10-3 determines to have such a shortage; or (3) a public or nonprofit
10-4 private medical facility or other facility which the secretary
10-5 determines has such a shortage as delineated in 42 U.S.C. Section
10-6 254(e)(a)(1).
10-7 (vi) "Medically under served area" means
10-8 an area in Texas with a medically under served population or an
10-9 urban or rural area designated by the secretary of health and human
10-10 services as an area in Texas with a shortage or personal health
10-11 services or a population group designated by the secretary as
10-12 having a shortage of such services (as defined in 42 U.S.C. Section
10-13 300(3)-1(7)<.> or as defined by the Texas Department of Health by
10-14 rule which is based upon Texas specific demographics, geographic
10-15 factors that affect access to health care and environmental health
10-16 factors.
10-17 (E) After making a determination under <either>
10-18 Subdivisions (D)(iv)(e), <or> (D)(iv)(f), or (D)(vi) that a site
10-19 serves a medically under served population, the Texas Department of
10-20 Health shall publish notice of its determination in the Texas
10-21 Register and provide an opportunity for public comment in the same
10-22 manner as for a proposed rule under the Government Code, Sec.
10-23 2001.001, et seq. <Administrative Procedure and Texas Register Act
10-24 (Article 6252-13a, Vernon's Texas Civil Statutes).>
10-25 (F) The authority granted to a physician to
11-1 delegate under this subdivision shall not be construed as limiting
11-2 the authority of a physician to delegate under any other
11-3 subdivision of this subsection.
11-4 (G) An advertisement for a site serving a
11-5 medically under served population shall include the name and
11-6 business address of the supervising physician for the site.
11-7 SECTION 6. Section 3.06(d)(6), Medical Practice Act, Article
11-8 4495b is amended to read as follows:
11-9 (6)(A) At a physician's primary practice site, a
11-10 physician licensed by the board shall be authorized to delegate to
11-11 a physician assistant acting under adequate supervision the act or
11-12 acts of administering, providing, carrying out or signing a
11-13 prescription drug order for dangerous drugs as authorized through
11-14 physician's orders, standing medical orders, standing delegation
11-15 orders, or other orders or protocols as defined by the board.
11-16 (B) Supervision by a physician shall be
11-17 continuous, but shall not be construed as necessarily requiring the
11-18 constant physical presence of the supervising physician at a place
11-19 where physician assistant services are performed while the services
11-20 are performed.
11-21 (C) The carrying out or signing of prescription
11-22 drug orders under this subsection shall comply with other
11-23 applicable laws.
11-24 (D) A physician's authority to delegate under
11-25 this subsection is limited to:
12-1 (i) two physician assistants or their full
12-2 time equivalents;
12-3 (ii) the patients with whom the physician
12-4 has established or will establish a physician/patient relationship;
12-5 and,
12-6 (iii) physician assistants who are
12-7 maintained and located with the physician at his primary practice
12-8 site.
12-9 (E) In this subsection:
12-10 (i) "physician assistant" has the meaning
12-11 assigned to that term by Section 2(3), Physician Assistant
12-12 Licensing Act, and is subsequent amendments;
12-13 (ii) "primary practice site" means:
12-14 (a) the practice location where the
12-15 physician spends the majority of his time and which is so
12-16 designated by the physician;
12-17 (b) a licensed hospital or nursing
12-18 home where both the physician and the physician assistant are
12-19 credentialed to practice; or
12-20 (c) where the physician is
12-21 physically present with the physician assistant.
12-22 (F) "Carrying out or signing a prescription drug
12-23 order" means either to complete a prescription drug order
12-24 pre-signed by a delegating physician or the signing of a
12-25 prescription by a physician assistant after such person has been
13-1 designated with the board by the delegating physician as a person
13-2 delegated to sign a prescription. The following information shall
13-3 be provided on each prescription: the patient's name and address;
13-4 the drug to be dispensed; directions to the patient in regard to
13-5 the taking and dosage; the name, address, and telephone number of
13-6 the physician; the name, address, telephone and identification
13-7 number of the physician assistant completing or signing the
13-8 prescription drug order; the date; and the number of refills
13-9 permitted. The board may adopt additional methods to carry into
13-10 effect or put into force a physician's prescription or delegation
13-11 of a prescription under physician's orders, standing medical
13-12 orders, standing delegation orders, or other orders or protocols.
13-13 SECTION 7. Title 2. Subtitle C. Chapter 32, Human
13-14 Resources Code, is amended by adding a new Subchapter C to read as
13-15 follows:
13-16 Sec. 32.051. This Subchapter may be cited as the Medical
13-17 Assistance Patient Protection Act.
13-18 Sec. 32.052. Definitions.
13-19 (a) "Department" means the Department of Human Services.
13-20 (b) "Qualified managed care plan" means a managed care plan
13-21 that the Commissioner certifies, upon application to the program,
13-22 as meeting the requirements of this section.
13-23 (c) "Utilization review law" means Article 21.58A, Insurance
13-24 Code.
13-25 (d) "Managed care plan" means a plan operated by a managed
14-1 care entity that provides for the financing and delivery of health
14-2 care services to persons enrolled in such plan through:
14-3 (1) arrangements with selected providers to furnish
14-4 health care services;
14-5 (2) explicit standards for the selection of
14-6 participating providers;
14-7 (3) organizational arrangements for ongoing quality
14-8 assurance, utilization review programs, and dispute resolution; and
14-9 (4) financial incentives for persons enrolled in the
14-10 plan to use the participating providers and procedures provided for
14-11 by the plan.
14-12 (e) "Managed care entity" means a licensed insurance
14-13 company, hospital or medical service plan, health maintenance
14-14 organization, an employer or employee organization, or a managed
14-15 care contractor that operated a managed care plan.
14-16 (f) "Managed care contractor" means a person that:
14-17 (1) establishes, operates or maintains a network of
14-18 participating providers;
14-19 (2) conducts or arranges for utilization review
14-20 activities; and
14-21 (3) contracts with an insurance company, a hospital or
14-22 medical service plan, an employer, an employee organization, or any
14-23 other entity providing coverage for health care services to operate
14-24 a managed care plan.
14-25 (g) "Participating provider" means a physician, physician
15-1 assistant, hospital, pharmacy, laboratory, or other appropriately
15-2 state licensed, registered, certified or otherwise state recognized
15-3 provider of health care services or supplies, that has entered into
15-4 an agreement with a managed care entity to provide such services or
15-5 supplies to a patient enrolled in a managed care plan.
15-6 Sec. 32.053. Protection of Consumer Choice. Nothing in this
15-7 Act shall be construed as prohibiting the following:
15-8 (1) An individual from purchasing any health care
15-9 services with that individual's own funds, whether such services
15-10 are covered within the individual's standard benefit package or
15-11 from another health care provider or plan.
15-12 (2) Employers from providing coverage for benefits in
15-13 addition to the comprehensive benefit package.
15-14 Sec. 32.054. Certification of Managed Care Plans.
15-15 (a)(1) All managed care plans offering or providing services
15-16 under Chapter 32 of this Code must be certified under the
15-17 provisions of this Subchapter.
15-18 (2) The Department shall establish a process for
15-19 certification of managed care plans meeting the requirements of
15-20 subsection (b).
15-21 (3) The Department shall establish procedures for the
15-22 periodic review and recertification of qualified managed care
15-23 plans.
15-24 (4) The Department shall terminate the certification
15-25 of a previously qualified managed care plan if the Department
16-1 determines that such plan or program no longer meets the applicable
16-2 requirements for certification. Before effecting a termination,
16-3 the Department shall provide the plan notice and opportunity for a
16-4 hearing on the proposed termination.
16-5 (A) An eligible organization, as defined in
16-6 section 1876(b) of the Social Security Act, shall be deemed to meet
16-7 the requirements of subsection (b) for certification as a qualified
16-8 managed care plan.
16-9 (B) If the Department finds that a national
16-10 accreditation body establishes a requirement or requirements for
16-11 accreditation of a managed care plan that are at least equivalent
16-12 to the requirement(s) established under subsection (b), the
16-13 Department may, to the extent appropriate, treat a managed care
16-14 plan thus accredited as meeting the requirement(s) of subsection
16-15 (b).
16-16 (b)(1) The Department shall establish standards for the
16-17 certification of qualified managed care plans that conduct business
16-18 in this state, including standards whereby:
16-19 (A) Prospective enrollees in a plan must be
16-20 provided information as to the terms and conditions of the plan so
16-21 that they can make informed decisions about accepting a certain
16-22 system of health care delivery. Where the plan is described orally
16-23 to enrollees, easily understood, truthful, and objective terms must
16-24 be used. All written plan descriptions must be in a readable and
16-25 understandable format, consistent with standards developed for
17-1 supplemental insurance coverage under Title XVII of the Social
17-2 Security Act. This format must be standardized so that customers
17-3 can compare the attributes of the plans. Specific items that must
17-4 be included are:
17-5 (i) coverage provisions, benefits, and any
17-6 exclusions by category of service, provider or physician, and if
17-7 applicable, by specific service;
17-8 (ii) any and all prior authorization or
17-9 other review requirements including preauthorization review,
17-10 concurrent review, post-service review, post payment review and any
17-11 procedures that may lead the patient to be denied coverage for or
17-12 not be provided a particular service;
17-13 (iii) financial arrangements or
17-14 contractual provisions with hospitals, review companies,
17-15 physicians, dentists, or any other provider of health care services
17-16 that would limit the services offered, restrict referral or
17-17 treatment options, or negatively affect the physician's or
17-18 dentist's fiduciary responsibility to his or her patients,
17-19 including but not limited to financial incentives not to provide
17-20 medical, dental, or other services;
17-21 (iv) explanation of how plan limitations
17-22 impact enrollees, including information on enrolled financial
17-23 responsibility for payment for coinsurance or other non-covered or
17-24 out-of-plan services;
17-25 (v) explanation of the physician or, as
18-1 appropriate, dentist network configuration that provides for
18-2 patient access to physicians and dentists including geographic
18-3 distribution of physicians and dentists by specialty and the
18-4 physician and, as appropriate, dentist to enrollee ratio by
18-5 specialty;
18-6 (vi) loss ratios; and
18-7 (vii) enrolled satisfaction statistics
18-8 (including percent re-enrollment and reasons for leaving plan).
18-9 (B) The plan must demonstrate that covered
18-10 enrollees have reasonably prompt access through the entity's
18-11 provider network to all items and services contained in the package
18-12 of benefits for which coverage is provided (including access to
18-13 emergency services on a 24-hour basis where medically necessary),
18-14 in a manner that assures the continuity of the provision of such
18-15 items and services. Such access shall take into account the
18-16 diverse needs of enrollees, including special language
18-17 requirements, and proximity to the workplaces or residences of
18-18 enrollees.
18-19 (C) For the purposes of this section, plans must
18-20 accept as providers under its plan all physicians and, as
18-21 appropriate, dentists who are historical Medicaid providers and who
18-22 agree to the terms and conditions of the plan for a minimum period
18-23 of three years from the effective date of this section. For the
18-24 purposes of this subsection, historical Medicaid provider means a
18-25 physician or, as appropriate, dentist who was a Medicaid provider
19-1 for one year or more on the effective date of this section. A plan
19-2 is not required to comply with this subsection if the exclusion of
19-3 a historical Medicaid provider is based on demonstrated quality of
19-4 care grounds and the plan also complies with the requirements of
19-5 subdivision (G)(vii). However, nothing in this subsection is to be
19-6 construed as prohibiting a plan from removing an historical
19-7 Medicaid provider from the plan for failing to comply with the
19-8 terms and conditions of the plan.
19-9 (D) In its establishment of criteria for
19-10 hospital participation, a plan shall be required to accept hospital
19-11 licensure by the Texas Department of Health, certification by the
19-12 Medicare program, (Title XVII of the Social Security Act (42 U.S.C.
19-13 1395, et seq)) or accreditation by the Joint Commission on
19-14 Accreditation of Healthcare Organizations.
19-15 (E) Plans must meet financial reserve
19-16 requirements that are established to assure proper payment for
19-17 covered services provided. An indemnity fund should be established
19-18 to provide for plan failures even when a plan has met the reserve
19-19 requirements.
19-20 (F) All plans shall be required to establish a
19-21 mechanism, with defined rights, under which physicians and dentists
19-22 participating in the plan provide meaningful input into the plan's
19-23 medical or, as appropriate, dental policy, (including coverage of
19-24 new technology and procedures), utilization review criteria and
19-25 procedures, quality and credentialing criteria, and medical or
20-1 dental management procedures.
20-2 (G) All plans shall be required to credential
20-3 physicians and dentists within the plan, and will allow all
20-4 physicians and dentists within the plan's geographic service area
20-5 to apply for such credentials. At least once per year, plans shall
20-6 notify physicians and dentists of the opportunity to apply for
20-7 credentials.
20-8 (i) Such a credentialing process shall
20-9 begin upon application of a physician or dentist to the plan for
20-10 inclusion.
20-11 (ii) Each application shall be reviewed by
20-12 a credentialing committee with appropriate representation of the
20-13 applicant's medical or, as appropriate, dental specialty.
20-14 (iii) Credentialing shall be based on
20-15 objective standards of quality with input from physicians or, as
20-16 appropriate, dentists credentialed in the plan and such standards
20-17 shall be available to applicants and enrollees. When economic
20-18 considerations are part of the decision, objective criteria must be
20-19 used and must be available to applicants, participating physicians,
20-20 dentists, and enrollees. Any economic profiling of physicians or
20-21 dentists must be adjusted to recognize case mix, disease,
20-22 physiologic and behavioral severity of the disease, including
20-23 comorbidities, age and sex risk adjustment of patients and other
20-24 features of a physician's or dentist's practice that may account
20-25 for higher than or lower than expected costs to assure fair
21-1 comparisons are made. Profiles must be made available to those so
21-2 profiled. When graduate medical education is a consideration in
21-3 credentialing, equal recognition will be given to training programs
21-4 accredited by the Accrediting Council on Graduate Medical Education
21-5 and by the American Osteopathic Association.
21-6 (iv) Plans shall be prohibited from
21-7 discriminating against enrollees with expensive medical conditions
21-8 requiring expensive tests and procedures to adequately diagnose and
21-9 treat enrollees by excluding practitioners who treat such
21-10 enrollees.
21-11 (v) All decisions shall be made on the
21-12 record, and the applicant shall be provided with all reasons used
21-13 if the application is denied or the contract not reviewed.
21-14 (vi) Plans shall not be allowed to include
21-15 clauses in physician, dentist, or other provider contracts that
21-16 allow for the plan to terminate the contract "without cause."
21-17 (vii) There shall be a due process appeal
21-18 from all adverse decisions. The Department shall establish a due
21-19 process appeal mechanism. The appeals process will be presumed to
21-20 be reasonable if it complies with the appeals process set forth in
21-21 the Health Care Quality Improvement Act of 1986, 42 U.S.C. Section
21-22 11101-11151.
21-23 (viii) The same standards and procedures
21-24 used for an application for credentials shall also be used in those
21-25 cases where the plan seeks to reduce or withdraw such credentials.
22-1 Prior to initiation of a proceeding leading to termination of a
22-2 contract "for cause," the physician or, as appropriate, dentist
22-3 shall be provided notice, an opportunity for discussion, and an
22-4 opportunity to enter into and complete a corrective action plan,
22-5 except in cases where there is imminent harm to patient health or
22-6 an action by a state medical or, as appropriate, dental board or
22-7 other government agency that effectively impairs the physician's or
22-8 dentist's ability to practice medicine within the jurisdiction.
22-9 (H) Procedures shall be established to ensure
22-10 that all applicable Federal and State laws designed to protect the
22-11 confidentiality of provider and individual medical and dental
22-12 records are followed.
22-13 (I) Plans must ensure that each enrollee is able
22-14 to choose a primary care physician and, as appropriate, dentist
22-15 from among participating physicians and dentists and change that
22-16 selection as appropriate.
22-17 (J) Plans must:
22-18 (i) cover medically necessary emergency
22-19 care services provided to covered individuals (including trauma
22-20 services, such as those provided by designated trauma centers),
22-21 without regard to whether or not the provider furnishing such
22-22 services has a contractual (or other) arrangement with the entity
22-23 to provide items or services to covered individuals and, in the
22-24 case of services furnished for the treatment of an emergency
22-25 medical condition (as defined in section 1867(e)(1) of the Social
23-1 Security Act), without regard to prior authorizations; and
23-2 (ii) provide that the prior authorization
23-3 requirement for medically necessary services or stabilizing
23-4 treatment in the emergency room shall be deemed to be approved
23-5 unless denied within 2 hours of a required request.
23-6 (2) Plans must ensure that enrollees, in plans where
23-7 prior authorization is a condition to coverage of a service, are
23-8 required to sign medical and dental information release consent
23-9 forms upon enrollment for use where services requiring prior
23-10 authorization are recommended or proposed by their physician or
23-11 dentist;
23-12 (3) When prior approval for a service or other covered
23-13 item is obtained, it shall be considered approval for all purposes,
23-14 and the service shall be considered to be covered unless there was
23-15 fraud or incorrect information provided at the time such prior
23-16 approval was obtained.
23-17 (4) Continuity of patient care is maintained when
23-18 physicians or dentists are deselected or otherwise are no longer
23-19 participating providers under the plan by providing for the
23-20 immediate reimbursement for copies of medical or dental records
23-21 that are created, kept or maintained by a physician or dentist and
23-22 provided by the physician for the patient or someone on his behalf.
23-23 (5) Not withstanding the provision of any other law,
23-24 all qualified managed care programs are subject to and shall meet
23-25 the requirements of the utilization review law.
24-1 (6) Standards shall first be established under this
24-2 subsection by not later than 12 months after the date of the
24-3 enactment of this section.
24-4 (7) The Department shall periodically review the
24-5 standards established under this subsection, and may revise the
24-6 standards from time to time to assure that such standards continue
24-7 to reflect appropriate policies and practices for the
24-8 cost-effective and medically appropriate use of services within
24-9 managed care plans.
24-10 Sec. 32.055. Choice of Plan. When offered and available in
24-11 the same service area, all eligible enrollees shall have the
24-12 opportunity to select the plan in which they will participate.
24-13 SECTION 8. Article 21.58A, Sections (4) and (14), Insurance
24-14 Code are amended to read as follows:
24-15 Sec. 4. Standards for utilization review.
24-16 (a) As a condition of certification or renewal thereof, a
24-17 utilization review agent shall be required to maintain compliance
24-18 with the provisions of this section.
24-19 (b) The utilization review plan, including reconsideration
24-20 and appeal requirements, shall be reviewed by a physician and
24-21 conducted in accordance with standards developed with input from
24-22 appropriate health care providers and approved by a physician.
24-23 (c)(1) Personnel employed by or under contract with the
24-24 utilization review agent to perform utilization review shall be
24-25 appropriately trained and qualified. Personnel who obtain
25-1 information directly from the physician or health care provider,
25-2 either orally or in writing, and who are not physicians shall be
25-3 nurses, physician assistants, registered records administrators, or
25-4 accredited records technicians, who are either licensed or
25-5 certified, or shall be individuals who have received formal
25-6 orientation and training in accordance with policies and procedures
25-7 established by the utilization review agent to assure compliance
25-8 with this section, and a description of such policies and
25-9 procedures shall be filed with the commissioner. This provision
25-10 shall not be interpreted to require such qualifications for
25-11 personnel who perform clerical or administrative tasks.
25-12 (2) Upon request, physicians or as appropriate,
25-13 dentists, will be provided the names and credentials of all
25-14 individuals conducting utilization review, subject to reasonable
25-15 safeguards and standards.
25-16 (d) A utilization review agent shall not set or impose any
25-17 notice or other review procedures contrary to the requirements of
25-18 the health insurance policy or health benefit plan.
25-19 (e) Unless approved for an individual patient by the
25-20 provider of record or modified by contract, a utilization review
25-21 agent shall be prohibited from observing, participating in, or
25-22 otherwise being present during a patient's examination, treatment,
25-23 procedure, or therapy. In no event shall this section otherwise be
25-24 construed to limit or deny contact with a patient for purposes of
25-25 conducting utilization review unless otherwise specifically
26-1 prohibited by law.
26-2 (f) A utilization review agent may not permit or provide
26-3 compensation or any thing of value to its employees or agents,
26-4 condition employment of its employee or agent evaluations, or set
26-5 its employee or agent performance standards, based on the amount of
26-6 volume of adverse determinations, reductions or limitations on
26-7 lengths of stay, benefits, services, or charges or on the number of
26-8 frequency of telephone calls or other contacts with health care
26-9 providers or patients, which are inconsistent with the provisions
26-10 of this article.
26-11 (g) A health care provider may designate one or more
26-12 individuals as the initial contact or contacts for utilization
26-13 review agents seeking routine information or data. In no event
26-14 shall the designation of such an individual or individuals preclude
26-15 a utilization review agent or medical advisor from contacting a
26-16 health care provider or others in his or her employ where a review
26-17 might otherwise be unreasonably delayed or where the designated
26-18 individual is unable to provide the necessary information or data
26-19 requested by the utilization review agent.
26-20 (h) Utilization review conducted by a utilization review
26-21 agent shall be under the direction of a physician licensed to
26-22 practice medicine by the Texas State Board of Medical Examiners <a
26-23 state licensing agency in the United States.>
26-24 (i) Each utilization review agent shall utilize written
26-25 medically acceptable screening criteria and review procedures which
27-1 are established and periodically evaluated and updated with
27-2 appropriate involvement from physicians, including practicing
27-3 physicians, and other health care providers. Such written
27-4 screening criteria and review procedures shall be available for
27-5 review and inspection by the commissioner and copying as necessary
27-6 for the commissioner to carry out his or her lawful duties under
27-7 this code, provided, however, that any information obtained or
27-8 acquired under the authority of this subsection and article is
27-9 confidential and privileged and not subject to the open records law
27-10 or subpoena except to the extent necessary for the board of
27-11 commissioner to enforce this article.
27-12 (j) A utilization review agent may not engage in unnecessary
27-13 or unreasonable repetitive contacts with the health care provider
27-14 or patient and shall base the frequency of contacts or reviews on
27-15 the severity or complexity of the patient's condition or on
27-16 necessary treatment and discharge planning activity.
27-17 (k) Subject to the notice requirements of Section 5 of this
27-18 article, in any instance where the utilization review agent is
27-19 questioning the medical necessity or appropriateness of health care
27-20 services, the health care provider who ordered the services shall
27-21 be afforded a reasonable opportunity to discuss the plan of
27-22 treatment for the patient and the clinical basis for the
27-23 utilization review agent's decision with a physician or, in the
27-24 case of a dental plan with a dentist, prior to issuance of an
27-25 adverse determination.
28-1 (l) <Unless precluded or modified by contract, a> A
28-2 utilization review agent shall reimburse health care providers for
28-3 the reasonable costs for providing medical information in writing,
28-4 including copying and transmitting any requested patient records or
28-5 other documents. A health care provider's charges for providing
28-6 medical information to a utilization review agent shall not exceed
28-7 the cost of copying set by rule of the Texas Workers' Compensation
28-8 Commission for records and may not include any costs that are
28-9 otherwise recouped as a part of the charge for health care.
28-10 (m) A utilization review agent shall establish and maintain
28-11 a complaint system that provides reasonable procedures for the
28-12 resolution of written complaints initiated by enrollees, patients,
28-13 or health care providers concerning the utilization review and
28-14 shall maintain records of such written complaints for two years
28-15 from the time the complaints are filed. The complaint procedure
28-16 shall include a written response to the complainant by the agent
28-17 within 60 days. The utilization review agent shall submit to the
28-18 commissioner a summary report of all complaints at such times and
28-19 in such forms as the board may require and shall permit the
28-20 commissioner to examine the complaints and all relevant documents
28-21 at any time.
28-22 (n) The utilization review agent may delegate utilization
28-23 review to qualified personnel in the hospital or health care
28-24 facility where the health care services were or are to be provided.
28-25 Sec. 14 (a) This article shall not apply to a person who
29-1 provides information to enrollees about scope of coverage or
29-2 benefits provided under a health insurance policy or health benefit
29-3 plan and who does not determine whether particular health care
29-4 services provided or to be provided to an enrollee are medically
29-5 necessary or appropriate.
29-6 (b)(1) This article shall not apply to any contract with the
29-7 federal government for utilization review of patients eligible for
29-8 services under Title XVIII or XIX of the Social Security Act (42
29-9 U.S.C. Section 1395 et seq. or Section 1396 et seq.).
29-10 (b)(2) This article shall not apply to <the Texas
29-11 Medicaid Program,> the chronically ill and disabled children's
29-12 services program created pursuant to Chapter 35, Health and Safety
29-13 Code, <any program administered under Title 2, Human Resources
29-14 Code> any program of the Texas Department of Mental Health and
29-15 Mental Retardation, or any program of the Texas Department of
29-16 Criminal Justice.
29-17 (c) This article shall not apply to utilization review of
29-18 health care services provided to patients under the authority of
29-19 the Texas Workers' Compensation Act (Article 8308-1.01 et seq.,
29-20 Vernon's Texas Civil Statutes).
29-21 <(d) This article shall not apply to utilization review of
29-22 health care services provided under a policy or contract of
29-23 automobile insurance promulgated by the board under Subchapter A,
29-24 Chapter 5 of this code or issued pursuant to Article 1.14-2 of this
29-25 code.>
30-1 (d) <(e)> This article shall not apply to the terms or
30-2 benefits of employee welfare benefit plans as defined in Section
30-3 31(I) of the Employee Retirement Income Security Act of 1974 (29
30-4 U.S.C. Section 1002).
30-5 (e) <(f)> Any regulations promulgated pursuant to this
30-6 article shall relate only to persons or entities subject to this
30-7 article.
30-8 <(g) A health maintenance organization is not subject to
30-9 this article except as expressly provided in this subsection and
30-10 Subsection (i) of this section. If such health maintenance
30-11 organization performs utilization review as defined herein, it
30-12 shall, as a condition of licensure:>
30-13 <(1) comply with Sections 4(b), (c), (e), (f), (h),
30-14 (i), and (l) of this article, and the board shall promulgate rules
30-15 for appropriate verification and enforcement of compliance.
30-16 However, nothing in this article shall be construed to prohibit or
30-17 limit the distribution of a proportion of the savings from the
30-18 reduction or elimination of unnecessary medical services,
30-19 treatment, supplies, confinements, or days of confinement, in a
30-20 health care facility through profit sharing, bonus, or withhold
30-21 arrangements to participating physicians or participating health
30-22 care providers for rendering health care services to enrollees;>
30-23 <(2) establish and maintain a system for:>
30-24 <(A) handling and responding to complaints by
30-25 enrollees, patients, or health care providers;>
31-1 <(B) providing health care providers with notice
31-2 of medical necessity or program requirements that have not been
31-3 met, including a reasonable opportunity to discuss the plan of
31-4 treatment and clinical basis for a utilization review determination
31-5 with a physician; and>
31-6 <(C) providing the enrollee, patient, and health
31-7 care provider an opportunity to appeal the determination; and>
31-8 <(3) submit to assessment of maintenance taxes under
31-9 Article 20A.33, Texas Health Maintenance Organization Act (Article
31-10 20A.33, Vernon's Texas Insurance Code), to cover the costs of
31-11 administering compliance of health maintenance organizations under
31-12 this section.>
31-13 (f) <(h)> An insurer which delivers or issues for delivery a
31-14 health insurance policy in Texas and is subject to this code is not
31-15 subject to this article except as expressly provided in this
31-16 subsection and Subsection (i) of this section. If an insurer
31-17 performs utilization review as defined herein it shall, as a
31-18 condition of licensure, comply with Sections 4 through 8 of this
31-19 article, and the board shall promulgate rules for appropriate
31-20 verification and enforcement of compliance. Such insurers shall be
31-21 subject to assessment of maintenance tax under Article 4.17 of this
31-22 code to cover the costs of administering compliance of insurers
31-23 under this section.
31-24 (g) <(i)> However, when an insurer subject to this code <or
31-25 a health maintenance organization> performs utilization review for
32-1 a person or entity subject to this article other than the one for
32-2 which it is the payor, such insurer <or health maintenance
32-3 organization> shall be required to obtain a certificate under
32-4 section 3 of this article and comply with all the provisions of
32-5 this article.
32-6 SECTION 9. Title 3, Subtitle A, Chapter 51, Subchapter Z,
32-7 Section 51.918(c), Education Code, is amended to read as follows:
32-8 Sec. 51.918 (c) The Center for Rural Health Initiatives
32-9 shall develop relief service programs for rural physicians and
32-10 allied health personnel to facilitate ready access to continuing
32-11 medical education or practice coverage for purposes other than
32-12 continuing medical education.
32-13 SECTION 10. Chapter 262.034, Texas Health & Safety Code, is
32-14 amended to read as follows:
32-15 Facilities and Services for Elderly and Disabled <Nursing
32-16 Homes>
32-17 <(a) This section applies to an authority created by a
32-18 municipality with a population of more than 24,000 that is located
32-19 in a county with a population of 1.5 million or more.>
32-20 (a) <(b)> The authority may construct, acquire, own,
32-21 operate, enlarge, improve, furnish, or equip one or more <nursing
32-22 homes or similar> of the following types of facilities or services
32-23 for the care of the elderly or disabled: long term care, elderly
32-24 housing, assisted living, home health, personal care, special care,
32-25 continuing care and durable medical equipment. <The nursing home
33-1 or similar facility> These facilities and services may be located
33-2 and/or offered outside the municipal limits.
33-3 (b) <(c)> The authority may lease or enter into an
33-4 operations or management agreement relating to all or part of <a
33-5 nursing home or similar> such a facility or service for the care of
33-6 the elderly or disabled that is owned by the authority. The
33-7 authority may close, transfer, sell or otherwise convey all or part
33-8 of these facilities and may discontinue these services <the nursing
33-9 home or similar facility>.
33-10 (c) <(d)> The authority may issue revenue bonds and other
33-11 notes in accordance with this chapter to acquire, construct, or
33-12 improve a <nursing home or similar> facility for the care of the
33-13 elderly or disabled or to implement the delivery of a service for
33-14 the care of the elderly or disabled.
33-15 (d) <(e)> For the purpose of this section, a <nursing home
33-16 or similar> facility or service described in 262.034(a) <for the
33-17 care of the elderly> is considered to be a hospital project under
33-18 Chapter 223 of the Health & Safety Code.
33-19 SECTION 11. Chapter 285, Texas Health & Safety Code, is
33-20 amended by adding Subchapter G to read as follows:
33-21 SUBCHAPTER G. LONG TERM CARE AND RELATED FACILITIES.
33-22 Sec. 1. Any hospital, hospital district or authority created
33-23 and operated under Article IX of the Texas Constitution, special
33-24 law or Title 4 of the Health & Safety Code may:
33-25 (a) Construct, acquire, own, operate, enlarge, improve,
34-1 furnish, or equip one or more of the following types of facilities
34-2 or services for the care of the elderly or disabled: long term
34-3 care, elderly housing, assisted living, home health, personal care,
34-4 special care, continuing care and durable medical equipment;
34-5 (b) Lease or enter into an operations or management
34-6 agreement relating to all or part of a facility or service
34-7 described in Sec. 1(a) that is owned by the hospital district or
34-8 authority;
34-9 (c) Close, transfer, sell or otherwise convey all or part of
34-10 such a facility and may discontinue these services;
34-11 (d) Issue revenue bonds and other notes to acquire,
34-12 construct or improve a facility for the care of the elderly or
34-13 disabled or to implement the delivery of a service for the care of
34-14 the elderly or disabled.
34-15 Sec. 2. For the purpose of this Subchapter, a facility or
34-16 service created pursuant to Section 1(a) shall be considered to be
34-17 a hospital project under Chapter 223 of the Health & Safety Code.
34-18 SECTION 12. Section 501.059, Government Code, is amended to
34-19 read as follows:
34-20 Sec. 501.059. Managed Health Care Advisory Committee.
34-21 (a) The Managed Health Care Advisory Committee to the Texas
34-22 Department of Criminal Justice is established.
34-23 (b) The committee consists of:
34-24 (1) two members employed full-time by the department,
34-25 at least one of whom is a physician, appointed by the executive
35-1 director,
35-2 (2) two members employed full-time by The University
35-3 of Texas Medical Branch at Galveston, at least one of whom is a
35-4 physician, appointed by the president of the medical branch; and
35-5 (3) two members employed fulltime by the Texas Tech
35-6 University Health Science Center, at least one of whom is a
35-7 physician, appointed by the president of the university.
35-8 (c) A committee member serves at the pleasure of the
35-9 appointing official or until termination of the member's employment
35-10 with the entity the member represents.
35-11 (d) An appointment to the committee shall be made without
35-12 regard to the race, creed, sex, religion, or national origin of the
35-13 appointee.
35-14 (e) A committee member serves without compensation but is
35-15 entitled to reimbursement of actual and necessary expenses incurred
35-16 in the performance of the duties of the committee.
35-17 (f) The committee may hire a managed health care
35-18 administrator and may employ personnel necessary for the
35-19 administration of the committee's duties.
35-20 (g) The committee shall develop a managed health care plan
35-21 for all inmates at the institutional division that includes:
35-22 (1) the establishment of a managed care network of
35-23 physicians and hospitals that will serve the institutional division
35-24 as the exclusive health care provider for inmates at each facility
35-25 of the institutional division;
36-1 (2) cost containment studies; <and>
36-2 (3) care case management and utilization management
36-3 studies performed exclusively for the institutional division; and
36-4 (4) as to the establishment of criteria for hospital
36-5 participation, a provision requiring the manage care plan to accept
36-6 hospital licensure by the Texas Department of Health, certification
36-7 by the Medicare program (Title XVII of the Social Security Act (42
36-8 U.S.C. 1395 et seq.)), or accreditation by the Joint Commission on
36-9 Accreditation of Healthcare Organizations.
36-10 <(h) To the extent possible the committee shall integrate
36-11 the manage care network with the public medical schools of this
36-12 state and the component hospitals of those medical schools.>
36-13 (h) <(i)> For those services for which the public medical
36-14 schools and their components cannot provide, the committee shall
36-15 initiate a competitive bidding process for contracts with other
36-16 providers for medical care to inmates confined in the institutional
36-17 division.
36-18 (i) <(j)> The committee may enter into a contract on behalf
36-19 of the department to fully implement the managed health care plan
36-20 under Subsection (g).
36-21 (j) <(k)> The department shall pay necessary costs for the
36-22 operation of the committee, including costs of personnel, from
36-23 funds appropriated by the legislature to the department.
36-24 (k) <(l)> The managed health care plan, inclusive of the
36-25 health care administrator and necessary personnel proposed by the
37-1 committee, must cost the state less than what is presently
37-2 provided, otherwise, the status quo shall be maintained.
37-3 SECTION 13. Emergency.
37-4 The importance of this legislation and the crowded condition
37-5 of the calendars in both houses create an emergency and an
37-6 imperative public necessity that the constitutional rule requiring
37-7 bills to be read on three several days in each house be suspended,
37-8 and this rule is hereby suspended, and that this Act take effect
37-9 and be in force according to its terms, and it is so enacted.