By: Madla S.B. No. 673
A BILL TO BE ENTITLED
AN ACT
1-1 relating to health care, including powers and duties of the center
1-2 for rural health initiatives, continuing medical education, the
1-3 delegation of prescription drug orders, services and patient
1-4 protection in the Medicaid program, standards for utilization
1-5 review, medically under served areas, health facilities and
1-6 services for the elderly and disabled.
1-7 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-8 SECTION 1. The Act may be cited as the Omnibus Rural Health
1-9 Services Enhancement and Patient Protection Act.
1-10 SECTION 2. Title 2, Chapter 106, Subchapter B, Sec.
1-11 106.025(a), Health and Safety Code, is amended to read as follows:
1-12 Sec. 106.025. Duties and Powers. (a) The center shall:
1-13 (1) educate the public and recommend appropriate
1-14 public policies regarding the continued viability of rural health
1-15 care delivery in this state;
1-16 (2) monitor and work with state and federal agencies
1-17 to assess the impact of proposed rules on rural areas;
1-18 (3) provide impact statements of proposed rules as
1-19 considered appropriate by the center;
1-20 (4) streamline regulations to assist in the
1-21 development of service diversification of health care facilities;
1-22 (5) target state and federal programs to rural areas;
1-23 (6) promote and develop community involvement and
2-1 community support in maintaining, rebuilding, or diversifying local
2-2 health services;
2-3 (7) promote and develop diverse and innovative health
2-4 care service models in rural areas;
2-5 (8) encourage the use of advanced communication
2-6 technology<;>:
2-7 (A) to ensure that rural areas receive the
2-8 maximum benefits of telemedicine and distance learning by promoting
2-9 a transmission rate structure which accommodates rural needs and by
2-10 improving the telecommunications infrastructure in rural areas; and
2-11 (B) to provide access to specialty expertise,
2-12 clinical consultation, and continuing education;
2-13 (9) assist rural health care providers, communities,
2-14 and individuals in applying for public and private grants and
2-15 programs;
2-16 (10) encourage the development of regional emergency
2-17 transportation networks;
2-18 (11) work with state agencies, universities, and
2-19 private interest groups to conduct and promote research on rural
2-20 health issues, maintain and collect a timely data base, and develop
2-21 and maintain a rural health resource library;
2-22 (12) solicit the assistance of other offices or
2-23 programs of rural health in this state that are university-based to
2-24 carry out the duties of this chapter;
2-25 (13) disseminate information and provide technical
3-1 assistance to communities, health care providers, and individual
3-2 consumers of health care services; and
3-3 (14) develop plans to implement a fee-for-service
3-4 health care professional recruitment service and a medical supplies
3-5 group purchasing program within the center.
3-6 (15)(A) develop and initiate a study of rural health
3-7 clinics to:
3-8 (i) determine the efficiency and
3-9 effectiveness of rural health clinics;
3-10 (ii) assess the impact on access to health
3-11 care;
3-12 (iii) identify and address efficiency
3-13 barriers for the professional clinical relationship of physicians,
3-14 nurses, and physician assistants;
3-15 (iv) assess the success of attracting
3-16 primary care physicians and allied health professionals to rural
3-17 areas; and
3-18 (v) assess the appropriateness of the
3-19 current clinic designation process; and
3-20 (B) develop and initiate a quality assessment
3-21 program to evaluate the health outcomes of rural patients treated
3-22 in rural health clinics and;
3-23 (16) encourage the active participation by physicians
3-24 and other health care providers in the Early Periodic Diagnosis and
3-25 Treatment Program.
4-1 (b) The center may:
4-2 (1) solicit, receive, and spend grants, gifts, and
4-3 donations from public and private sources; and
4-4 (2) contract with public and private entities in the
4-5 performance of its responsibilities.
4-6 SECTION 3. Title 2, Chapter 105, Health and Safety Code, is
4-7 amended by adding a new section 105.005 and renumbering subsequent
4-8 sections accordingly. The new subsection 105.005 reads as follows:
4-9 105.005(a) The health professions resource center shall
4-10 develop and establish a clearinghouse for health professionals
4-11 seeking collaborative practice in rural or medically under served
4-12 areas.
4-13 (b) The health professions resource center may:
4-14 (1) set and collect a reasonable fee to offset the
4-15 cost of complying with the requirements of this section;
4-16 (2) solicit, receive, and spend grants, gifts, and
4-17 donations from public and private sources, to comply with the
4-18 requirements of this section; and
4-19 (3) contract with public or private entities in the
4-20 performance of its responsibilities under this section.
4-21 SECTION 4. Title 8, Chapter 671, Subchapter A, Sections
4-22 671.001 and 671.002, Health & Safety Code are amended to read as
4-23 follows:
4-24 Sec. 671.001. Standard Used in Determining Death. (a) A
4-25 person is dead when, according to ordinary standards of medical
5-1 practice, there is irreversible cessation of the person's
5-2 spontaneous respiratory and circulatory functions.
5-3 (b) If artificial means of support preclude a determination
5-4 that a person's spontaneous respiratory and circulatory functions
5-5 have ceased, the person is dead when, in the announced opinion of a
5-6 physician, according to ordinary standards of medical practice,
5-7 there is irreversible cessation of all spontaneous brain function.
5-8 Death occurs when the relevant functions cease.
5-9 (c) Death must be pronounced before artificial means of
5-10 supporting a person's respiratory and circulatory functions are
5-11 terminated.
5-12 (d) A registered nurse or physicians assistant may determine
5-13 and pronounce a person dead in situations other than those
5-14 described by Subsection (b) if permitted by written policies of a
5-15 licensed health care facility, institution, or entity providing
5-16 services to that person. If the facility, institution, or entity
5-17 has an organized nursing staff or medical consultant, the nursing
5-18 staff and medical staff or consultant shall jointly develop and
5-19 approve those policies. For purposes of this section, such
5-20 policies shall take into account physician assistants who are
5-21 credentialed or otherwise permitted to practice at the facility,
5-22 institution or entity. The board shall adopt rules to govern
5-23 policies for facilities, institutions, or entities that do not have
5-24 organized nursing staffs and organized medical staffs or medical
5-25 consultants.
6-1 Sec. 671.002. Limitation of Liability. (a) A physician who
6-2 determines death in accordance with Section 671.001(b) <or>, a
6-3 registered nurse, or a physician assistant, is not liable for civil
6-4 damages or subject to criminal prosecution for the physician's
6-5 <or>, registered nurse's, or physician assistant's actions or the
6-6 actions of others based on the determination of death.
6-7 (b) A person who acts in good faith in reliance on a
6-8 physician's <or>, registered nurse's, or physician assistant's
6-9 determination of death is not liable for civil damages or subject
6-10 to criminal prosecution for the person's actions.
6-11 SECTION 5. Section 3.06(d)(5), Medical Practice Act, Article
6-12 4495b is amended to read as follows:
6-13 (5)(A) At a site serving a medically underserved
6-14 population, a physician licensed by the board shall be authorized
6-15 to delegate to a registered nurse or physician assistant acting
6-16 under adequate physician supervision, the act or acts of
6-17 administering, providing, carrying out or signing a prescription
6-18 drug order as authorized by the physician through physician's
6-19 orders, standing medical orders, standing delegation orders, or
6-20 other orders or protocols as defined by the board.
6-21 (B)(i) The carrying out or signing of
6-22 prescription drug orders under this subsection shall comply with
6-23 other applicable laws.
6-24 (ii) The authority of a physician to
6-25 delegate the carrying out or signing of prescription drug orders is
7-1 limited to dangerous drugs and is limited to the practice locations
7-2 designated by the physician in physician's orders, standing medical
7-3 orders, standing delegation orders or other orders or protocols
7-4 approved by the board.
7-5 (C) Physician supervision shall be adequate if a
7-6 delegating physician:
7-7 (i) is responsible for the formulation or
7-8 approval of such physician's orders, standing medical orders,
7-9 standing delegation orders, or other orders or protocols and
7-10 periodically reviews such orders and the services provided patients
7-11 under such orders;
7-12 (ii) is on site at least once a week to
7-13 provide medical direction and consultation;
7-14 (iii) receives a daily status report from
7-15 the registered nurse or physician assistant on any problems or
7-16 complications encountered; and
7-17 (iv) is available through direct
7-18 telecommunication for consultation, assistance with medical
7-19 emergencies, or patient referral.
7-20 (D) In this subsection:
7-21 (i) "Registered nurse" means a registered
7-22 nurse recognized by the Board of Nurse Examiners as having the
7-23 specialized education and training required under Section 7,
7-24 Article 4514, Revised Statutes.
7-25 (ii) "Physician assistant" has the meaning
8-1 assigned to that term by Section 2(3), Physician Assistant
8-2 Licensing Act, and its subsequent amendments.
8-3 (iii) "Carrying out or signing a
8-4 prescription drug order" means either to complete a prescription
8-5 drug order presigned by the delegating physician or the signing of
8-6 a prescription by a registered nurse or physician assistant after
8-7 such person has been designated with the board by the delegating
8-8 physician as a person delegated to sign a prescription. The
8-9 following information shall be provided on each prescription <by
8-10 providing the following information>: the patient's name and
8-11 address; the drug to be dispensed; directions to the patient in
8-12 regard to the taking and dosage; the name, address, and telephone
8-13 number of the physician; the name, address, telephone and
8-14 identification number of the registered nurse or physician
8-15 assistant completing or signing the prescription drug order; the
8-16 date; and the number of refills permitted. The board may adopt
8-17 additional methods to carry into effect or put into force a
8-18 physician's prescription or delegation of a prescription under
8-19 physician's orders, standing medical orders, standing delegation
8-20 orders, or other orders or protocols.
8-21 (iv) "A site serving a medically
8-22 underserved population" means:
8-23 (a) a site located in a medically underserved area;
8-24 (b) a site located in a health manpower shortage area;
8-25 (c) a clinic designated as a rural health clinic under the Rural
9-1 Health Clinic Services Act of 1977 (Pub. L. No. 95-210);
9-2 (d) a public health clinic or a family planning clinic under
9-3 contract with the Texas Department of Human Services or the Texas
9-4 Department of Health;
9-5 (e) a site located in an area in which the Texas Department of
9-6 Health determines there exists an insufficient number of physicians
9-7 providing services to eligible clinics of federal, state, or
9-8 locally funded health care programs; or
9-9 (f) a site that the Texas Department of Health determines serves a
9-10 disproportionate number of clients eligible to participate in
9-11 federal, state, or locally funded health care programs.
9-12 (v) "Health manpower shortage area" means
9-13 (1) an area in an urban or rural area of Texas (which need not
9-14 conform to the geographic boundaries of a political subdivision and
9-15 which is a rational area for the delivery of health services) which
9-16 the secretary of health and human services determines has a health
9-17 manpower shortage and which is not reasonably accessible to an
9-18 adequately served area; (2) a population group which the secretary
9-19 determines to have such a shortage; or (3) a public or nonprofit
9-20 private medical facility or other facility which the secretary
9-21 determines has such a shortage as delineated in 42 U.S.C. Section
9-22 254(e)(a)(1).
9-23 (vi) "Medically underserved area" means an
9-24 area in Texas with a medically underserved population or an urban
9-25 or rural area designated by the secretary of health and human
10-1 services as an area in Texas with a shortage of personal health
10-2 services or a population group designated by the secretary as
10-3 having a shortage of such services (as defined in 42 U.S.C. Section
10-4 300(3)-1(7))<.> or as defined by the Texas Department of Health by
10-5 rule which is based upon Texas specific demographics, geographic
10-6 factors that affect access to health care and environmental health
10-7 factors.
10-8 (E) After making a determination under <either>
10-9 Subdivisions (D)(iv)(e), <or> (D)(iv)(f), or (D)(vi) that a site
10-10 serves a medically underserved population, the Texas Department of
10-11 Health shall publish notice of its determination in the Texas
10-12 Register and provide an opportunity for public comment in the same
10-13 manner as for a proposed rule under the Government Code, Sec.
10-14 2001.001, et seq. <Administrative Procedure and Texas Register Act
10-15 (Article 6252-13a, Vernon's Texas Civil Statutes).>
10-16 (F) The authority granted to a physician to
10-17 delegate under this subdivision shall not be construed as limiting
10-18 the authority of a physician to delegate under any other
10-19 subdivision of this subsection.
10-20 (G) An advertisement for a site serving a
10-21 medically underserved population shall include the name and
10-22 business address of the supervising physician for the site.
10-23 SECTION 6. Section 3.06(d)(6), Medical Practice Act, Article
10-24 4495b is amended to read as follows:
10-25 (6)(A) At a physician's primary practice site, a
11-1 physician licensed by the board shall be authorized to delegate to
11-2 a physician assistant acting under adequate supervision the act or
11-3 acts of administering, providing, carrying out or signing a
11-4 prescription drug order for dangerous drugs as authorized through
11-5 physician's orders, standing medical orders, standing delegation
11-6 orders, or other orders or protocols as defined by the board.
11-7 (B) Supervision by a physician shall be
11-8 continuous, but shall not be construed as necessarily requiring the
11-9 constant physical presence of the supervising physician at a place
11-10 where physician assistant services are performed while the services
11-11 are performed.
11-12 (C) The carrying out or signing of prescription
11-13 drug orders under this subsection shall comply with other
11-14 applicable laws.
11-15 (D) A physician's authority to delegate under
11-16 this subsection is limited to:
11-17 (i) two physician assistants or their full
11-18 time equivalents;
11-19 (ii) the patients with whom the physician
11-20 has established or will establish a physician/patient relationship;
11-21 and,
11-22 (iii) physician assistants who are
11-23 maintained and located with the physician at his primary practice
11-24 site.
11-25 (E) In this subsection:
12-1 (i) "physician assistant" has the meaning
12-2 assigned to that term by Section 2(3), Physician Assistant
12-3 Licensing Act, and is subsequent amendments;
12-4 (ii) "primary practice site" means:
12-5 (a) the practice location where the physician spends the majority
12-6 of his time and which is so designated by the physician;
12-7 (b) a licensed hospital or nursing home where both the physician
12-8 and the physician assistant are credentialed to practice; or
12-9 (c) where the physician is physically present with the physician
12-10 assistant.
12-11 (F) "Carrying out or signing a prescription drug
12-12 order" means either to complete a prescription drug order
12-13 pre-signed by a delegating physician or the signing of a
12-14 prescription by a physician assistant after such person has been
12-15 designated with the board by the delegating physician as a person
12-16 delegated to sign a prescription. The following information shall
12-17 be provided on each prescription: the patient's name and address;
12-18 the drug to be dispensed; directions to the patient in regard to
12-19 the taking and dosage; the name, address, and telephone number of
12-20 the physician; the name, address, telephone and identification
12-21 number of the physician assistant completing or signing the
12-22 prescription drug order; the date; and the number of refills
12-23 permitted. The board may adopt additional methods to carry into
12-24 effect or put into force a physician's prescription or delegation
12-25 of a prescription under physician's orders, standing medical
13-1 orders, standing delegation orders, or other orders or protocols.
13-2 SECTION 7. Title 2. Subtitle C. Chapter 32, Human
13-3 Resources Code, is amended by adding a new Subchapter C to read as
13-4 follows:
13-5 Sec. 32.051. This Subchapter may be cited as the Medical
13-6 Assistance Patient Protection Act.
13-7 Sec. 32.052. DEFINITIONS.
13-8 (a) "Department" means the Department of Human Services.
13-9 (b) "Qualified managed care plan" means a managed care plan
13-10 that the Commissioner certifies, upon application to the program,
13-11 as meeting the requirements of this section.
13-12 (c) "Utilization review law" means Article 21.58A, Insurance
13-13 Code.
13-14 (d) "Managed care plan" means a plan operated by a managed
13-15 care entity that provides for the financing and delivery of health
13-16 care services to persons enrolled in such plan through:
13-17 (1) arrangements with selected providers to furnish
13-18 health care services;
13-19 (2) explicit standards for the selection of
13-20 participating providers;
13-21 (3) organizational arrangements for ongoing quality
13-22 assurance, utilization review programs, and dispute resolution; and
13-23 (4) financial incentives for persons enrolled in the
13-24 plan to use the participating providers and procedures provided for
13-25 by the plan.
14-1 (e) "Managed care entity" means a licensed insurance
14-2 company, hospital or medical service plan, health maintenance
14-3 organization, an employer or employee organization, or a managed
14-4 care contractor that operated a managed care plan.
14-5 (f) "Managed care contractor" means a person that:
14-6 (1) establishes, operates or maintains a network of
14-7 participating providers;
14-8 (2) conducts or arranges for utilization review
14-9 activities; and
14-10 (3) contracts with an insurance company, a hospital or
14-11 medical service plan, an employer, an employee organization, or any
14-12 other entity providing coverage for health care services to operate
14-13 a managed care plan.
14-14 (g) "Participating provider" means a physician, physician
14-15 assistant, hospital, pharmacy, laboratory, or other appropriately
14-16 state licensed, registered, certified or otherwise state recognized
14-17 provider of health care services or supplies, that has entered into
14-18 an agreement with a managed care entity to provide such services or
14-19 supplies to a patient enrolled in a managed care plan.
14-20 Sec. 32.053. PROTECTION OF CONSUMER CHOICE. Nothing in this
14-21 Act shall be construed as prohibiting the following:
14-22 (1) An individual from purchasing any health care
14-23 services with that individual's own funds, whether such services
14-24 are covered within the individual's standard benefit package or
14-25 from another health care provider or plan.
15-1 (2) Employers from providing coverage for benefits in
15-2 addition to the comprehensive benefit package.
15-3 Sec. 32.054. CERTIFICATION OF MANAGED CARE PLANS.
15-4 (a)(1) All managed care plans offering or providing services
15-5 under Chapter 32 of this Code must be certified under the
15-6 provisions of this Subchapter.
15-7 (2) The Department shall establish a process for
15-8 certification of managed care plans meeting the requirements of
15-9 subsection (b).
15-10 (3) The Department shall establish procedures for the
15-11 periodic review and recertification of qualified managed care
15-12 plans.
15-13 (4) The Department shall terminate the certification
15-14 of a previously qualified managed care plan if the Department
15-15 determines that such plan or program no longer meets the applicable
15-16 requirements for certification. Before effecting a termination,
15-17 the Department shall provide the plan notice and opportunity for a
15-18 hearing on the proposed termination.
15-19 (A) An eligible organization, as defined in
15-20 section 1876(b) of the Social Security Act, shall be deemed to meet
15-21 the requirements of subsection (b) for certification as a qualified
15-22 managed care plan.
15-23 (B) If the Department finds that a national
15-24 accreditation body establishes a requirement or requirements for
15-25 accreditation of a managed care plan that are at least equivalent
16-1 to the requirement(s) established under subsection (b), the
16-2 Department may, to the extent appropriate, treat a managed care
16-3 plan thus accredited as meeting the requirement(s) of subsection
16-4 (b).
16-5 (b)(1) The Department shall establish standards for the
16-6 certification of qualified managed care plans that conduct business
16-7 in this state, including standards whereby:
16-8 (A) Prospective enrollees in a plan must be
16-9 provided information as to the terms and conditions of the plan so
16-10 that they can make informed decisions about accepting a certain
16-11 system of health care delivery. Where the plan is described orally
16-12 to enrollees, easily understood, truthful, and objective terms must
16-13 be used. All written plan descriptions must be in a readable and
16-14 understandable format, consistent with standards developed for
16-15 supplemental insurance coverage under Title XVII of the Social
16-16 Security Act. This format must be standardized so that customers
16-17 can compare the attributes of the plans. Specific items that must
16-18 be included are:
16-19 (i) coverage provisions, benefits, and any
16-20 exclusions by category of service, provider or physician, and if
16-21 applicable, by specific service;
16-22 (ii) any and all prior authorization or
16-23 other review requirements including preauthorization review,
16-24 concurrent review, post-service review, post payment review and any
16-25 procedures that may lead the patient to be denied coverage for or
17-1 not be provided a particular service;
17-2 (iii) financial arrangements or
17-3 contractual provisions with hospitals, review companies,
17-4 physicians, dentists, or any other provider of health care services
17-5 that would limit the services offered, restrict referral or
17-6 treatment options, or negatively affect the physician's or
17-7 dentist's fiduciary responsibility to his or her patients,
17-8 including but not limited to financial incentives not to provide
17-9 medical, dental, or other services;
17-10 (iv) explanation of how plan limitations
17-11 impact enrollees, including information on enrolled financial
17-12 responsibility for payment for coinsurance or other non-covered or
17-13 out-of-plan services;
17-14 (v) explanation of the physician or, as
17-15 appropriate, dentist network configuration that provides for
17-16 patient access to physicians and dentists including geographic
17-17 distribution of physicians and dentists by specialty and the
17-18 physician and, as appropriate, dentist to enrollee ratio by
17-19 specialty;
17-20 (vi) loss ratios; and
17-21 (vii) enrolled satisfaction statistics
17-22 (including percent re-enrollment and reasons for leaving plan).
17-23 (B) The plan must demonstrate that covered
17-24 enrollees have reasonably prompt access through the entity's
17-25 provider network to all items and services contained in the package
18-1 of benefits for which coverage is provided (including access to
18-2 emergency services on a 24-hour basis where medically necessary),
18-3 in a manner that assures the continuity of the provision of such
18-4 items and services. Such access shall take into account the
18-5 diverse needs of enrollees, including special language
18-6 requirements, and proximity to the workplaces or residences of
18-7 enrollees.
18-8 (C) For the purposes of this section, plans must
18-9 accept as providers under its plan all physicians and, as
18-10 appropriate, dentists who are historical Medicaid providers and who
18-11 agree to the terms and conditions of the plan for a minimum period
18-12 of three years from the effective date of this section. For the
18-13 purposes of this subsection, historical Medicaid provider means a
18-14 physician or, as appropriate, dentist who was a Medicaid provider
18-15 for one year or more on the effective date of this section. A plan
18-16 is not required to comply with this subsection if the exclusion of
18-17 a historical Medicaid provider is based on demonstrated quality of
18-18 care grounds and the plan also complies with the requirements of
18-19 subdivision (G)(vii). However, nothing in this subsection is to be
18-20 construed as prohibiting a plan from removing an historical
18-21 Medicaid provider from the plan for failing to comply with the
18-22 terms and conditions of the plan.
18-23 (D) In its establishment of criteria for
18-24 hospital participation, a plan shall be required to accept hospital
18-25 licensure by the Texas Department of Health, certification by the
19-1 Medicare program, (Title XVII of the Social Security Act (42 U.S.C.
19-2 1395, et seq.)) or accreditation by the Joint Commission on
19-3 Accreditation of Healthcare Organizations.
19-4 (E) Plans must meet financial reserve
19-5 requirements that are established to assure proper payment for
19-6 covered services provided. An indemnity fund should be established
19-7 to provide for plan failures even when a plan has met the reserve
19-8 requirements.
19-9 (F) All plans shall be required to establish a
19-10 mechanism, with defined rights, under which physicians and dentists
19-11 participating in the plan provide meaningful input into the plan's
19-12 medical or, as appropriate, dental policy, (including coverage of
19-13 new technology and procedures), utilization review criteria and
19-14 procedures, quality and credentialing criteria, and medical or
19-15 dental management procedures.
19-16 (G) All plans shall be required to credential
19-17 physicians and dentists within the plan, and will allow all
19-18 physicians and dentists within the plan's geographic service area
19-19 to apply for such credentials. At least once per year, plans shall
19-20 notify physicians and dentists of the opportunity to apply for
19-21 credentials.
19-22 (i) Such a credentialing process shall
19-23 begin upon application of a physician or dentist to the plan for
19-24 inclusion.
19-25 (ii) Each application shall be reviewed by
20-1 a credentialing committee with appropriate representation of the
20-2 applicant's medical or, as appropriate, dental specialty.
20-3 (iii) Credentialing shall be based on
20-4 objective standards of quality with input from physicians or, as
20-5 appropriate, dentists credentialed in the plan and such standards
20-6 shall be available to applicants and enrollees. When economic
20-7 considerations are part of the decision, objective criteria must be
20-8 used and must be available to applicants, participating physicians,
20-9 dentists, and enrollees. Any economic profiling of physicians or
20-10 dentists must be adjusted to recognize case mix, disease,
20-11 physiologic and behavioral severity of the disease, including
20-12 comorbidities, age and sex risk adjustment of patients and other
20-13 features of a physician's or dentist's practice that may account
20-14 for higher than or lower than expected costs to assure fair
20-15 comparisons are made. Profiles must be made available to those so
20-16 profiled. When graduate medical education is a consideration in
20-17 credentialing, equal recognition will be given to training programs
20-18 accredited by the Accrediting Council on Graduate Medical Education
20-19 and by the American Osteopathic Association.
20-20 (iv) Plans shall be prohibited from
20-21 discriminating against enrollees with expensive medical conditions
20-22 requiring expensive tests and procedures to adequately diagnose and
20-23 treat enrollees by excluding practitioners who treat such
20-24 enrollees.
20-25 (v) All decisions shall be made on the
21-1 record, and the applicant shall be provided with all reasons used
21-2 if the application is denied or the contract not reviewed.
21-3 (vi) Plans shall not be allowed to include
21-4 clauses in physician, dentist, or other provider contracts that
21-5 allow for the plan to terminate the contract "without cause."
21-6 (vii) There shall be a due process appeal
21-7 from all adverse decisions. The Department shall establish a due
21-8 process appeal mechanism. The appeals process will be presumed to
21-9 be reasonable if it complies with the appeals process set forth in
21-10 the Health Care Quality Improvement Act of 1986, 42 U.S.C.
21-11 Subsection 11101-11151.
21-12 (viii) The same standards and procedures
21-13 used for an application for credentials shall also be used in those
21-14 cases where the plan seeks to reduce or withdraw such credentials.
21-15 Prior to initiation of a proceeding leading to termination of a
21-16 contract "for cause," the physician or, as appropriate, dentist
21-17 shall be provided notice, an opportunity for discussion, and an
21-18 opportunity to enter into and complete a corrective action plan,
21-19 except in cases where there is imminent harm to patient health or
21-20 an action by a state medical or, as appropriate, dental board or
21-21 other government agency that effectively impairs the physician's or
21-22 dentist's ability to practice medicine within the jurisdiction.
21-23 (H) Procedures shall be established to ensure
21-24 that all applicable Federal and State laws designed to protect the
21-25 confidentiality of provider and individual medical and dental
22-1 records are followed.
22-2 (I) Plans must ensure that each enrollee is able
22-3 to choose a primary care physician and, as appropriate, dentist
22-4 from among participating physicians and dentists and change that
22-5 selection as appropriate.
22-6 (J) Plans must:
22-7 (i) cover medically necessary emergency
22-8 care services provided to covered individuals (including trauma
22-9 services, such as those provided by designated trauma centers),
22-10 without regard to whether or not the provider furnishing such
22-11 services has a contractual (or other) arrangement with the entity
22-12 to provide items or services to covered individuals and, in the
22-13 case of services furnished for the treatment of an emergency
22-14 medical condition (as defined in section 1867(e)(1) of the Social
22-15 Security Act), without regard to prior authorizations; and
22-16 (ii) provide that the prior authorization
22-17 requirement for medically necessary services or stabilizing
22-18 treatment in the emergency room shall be deemed to be approved
22-19 unless denied within 2 hours of a required request.
22-20 (2) Plans must ensure that enrollees, in plans where
22-21 prior authorization is a condition to coverage of a service, are
22-22 required to sign medical and dental information release consent
22-23 forms upon enrollment for use where services requiring prior
22-24 authorization are recommended or proposed by their physician or
22-25 dentist;
23-1 (3) When prior approval for a service or other covered
23-2 item is obtained, it shall be considered approval for all purposes,
23-3 and the service shall be considered to be covered unless there was
23-4 fraud or incorrect information provided at the time such prior
23-5 approval was obtained.
23-6 (4) Continuity of patient care is maintained when
23-7 physicians or dentists are deselected or otherwise are no longer
23-8 participating providers under the plan by providing for the
23-9 immediate reimbursement for copies of medical or dental records
23-10 that are created, kept or maintained by a physician or dentist and
23-11 provided by the physician for the patient or someone on his behalf.
23-12 (5) Not withstanding the provision of any other law,
23-13 all qualified managed care programs are subject to and shall meet
23-14 the requirements of the utilization review law.
23-15 (6) Standards shall first be established under this
23-16 subsection by not later than 12 months after the date of the
23-17 enactment of this section.
23-18 (7) The Department shall periodically review the
23-19 standards established under this subsection, and may revise the
23-20 standards from time to time to assure than such standards continue
23-21 to reflect appropriate policies and practices for the
23-22 cost-effective and medically appropriate use of services within
23-23 managed care plans.
23-24 Sec. 32.055. CHOICE OF PLAN. When offered and available in
23-25 the same service area, all eligible enrollees shall have the
24-1 opportunity to select the plan in which they will participate.
24-2 SECTION 8. Article 21.58A, Sections (4) and (14), Insurance
24-3 Code are amended to read as follows:
24-4 Sec. 4. Standards for utilization review. (a) As a
24-5 condition of certification or renewal thereof, a utilization review
24-6 agent shall be required to maintain compliance with the provisions
24-7 of this section.
24-8 (b) The utilization review plan, including reconsideration
24-9 and appeal requirements, shall be reviewed by a physician and
24-10 conducted in accordance with standards developed with input from
24-11 appropriate health care providers and approved by a physician.
24-12 (c)(1) Personnel employed by or under contract with the
24-13 utilization review agent to perform utilization review shall be
24-14 appropriately trained and qualified. Personnel who obtain
24-15 information directly from the physician or health care provider,
24-16 either orally or in writing, and who are not physicians shall be
24-17 nurses, physician assistants, registered records administrators, or
24-18 accredited records technicians, who are either licensed or
24-19 certified, or shall be individuals who have received formal
24-20 orientation and training in accordance with policies and procedures
24-21 established by the utilization review agent to assure compliance
24-22 with this section, and a description of such policies and
24-23 procedures shall be filed with the commissioner. This provision
24-24 shall not be interpreted to require such qualifications for
24-25 personnel who perform clerical or administrative tasks.
25-1 (2) Upon request, physicians or as appropriate,
25-2 dentists, will be provided the names and credentials of all
25-3 individuals conducting utilization review, subject to reasonable
25-4 safeguards and standards.
25-5 (d) A utilization review agent shall not set or impose any
25-6 notice or other review procedures contrary to the requirements of
25-7 the health insurance policy or health benefit plan.
25-8 (e) Unless approved for an individual patient by the
25-9 provider of record or modified by contract, a utilization review
25-10 agent shall be prohibited from observing, participating in, or
25-11 otherwise being present during a patient's examination, treatment,
25-12 procedure, or therapy. In no event shall this section otherwise be
25-13 construed to limit or deny contact with a patient for purposes of
25-14 conducting utilization review unless otherwise specifically
25-15 prohibited by law.
25-16 (f) A utilization review agent may not permit or provide
25-17 compensation or any thing of value to its employees or agents,
25-18 condition employment of its employee or agent evaluations, or set
25-19 its employee or agent performance standards, based on the amount of
25-20 volume of adverse determinations, reductions or limitations on
25-21 lengths of stay, benefits, services, or charges or on the number or
25-22 frequency of telephone calls or other contacts with health care
25-23 providers or patients, which are inconsistent with the provisions
25-24 of this article.
25-25 (g) A health care provider may designate one or more
26-1 individuals as the initial contact or contacts for utilization
26-2 review agents seeking routine information or data. In no event
26-3 shall the designation of such an individual or individuals preclude
26-4 a utilization review agent or medical advisor from contacting a
26-5 health care provider or others in his or her employ where a review
26-6 might otherwise be unreasonably delayed or where the designated
26-7 individual is unable to provide the necessary information or data
26-8 requested by the utilization review agent.
26-9 (h) Utilization review conducted by a utilization review
26-10 agent shall be under the direction of a physician licensed to
26-11 practice medicine by the Texas State Board of Medical Examiners <a
26-12 state licensing agency in the United States>.
26-13 (i) Each utilization review agent shall utilize written
26-14 medically acceptable screening criteria and review procedures which
26-15 are established and periodically evaluated and updated with
26-16 appropriate involvement from physicians, including practicing
26-17 physicians, and other health care providers. Such written
26-18 screening criteria and review procedures shall be available for
26-19 review and inspection by the commissioner and copying as necessary
26-20 for the commissioner to carry out his or her lawful duties under
26-21 this code, provided, however, that any information obtained or
26-22 acquired under the authority of this subsection and article is
26-23 confidential and privileged and not subject to the open records law
26-24 or subpoena except to the extent necessary for the board or
26-25 commissioner to enforce this article.
27-1 (j) A utilization review agent may not engage in unnecessary
27-2 or unreasonable repetitive contacts with the health care provider
27-3 or patient and shall base the frequency of contacts or reviews on
27-4 the severity or complexity of the patient's condition or on
27-5 necessary treatment and discharge planning activity.
27-6 (k) Subject to the notice requirements of Section 5 of this
27-7 article, in any instance where the utilization review agent is
27-8 questioning the medical necessity or appropriateness of health care
27-9 services, the health care provider who ordered the services shall
27-10 be afforded a reasonable opportunity to discuss the plan of
27-11 treatment for the patient and the clinical basis for the
27-12 utilization review agent's decision with a physician or, in the
27-13 case of a dental plan with a dentist, prior to issuance of an
27-14 adverse determination.
27-15 (l) <Unless precluded or modified by contract, a> A
27-16 utilization review agent shall reimburse health care providers for
27-17 the reasonable costs for providing medical information in writing,
27-18 including copying and transmitting any requested patient records or
27-19 other documents. A health care provider's charges for providing
27-20 medical information to a utilization review agent shall not exceed
27-21 the cost of copying set by rule of the Texas Workers' Compensation
27-22 Commission for records and may not include any costs that are
27-23 otherwise recouped as a part of the charge for health care.
27-24 (m) A utilization review agent shall establish and maintain
27-25 a complaint system that provides reasonable procedures for the
28-1 resolution of written complaints initiated by enrollees, patients,
28-2 or health care providers concerning the utilization review and
28-3 shall maintain records of such written complaints for two years
28-4 from the time the complaints are filed. The complaint procedure
28-5 shall include a written response to the complainant by the agent
28-6 within 60 days. The utilization review agent shall submit to the
28-7 commissioner a summary report of all complaints at such times and
28-8 in such forms as the board may require and shall permit the
28-9 commissioner to examine the complaints and all relevant documents
28-10 at any time.
28-11 (n) The utilization review agent may delegate utilization
28-12 review to qualified personnel in the hospital or health care
28-13 facility where the health care services were or are to be provided.
28-14 Sec. 14(a) This article shall not apply to a person who
28-15 provides information to enrollees about scope of coverage or
28-16 benefits provided under a health insurance policy or health benefit
28-17 plan and who does not determine whether particular health care
28-18 services provided or to be provided to an enrollee are medically
28-19 necessary or appropriate.
28-20 (b)(1) This article shall not apply to any contract with the
28-21 federal government for utilization review of patients eligible for
28-22 services under Title XVIII or XIX of the Social Security Act (42
28-23 U.S.C. Section 1395 et seq. or Section 1396 et seq.).
28-24 (b)(2) This article shall not apply to <the Texas Medicaid
28-25 Program,> the chronically ill and disabled children's services
29-1 program created pursuant to Chapter 35, Health and Safety Code,
29-2 <any program administered under Title 2, Human Resources Code> any
29-3 program of the Texas Department of Mental Health and Mental
29-4 Retardation, or any program of the Texas Department of Criminal
29-5 Justice.
29-6 (c) This article shall not apply to utilization review of
29-7 health care services provided to patients under the authority of
29-8 the Texas Workers' Compensation Act (Article 8308-1.01 et seq.,
29-9 Vernon's Texas Civil Statutes).
29-10 <(d) This article shall not apply to utilization review of
29-11 health care services provided under a policy or contract of
29-12 automobile insurance promulgated by the board under Subchapter A,
29-13 Chapter 5 of this code or issued pursuant to Article 1.14-2 of this
29-14 code.>
29-15 (d) <(e)> This article shall not apply to the terms or
29-16 benefits of employee welfare benefit plans as defined in Section
29-17 31(I) of the Employee Retirement Income Security Act of 1974 (29
29-18 U.S.C. Section 1002).
29-19 (e) <(f)> Any regulations promulgated pursuant to this
29-20 article shall relate only to persons or entities subject to this
29-21 article.
29-22 <(g) A health maintenance organization is not subject to
29-23 this article except as expressly provided in this subsection and
29-24 Subsection (i) of this section. If such health maintenance
29-25 organization performs utilization review as defined herein, it
30-1 shall, as a condition of licensure:>
30-2 <(1) comply with Sections 4(b), (c), (e), (f), (h),
30-3 (i), and (l) of this article, and the board shall promulgate rules
30-4 for appropriate verification and enforcement of compliance.
30-5 However, nothing in this article shall be construed to prohibit or
30-6 limit the distribution of a proportion of the savings from the
30-7 reduction or elimination of unnecessary medical services,
30-8 treatment, supplies, confinements, or days of confinement, in a
30-9 health care facility through profit sharing, bonus, or withhold
30-10 arrangements to participating physicians or participating health
30-11 care providers for rendering health care services to enrollees;>
30-12 <(2) establish and maintain a system for:>
30-13 <(A) handling and responding to complaints by
30-14 enrollees, patients, or health care providers;>
30-15 <(B) providing health care providers with notice
30-16 of medical necessity or program requirements that have not been
30-17 met, including a reasonable opportunity to discuss the plan of
30-18 treatment and clinical basis for a utilization review determination
30-19 with a physician; and>
30-20 <(C) providing the enrollee, patient, and health
30-21 care provider an opportunity to appeal the determination; and>
30-22 <(3) submit to assessment of maintenance taxes under
30-23 Article 20A.33, Texas Health Maintenance Organization Act (Article
30-24 20A.33, Vernon's Texas Insurance Code), to cover the costs of
30-25 administering compliance of health maintenance organizations under
31-1 this section.>
31-2 (f) <(h)> An insurer which delivers or issues for delivery a
31-3 health insurance policy in Texas and is subject to this code is not
31-4 subject to this article except as expressly provided in this
31-5 subsection and Subsection (i) of this section. If an insurer
31-6 performs utilization review as defined herein it shall, as a
31-7 condition of licensure, comply with Sections 4 through 8 of this
31-8 article, and the board shall promulgate rules for appropriate
31-9 verification and enforcement of compliance. Such insurers shall be
31-10 subject to assessment of maintenance tax under Article 4.17 of this
31-11 code to cover the costs of administering compliance of insurers
31-12 under this section.
31-13 (g) <(i)> However, when an insurer subject to this code <or
31-14 a health maintenance organization> performs utilization review for
31-15 a person or entity subject to this article other than the one for
31-16 which it is the payor, such insurer <or health maintenance
31-17 organization> shall be required to obtain a certificate under
31-18 Section 3 of this article and comply with all the provisions of
31-19 this article.
31-20 SECTION 9. Title 3, Subtitle A, Chapter 51, Subchapter Z,
31-21 Section 51.918(c), Education Code, is amended to read as follows:
31-22 Sec. 51.918(c) The Center for Rural Health Initiatives shall
31-23 develop relief service programs for rural physicians and allied
31-24 health personnel to facilitate ready access to continuing medical
31-25 education or practice coverage for purposes other than continuing
32-1 medical education.
32-2 SECTION 10. Chapter 262.034, Texas Health & Safety Code, is
32-3 amended to read as follows:
32-4 Facilities and Services for Elderly and Disabled <Nursing
32-5 Homes>
32-6 <(a) This section applies to an authority created by a
32-7 municipality with a population of more than 24,000 that is located
32-8 in a county with a population of 1.5 million or more.>
32-9 (a) <(b)> The authority may construct, acquire, own,
32-10 operate, enlarge, improve, furnish, or equip one or more <nursing
32-11 homes or similar> of the following types of facilities or services
32-12 for the care of the elderly or disabled: long term care, elderly
32-13 housing, assisted living, home health, personal care, special care,
32-14 continuing care and durable medical equipment. <The nursing home
32-15 or similar facility> These facilities and services may be located
32-16 and/or offered outside the municipal limits.
32-17 (b) <(c)> The authority may lease or enter into an
32-18 operations or management agreement relating to all or part of <a
32-19 nursing home or similar> such a facility or service for the care of
32-20 the elderly or disabled that is owned by the authority. The
32-21 authority may close, transfer, sell or otherwise convey all or part
32-22 of these facilities and may discontinue these services <the nursing
32-23 home or similar facility>.
32-24 (c) <(d)> The authority may issue revenue bonds and other
32-25 notes in accordance with this chapter to acquire, construct, or
33-1 improve a <nursing home or similar> facility for the care of the
33-2 elderly or disabled or to implement the delivery of a service for
33-3 the care of the elderly or disabled.
33-4 (d) <(e)> For the purpose of this section, a <nursing home
33-5 or similar> facility or service described in 262.034(a) <for the
33-6 care of the elderly> is considered to be a hospital project under
33-7 Chapter 223 of the Health & Safety Code.
33-8 SECTION 11. Chapter 285, Texas Health & Safety Code, is
33-9 amended by adding Subchapter G to read as follows:
33-10 SUBCHAPTER G. LONG TERM CARE AND RELATED FACILITIES.
33-11 Sec. 1. Any hospital, hospital district or authority created
33-12 and operated under Article IX of the Texas Constitution, special
33-13 law or Title 4 of the Health & Safety Code may:
33-14 (a) Construct, acquire, own, operate, enlarge, improve,
33-15 furnish, or equip one or more of the following types of facilities
33-16 or services for the care of the elderly or disabled: long term
33-17 care, elderly housing, assisted living, home health, personal care,
33-18 special care, continuing care and durable medical equipment;
33-19 (b) Lease or enter into an operations or management
33-20 agreement relating to all or part of a facility or service
33-21 described in Sec. 1(a) that is owned by the hospital district or
33-22 authority;
33-23 (c) Close, transfer, sell or otherwise convey all or part of
33-24 such a facility and may discontinue these services;
33-25 (d) Issue revenue bonds and other notes to acquire,
34-1 construct or improve a facility for the care of the elderly or
34-2 disabled or to implement the delivery of a service for the care of
34-3 the elderly or disabled.
34-4 Sec. 2. For the purpose of this Subchapter, a facility or
34-5 service created pursuant to Section 1(a) shall be considered to be
34-6 a hospital project under Chapter 223 of the Health & Safety Code.
34-7 SECTION 12. Section 501.059, Government Code, is amended to
34-8 read as follows:
34-9 Sec. 501.059. Managed Health Care Advisory Committee.
34-10 (a) The Managed Health Care Advisory Committee to the Texas
34-11 Department of Criminal Justice is established.
34-12 (b) The committee consists of:
34-13 (1) two members employed full-time by the department,
34-14 at least one of whom is a physician, appointed by the executive
34-15 director;
34-16 (2) two members employed full-time by The University
34-17 of Texas Medical Branch at Galveston, at least one of whom is a
34-18 physician, appointed by the president of the medical branch; and
34-19 (3) two members employed full-time by the Texas Tech
34-20 University Health Sciences Center, at least one of whom is a
34-21 physician, appointed by the president of the university.
34-22 (c) A committee member serves at the pleasure of the
34-23 appointing official or until termination of the member's employment
34-24 with the entity the member represents.
34-25 (d) An appointment to the committee shall be made without
35-1 regard to the race, creed, sex, religion, or national origin of the
35-2 appointee.
35-3 (e) A committee member serves without compensation but is
35-4 entitled to reimbursement of actual and necessary expenses incurred
35-5 in the performance of the duties of the committee.
35-6 (f) The committee may hire a managed health care
35-7 administrator and may employ personnel necessary for the
35-8 administration of the committee's duties.
35-9 (g) The committee shall develop a managed health care plan
35-10 for all inmates at the institutional division that includes:
35-11 (1) the establishment of a managed care network of
35-12 physicians and hospitals that will serve the institutional division
35-13 as the exclusive health care provider for inmates at each facility
35-14 of the institutional division;
35-15 (2) cost containment studies; <and>
35-16 (3) care case management and utilization management
35-17 studies performed exclusively for the institutional division; and
35-18 (4) as to the establishment of criteria for hospital
35-19 participation, a provision requiring the manage care plan to accept
35-20 hospital licensure by the Texas Department of Health, certification
35-21 by the Medicare program (Title XVII of the Social Security Act (42
35-22 U.S.C. 1395 et seq.)), or accreditation by the Joint Commission on
35-23 Accreditation of Healthcare Organizations.
35-24 <(h) To the extent possible the committee shall integrate
35-25 the managed care network with the public medical schools of this
36-1 state and the component hospitals of those medical schools.>
36-2 (h) <(i)> For those services for which the public medical
36-3 schools and their components cannot provide, the committee shall
36-4 initiate a competitive bidding process for contracts with other
36-5 providers for medical care to inmates confined in the institutional
36-6 division.
36-7 (i) <(j)> The committee may enter into a contract on behalf
36-8 of the department to fully implement the managed health care plan
36-9 under Subsection (g).
36-10 (j) <(k)> The department shall pay necessary costs for the
36-11 operation of the committee, including costs of personnel, from
36-12 funds appropriated by the legislature to the department.
36-13 (k) <(l)> The managed health care plan, inclusive of the
36-14 health care administrator and necessary personnel proposed by the
36-15 committee, must cost the state less than what is presently
36-16 provided, otherwise, the status quo shall be maintained.
36-17 SECTION 13. EMERGENCY. The importance of this legislation
36-18 and the crowded condition of the calendars in both houses create an
36-19 emergency and an imperative public necessity that the
36-20 constitutional rule requiring bills to be read on three several
36-21 days in each house be suspended, and this rule is hereby suspended,
36-22 and that this Act take effect and be in force according to its
36-23 terms, and it is so enacted.