By: Armbrister S.B. No. 1618
A BILL TO BE ENTITLED
AN ACT
1-1 relating to the certification of providers by health maintenance
1-2 organizations.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subsection (a), Section 6, Texas Health
1-5 Maintenance Organization Act (Article 20A.06, Vernon's Texas
1-6 Insurance Code), is amended to read as follows:
1-7 (a) The powers of a health maintenance organization include,
1-8 but are not limited to, the following:
1-9 (1) the purchase, lease, construction, renovation,
1-10 operation, or maintenance of hospitals, medical facilities, or
1-11 both, and ancillary equipment and such property as may reasonably
1-12 be required for its principal office or for such other purposes as
1-13 may be necessary in the transaction of the business of the health
1-14 maintenance organization;
1-15 (2) the making of loans to a medical group, under an
1-16 independent contract with it in furtherance of its program, or
1-17 corporations under its control, for the purpose of acquiring or
1-18 constructing medical facilities and hospitals, or in the
1-19 furtherance of a program providing health care services to
1-20 enrollees;
1-21 (3) the furnishing of or arranging for medical care
1-22 services only through physicians or groups of physicians who have
1-23 independent contracts with the health maintenance organizations;
2-1 the furnishing of or arranging for the delivery of health care
2-2 services only through providers or groups of providers who are
2-3 under contract with or employed by the health maintenance
2-4 organization or through physicians or providers who have contracted
2-5 for health care services with those physicians or providers, except
2-6 for the furnishing of or authorization for emergency services,
2-7 services by referral, and services to be provided outside of the
2-8 service area as approved by the commissioner; provided, however,
2-9 that a health maintenance organization is not authorized to employ
2-10 or contract with physicians or providers in any manner which is
2-11 prohibited by any licensing law of this state under which such
2-12 physicians or providers are licensed; however, if a hospital,
2-13 facility, agency, or supplier is certified by the Medicare program
2-14 under Title XVIII, Social Security Act, as amended (42 U.S.C.
2-15 Section 1395 et seq.), or accredited by the Joint Commission on
2-16 Accreditation of Healthcare Organizations or another national
2-17 accrediting body, the health maintenance organization shall be
2-18 required to accept such certification or accreditation;
2-19 (4) the contracting with any person for the
2-20 performance on its behalf of certain functions such as marketing,
2-21 enrollment, and administration;
2-22 (5) the contracting with an insurance company licensed
2-23 in this state, or with a group hospital service corporation
2-24 authorized to do business in the state, for the provision of
2-25 insurance, reinsurance, indemnity, or reimbursement against the
3-1 cost of health care and medical care services provided by the
3-2 health maintenance organization;
3-3 (6) the offering of:
3-4 (A) indemnity benefits covering out-of-area
3-5 emergency services; and
3-6 (B) indemnity benefits in addition to those
3-7 relating to out-of-area and emergency services, provided through
3-8 insurers or group hospital service corporations;
3-9 (7) receiving and accepting from government or private
3-10 agencies payments covering all or part of the cost of the services
3-11 provided or arranged for by the organization;
3-12 (8) all powers given to corporations (including
3-13 professional corporations and associations), partnerships, and
3-14 associations pursuant to their organizational documents which are
3-15 not in conflict with provisions of this Act, or other applicable
3-16 law.
3-17 SECTION 2. Subsection (g), Section 14, Texas Health
3-18 Maintenance Organization Act (Article 20A.14, Vernon's Texas
3-19 Insurance Code), is amended to read as follows:
3-20 (g) No type of provider licensed or otherwise authorized to
3-21 practice in this state may be denied participation to provide
3-22 health care services which are delivered by the health maintenance
3-23 organization and which are within the scope of licensure or
3-24 authorization of the type of provider on the sole basis of type of
3-25 license or authorization. However, if a hospital, facility,
4-1 agency, or supplier is certified by the Medicare program under
4-2 Title XVIII, Social Security Act, as amended (42 U.S.C. Section
4-3 1395 et seq.), or accredited by the Joint Commission on
4-4 Accreditation of Healthcare Organizations or another national
4-5 accrediting body, the health maintenance organization shall be
4-6 required to accept such certification or accreditation. This
4-7 section may not be construed to (1) require a health maintenance
4-8 organization to utilize a particular type of provider in its
4-9 operation; (2) require that a health maintenance organization
4-10 accept each provider of a category or type; or (3) require that
4-11 health maintenance organizations contract directly with such
4-12 providers. Notwithstanding any other provision nothing herein
4-13 shall be construed to limit the health maintenance organization's
4-14 authority to set the terms and conditions under which health care
4-15 services will be rendered by providers. All providers must comply
4-16 with the terms and conditions established by the health maintenance
4-17 organization for the provision of health services and for
4-18 designation as a provider.
4-19 SECTION 3. Section 32.027, Human Resources Code, is amended
4-20 by adding Subsection (i) to read as follows:
4-21 (i) In its establishment of provider criteria for hospitals,
4-22 home health providers, or hospice providers, the department shall
4-23 accept licensure by the Texas Department of Health or certification
4-24 by the Medicare program under Title XVIII, Social Security Act, as
4-25 amended (42 U.S.C. Section 1395 et seq.).
5-1 SECTION 4. Subsection (g), Section 501.059, Government Code,
5-2 as added by Chapter 238, Acts of the 73rd Legislature, 1993, is
5-3 amended to read as follows:
5-4 (g) The committee shall develop a managed health care plan
5-5 for all inmates at the institutional division that includes:
5-6 (1) the establishment of a managed care network of
5-7 physicians and hospitals that will serve the institutional division
5-8 as the exclusive health care provider for inmates at each facility
5-9 of the institutional division;
5-10 (2) cost containment studies; <and>
5-11 (3) care case management and utilization management
5-12 studies performed exclusively for the institutional division; and
5-13 (4) as to the establishment of criteria for hospitals,
5-14 home health providers, or hospice providers, acceptance of
5-15 licensure by the Texas Department of Health or certification by the
5-16 Medicare program under Title XVIII, Social Security Act, as amended
5-17 (42 U.S.C. Section 1395 et seq.).
5-18 SECTION 5. The importance of this legislation and the
5-19 crowded condition of the calendars in both houses create an
5-20 emergency and an imperative public necessity that the
5-21 constitutional rule requiring bills to be read on three several
5-22 days in each house be suspended, and this rule is hereby suspended,
5-23 and that this Act take effect and be in force from and after its
5-24 passage, and it is so enacted.