1-1 By: Armbrister S.B. No. 1618
1-2 (In the Senate - Filed March 23, 1995; March 27, 1995, read
1-3 first time and referred to Committee on Economic Development;
1-4 April 28, 1995, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 8, Nays 0; April 28, 1995,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1618 By: Shapiro
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to the certification of providers by health maintenance
1-11 organizations.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Subsection (a), Section 6, Texas Health
1-14 Maintenance Organization Act (Article 20A.06, Vernon's Texas
1-15 Insurance Code), is amended to read as follows:
1-16 (a) The powers of a health maintenance organization include,
1-17 but are not limited to, the following:
1-18 (1) the purchase, lease, construction, renovation,
1-19 operation, or maintenance of hospitals, medical facilities, or
1-20 both, and ancillary equipment and such property as may reasonably
1-21 be required for its principal office or for such other purposes as
1-22 may be necessary in the transaction of the business of the health
1-23 maintenance organization;
1-24 (2) the making of loans to a medical group, under an
1-25 independent contract with it in furtherance of its program, or
1-26 corporations under its control, for the purpose of acquiring or
1-27 constructing medical facilities and hospitals, or in the
1-28 furtherance of a program providing health care services to
1-29 enrollees;
1-30 (3) the furnishing of or arranging for medical care
1-31 services only through physicians or groups of physicians who have
1-32 independent contracts with the health maintenance organizations;
1-33 the furnishing of or arranging for the delivery of health care
1-34 services only through providers or groups of providers who are
1-35 under contract with or employed by the health maintenance
1-36 organization or through physicians or providers who have contracted
1-37 for health care services with those physicians or providers, except
1-38 for the furnishing of or authorization for emergency services,
1-39 services by referral, and services to be provided outside of the
1-40 service area as approved by the commissioner; provided, however,
1-41 that a health maintenance organization is not authorized to employ
1-42 or contract with physicians or providers in any manner which is
1-43 prohibited by any licensing law of this state under which such
1-44 physicians or providers are licensed; however, if a hospital,
1-45 facility, agency, or supplier is certified by the Medicare program
1-46 under Title XVIII, Social Security Act, as amended (42 U.S.C.
1-47 Section 1395 et seq.), or accredited by the Joint Commission on
1-48 Accreditation of Healthcare Organizations or another national
1-49 accrediting body, the health maintenance organization shall be
1-50 required to accept such certification or accreditation;
1-51 (4) the contracting with any person for the
1-52 performance on its behalf of certain functions such as marketing,
1-53 enrollment, and administration;
1-54 (5) the contracting with an insurance company licensed
1-55 in this state, or with a group hospital service corporation
1-56 authorized to do business in the state, for the provision of
1-57 insurance, reinsurance, indemnity, or reimbursement against the
1-58 cost of health care and medical care services provided by the
1-59 health maintenance organization;
1-60 (6) the offering of:
1-61 (A) indemnity benefits covering out-of-area
1-62 emergency services; and
1-63 (B) indemnity benefits in addition to those
1-64 relating to out-of-area and emergency services, provided through
1-65 insurers or group hospital service corporations;
1-66 (7) receiving and accepting from government or private
1-67 agencies payments covering all or part of the cost of the services
1-68 provided or arranged for by the organization;
2-1 (8) all powers given to corporations (including
2-2 professional corporations and associations), partnerships, and
2-3 associations pursuant to their organizational documents which are
2-4 not in conflict with provisions of this Act, or other applicable
2-5 law.
2-6 SECTION 2. Subsection (g), Section 14, Texas Health
2-7 Maintenance Organization Act (Article 20A.14, Vernon's Texas
2-8 Insurance Code), is amended to read as follows:
2-9 (g) No type of provider licensed or otherwise authorized to
2-10 practice in this state may be denied participation to provide
2-11 health care services which are delivered by the health maintenance
2-12 organization and which are within the scope of licensure or
2-13 authorization of the type of provider on the sole basis of type of
2-14 license or authorization. However, if a hospital, facility,
2-15 agency, or supplier is certified by the Medicare program under
2-16 Title XVIII, Social Security Act, as amended (42 U.S.C. Section
2-17 1395 et seq.), or accredited by the Joint Commission on
2-18 Accreditation of Healthcare Organizations or another national
2-19 accrediting body, the health maintenance organization shall be
2-20 required to accept such certification or accreditation. This
2-21 section may not be construed to (1) require a health maintenance
2-22 organization to utilize a particular type of provider in its
2-23 operation; (2) require that a health maintenance organization
2-24 accept each provider of a category or type; or (3) require that
2-25 health maintenance organizations contract directly with such
2-26 providers. Notwithstanding any other provision nothing herein
2-27 shall be construed to limit the health maintenance organization's
2-28 authority to set the terms and conditions under which health care
2-29 services will be rendered by providers. All providers must comply
2-30 with the terms and conditions established by the health maintenance
2-31 organization for the provision of health services and for
2-32 designation as a provider.
2-33 SECTION 3. Section 32.027, Human Resources Code, is amended
2-34 by adding Subsection (i) to read as follows:
2-35 (i) In its establishment of provider criteria for hospitals,
2-36 home health providers, or hospice providers, the department shall
2-37 accept licensure by the Texas Department of Health or certification
2-38 by the Medicare program under Title XVIII, Social Security Act, as
2-39 amended (42 U.S.C. Section 1395 et seq.).
2-40 SECTION 4. Subsection (g), Section 501.059, Government Code,
2-41 as added by Chapter 238, Acts of the 73rd Legislature, 1993, is
2-42 amended to read as follows:
2-43 (g) The committee shall develop a managed health care plan
2-44 for all inmates at the institutional division that includes:
2-45 (1) the establishment of a managed care network of
2-46 physicians and hospitals that will serve the institutional division
2-47 as the exclusive health care provider for inmates at each facility
2-48 of the institutional division;
2-49 (2) cost containment studies; <and>
2-50 (3) care case management and utilization management
2-51 studies performed exclusively for the institutional division; and
2-52 (4) as to the establishment of criteria for hospitals,
2-53 home health providers, or hospice providers, acceptance of
2-54 licensure by the Texas Department of Health or certification by the
2-55 Medicare program under Title XVIII, Social Security Act, as amended
2-56 (42 U.S.C. Section 1395 et seq.).
2-57 SECTION 5. The importance of this legislation and the
2-58 crowded condition of the calendars in both houses create an
2-59 emergency and an imperative public necessity that the
2-60 constitutional rule requiring bills to be read on three several
2-61 days in each house be suspended, and this rule is hereby suspended,
2-62 and that this Act take effect and be in force from and after its
2-63 passage, and it is so enacted.
2-64 * * * * *