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.