By Madla S.B. No. 818
74R4607 DLF-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to managed care plans.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-5 amended by adding Article 21.52F to read as follows:
1-6 Art. 21.52F. MANAGED CARE PLANS
1-7 Sec. 1. DEFINITIONS. In this article:
1-8 (1) "Managed care plan" means any health maintenance
1-9 organization, a preferred provider organization, or another
1-10 organization that, under a contract or other agreement entered into
1-11 with a participant in the plan:
1-12 (A) provides health care benefits, or arranges
1-13 for health care benefits to be provided, to a participant in the
1-14 plan; and
1-15 (B) requires or encourages those participants to
1-16 use practitioners designated by the plan.
1-17 (2) "Practitioner" means a pharmacist, dentist,
1-18 optometrist, psychologist, advanced nurse practitioner, podiatrist,
1-19 or chiropractor licensed to practice in this state.
1-20 Sec. 2. DUTIES OF MANAGED CARE PLAN. A managed care plan
1-21 shall:
1-22 (1) demonstrate to the department that the plan has
1-23 access to a number of practitioners that is adequate to ensure
1-24 that:
2-1 (A) all health care services covered by the plan
2-2 are provided in a timely manner; and
2-3 (B) a participant has access to the type of
2-4 practitioner the participant chooses;
2-5 (2) establish a mechanism for each practitioner who
2-6 has contracted to provide health care services under the plan to
2-7 comment and provide information relating to:
2-8 (A) the payment of benefits for new medical
2-9 technology and procedures;
2-10 (B) utilization review criteria and procedures;
2-11 (C) quality of care and credentialing criteria;
2-12 and
2-13 (D) medical management procedures; and
2-14 (3) provide prospective participants with information
2-15 on the terms and conditions of the plan sufficient to enable them
2-16 to make informed decisions about accepting the managed care system
2-17 of health care delivery.
2-18 Sec. 3. PROVIDER CONTRACTS. (a) Any qualified practitioner
2-19 who agrees to comply with reasonable contractual terms and
2-20 conditions of participation may participate as a contracting
2-21 provider for a managed care plan. The managed care plan may not
2-22 limit the number of participating practitioners.
2-23 (b) This section does not apply to a managed care plan that
2-24 provides all medical services to participants through health care
2-25 providers who are:
2-26 (1) employed by the managed care plan; or
2-27 (2) contractually prohibited from treating individuals
3-1 who are not participants in the plan.
3-2 Sec. 4. TERMINATION OF PROVIDER CONTRACTS. (a) Before
3-3 terminating a provider contract with a practitioner, the managed
3-4 care plan shall provide the practitioner with notice, an
3-5 opportunity for discussion, and an opportunity to enter into and
3-6 complete a corrective action program to cure any deficiency.
3-7 (b) This section does not apply to termination of a provider
3-8 contract in a case in which there is a risk of imminent harm to
3-9 patient health or in which the practitioner's license has been
3-10 suspended, revoked, or limited by a state regulatory agency.
3-11 Sec. 5. PRIOR AUTHORIZATION. A managed care plan shall
3-12 respond to practitioner requests for prior authorization not later
3-13 than the 24th hour after the time the request was made and shall
3-14 provide qualified personnel for same-day telephone responses to
3-15 inquiries about medical necessity, including certification of
3-16 continued length of stay. This section does not authorize a
3-17 managed care plan to require prior authorization for emergency
3-18 care.
3-19 Sec. 6. SCOPE OF PRACTICE. (a) A managed care plan may not
3-20 restrict a practitioner's scope of practice under the
3-21 practitioner's professional license and may not require
3-22 credentials in addition to state licensure.
3-23 (b) This section does not affect a hospital's right to
3-24 credential practitioners as otherwise permitted by law.
3-25 Sec. 7. APPLICATION; FEES. This article does not prohibit a
3-26 managed care plan from requiring a practitioner to pay a reasonable
3-27 application or other administrative fee applicable to all
4-1 contracting providers.
4-2 SECTION 2. This Act takes effect September 1, 1995, and
4-3 applies only to a contract between a practitioner and a managed
4-4 care plan entered into on or after that date. A contract entered
4-5 into before the effective date of this Act is governed by the law
4-6 as it existed immediately before that date, and that law is
4-7 continued in effect for this purpose.
4-8 SECTION 3. The importance of this legislation and the
4-9 crowded condition of the calendars in both houses create an
4-10 emergency and an imperative public necessity that the
4-11 constitutional rule requiring bills to be read on three several
4-12 days in each house be suspended, and this rule is hereby suspended.