Amend CSSB 385 as follows:
(1) After SECTION 26 of the bill (page 77, between lines 23
and 24, House Committee Report Printing), insert a new SECTION 27
to read as follows:
SECTION 27. The Insurance Code is amended by adding Chapter
20B to read as follows:
CHAPTER 20B. INTEGRATED HEALTH PLANS
SUBCHAPTER A. GENERAL PROVISIONS
Art. 20B.001. DEFINITIONS. In this chapter:
(1) "Basic health services" has the meaning assigned
by Section 2, Health Maintenance Organization Act of 1973, as
amended (42 U.S.C. Section 300e-1).
(2) "Group medical practice" means a group that:
(A) is composed of physicians and other
providers who are salaried employees or affiliates of the group
medical practice;
(B) has a physician as its chief executive
officer;
(C) voluntarily supports medical education and
research through a formal affiliation with the medical school
component of an institution of higher education in this state; and
(D) provides a majority of the professional
medical services rendered to a plan's members.
(3) "Health maintenance organization" means a health
maintenance organization organized under the Texas Health
Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
Code).
(4) "Integrated health plan" means a nonprofit health
maintenance organization that holds a certificate of authority
under this chapter.
(5) "Life-threatening disease or condition" means a
disease or condition:
(A) in which the likelihood of death within one
year or less is high unless the course of the disease or condition
is interrupted; or
(B) that has a potentially fatal outcome within
one year or less and in which the goal of clinical intervention is
survival.
(6) "Member" means an eligible person who is enrolled
for coverage in a plan.
(7) "Plan" means:
(A) an integrated health plan; or
(B) a nonprofit health maintenance organization
that has submitted a certificate of authority application under
Article 20B.011 of this code.
(8) "Provider" means:
(A) a physician; or
(B) another licensed health care practitioner
who provides health care services under the scope of the
practitioner's license.
(9) "Subscriber" means an individual who is properly
enrolled for coverage under a plan because the individual is:
(A) an eligible employee of an eligible
employer; or
(B) another person whose employment or other
status, other than dependent status, is the basis for eligibility
for coverage under the plan.
Art. 20B.002. RULES. The commissioner shall adopt rules as
necessary to implement this chapter.
Art. 20B.003. EFFECT OF CERTIFICATION. A health maintenance
organization that is certified as an integrated health plan is
subject to regulation only as provided by this chapter.
Articles 20B.004-20B.010 reserved for expansion
SUBCHAPTER B. CERTIFICATION REQUIREMENTS
Art. 20B.011. CERTIFICATION BY COMMISSIONER. On submission
of an application to the department, the commissioner shall issue a
certificate of authority as an integrated health plan to an
eligible nonprofit health maintenance organization that:
(1) meets the requirements described under Subchapters
C, D, E, F, and G of this chapter; and
(2) is accredited by:
(A) the National Committee on Quality Assurance;
or
(B) a similar nationally recognized review
organization acceptable to the commissioner.
Art. 20B.012. ELIGIBILITY. The commissioner may not issue a
certificate of authority under this chapter to a single service or
limited service health maintenance organization.
Art. 20B.013. REVOCATION OF CERTIFICATE. (a) After notice
to an integrated health plan and an opportunity for a hearing, the
commissioner may revoke that plan's certificate issued under this
chapter for a material violation of this chapter.
(b) The commissioner shall notify the integrated health plan
in writing not later than the 30th day before the effective date of
the proposed revocation. The notice must specify in detail the
reasons for the proposed revocation.
(c) The integrated health plan has 30 days after the date on
which the notice is sent to:
(1) correct the problems listed in the notice; or
(2) show to the satisfaction of the commissioner that
the information in the notice is incorrect.
(d) An integrated health plan that receives a notice under
this article may dispute the assertions in the notice and request a
hearing under Chapter 2001, Government Code, to resolve the
dispute.
Art. 20B.014. COMPLIANCE WITH STANDARDS OR RATIOS.
Notwithstanding any other provision of this chapter, the
commissioner may not issue a certificate of authority to, and may
revoke the certificate of authority of, an integrated health plan
that fails to meet or maintain complaint standards or ratios,
quality of care standards or ratios, or financial stability or
viability standards or ratios considered appropriate by the
commissioner.
Articles 20B.015-20B.020 reserved for expansion
SUBCHAPTER C. ADMINISTRATION AND ORGANIZATION OF PLAN
Art. 20B.021. NONPROFIT ENTITY. Each plan must be organized
as a nonprofit entity.
Art. 20B.022. BOARD OF DIRECTORS. Each plan must have a
board of directors that includes:
(1) members; and
(2) physicians, or a combination of physicians and
other types of providers, who provide health care services to
members.
Art. 20B.023. GROUP MEDICAL PRACTICE. (a) Each plan shall
provide the majority of its professional medical services through a
single group medical practice.
(b) The plan shall:
(1) appoint as chief executive officer of the plan a
physician who is a member of the group medical practice; or
(2) adopt procedures that ensure that medical
management policies are a cooperative endeavor between the group
medical practice and the plan.
(c) The procedures adopted under Subsection (b) of this
article must establish methods by which the health care interests
of plan members and the medical interests of the physicians of the
group medical practice are represented at the policy and
decision-making levels of the plan.
(d) Physicians from the group medical practice, other
qualified providers, or other licensed medical personnel under the
direct supervision of physicians from the group medical practice,
shall make each determination regarding:
(1) medical utilization management;
(2) medical quality assurance;
(3) medical issues relating to coverage;
(4) medical necessity or appropriateness of treatment;
and
(5) medical issues relating to pre-authorization and
post-authorization of treatment.
Art. 20B.024. RIGHTS OF PROVIDERS. (a) A plan may not
prohibit a physician or other provider from discussing treatment
options or restrict the provider's discussion of treatment options
based on whether the plan covers the treatment or the cost of the
treatment. This subsection does not require the plan to provide
services or to cover treatments not otherwise included in its
applicable benefit plan.
(b) The plan or group medical practice, as appropriate,
shall:
(1) make available and disclose to each provider who
applies for participation in the plan its written application
procedures and qualification requirements for contracting with the
plan; and
(2) provide a written notice of the reasons an initial
application by a provider may be denied, which may include
rejection of an initial application on the basis that the plan has
a sufficient number of qualified providers of that type.
Art. 20B.025. CREDENTIALING PROGRAM; REQUIREMENTS. (a) A
plan shall use physicians and other providers whose credentials are
verified through a program that meets the requirements of this
article.
(b) The plan shall implement its credentialing program
through written policies and procedures establishing the
credentialing process, including methods for original
credentialing, recredentialing, recertification, and reappointment
of physicians and providers who fall within the scope of services
provided by the plan.
(c) The credentialing program shall obtain and review
evidence of the following from primary sources:
(1) a license to practice from the appropriate
licensing authority;
(2) a valid Drug Enforcement Administration
registration under 21 U.S.C. Section 823 or a controlled
substances registration under Subchapter C, Chapter 481, Health and
Safety Code, as applicable;
(3) graduation from an accredited medical school and
completion of a residency, or board certification, as applicable;
(4) work history;
(5) adequate professional liability insurance in
accordance with the requirements adopted by the plan;
(6) history of professional liability claims; and
(7) sufficient information to enable the plan to
request information on the applicant from the National Practitioner
Data Bank and from the appropriate professional licensing agency
for this state.
(d) The credentialing program shall also establish methods
by which a periodic review is conducted to verify the credentials
of a provider and to evaluate:
(1) members' complaints and comments;
(2) the plan's quality reviews;
(3) utilization management; and
(4) the results of member satisfaction surveys.
Art. 20B.026. PROVIDER INCENTIVE ARRANGEMENTS. (a) A plan
may not provide incentives or rewards to its providers for denying
or limiting necessary care to members.
(b) A plan's payment arrangements for physicians and other
providers may not place an individual provider at such a
substantial personal financial risk that it induces the provider to
either inappropriately restrict medically necessary care or provide
care beyond that which is conservatively needed by the patient.
Physicians and other providers shall have the freedom to make
clinical treatment decisions without substantial personal financial
risk or reward.
Art. 20B.027. REVENUE TO BE SPENT ON SERVICES TO MEMBERS.
(a) Each plan shall spend, on average over a three-year period, at
least 85 percent of the revenue received from its members on the
provision of services to its members.
(b) The commissioner shall consider a plan to have met the
requirement of Subsection (a) of this article if compliance by the
plan with the requirement may be inferred by periodic reports made
by the plan to the National Association of Insurance Commissioners.
Art. 20B.028. MARKETING REQUIREMENTS. (a) In offering its
benefit plan to employers, each plan shall provide adequate written
descriptions of its rules, procedures, benefits, fees and other
charges, and services.
(b) The plan shall publicize through appropriate methods its
enrollment periods and shall specify whether an enrollment period
is limited or of continuous duration.
(c) On request by a member, the plan shall provide to the
member a written copy of the most current statement of member rules
and rights. The information must include:
(1) a description of the benefits provided;
(2) how and where to obtain services;
(3) restrictions on coverage, if any;
(4) a description of the plan's grievance resolution
and appeals procedures;
(5) rights of a member regarding termination of
enrollment;
(6) findings from patient satisfaction surveys and
quality reviews conducted by external organizations; and
(7) a statement of the obligation of the plan to
assume financial responsibility and provide reasonable
reimbursement for medically necessary emergency services and
urgently needed services.
(d) The plan may not discriminate in its marketing by:
(1) discouraging participation on the basis of age or
race; or
(2) attempting to enroll persons from a high-income
area if a comparable effort is not made to enroll persons from
lower-income areas.
(e) The plan may not market its benefit plan in a manner
that would mislead, confuse, or misrepresent.
(f) The plan may not offer gifts or payment as an inducement
to enroll in the plan, except for marketing materials, meals,
souvenirs, and other items of nominal value.
Articles 20B.029-20B.040 reserved for expansion
SUBCHAPTER D. QUALITY IMPROVEMENT
Art. 20B.041. QUALITY IMPROVEMENT PROGRAM. (a) Each plan
shall adopt an ongoing quality improvement program designed to
monitor and evaluate the quality and appropriateness of care and
service provided to members and to pursue opportunities for
improvement. The scope and content of the program shall reflect
the delivery system of the plan and shall include both the quality
of clinical care and the quality of service. The program shall
have a written quality improvement statement that contains, at a
minimum:
(1) a methodology that stresses health outcomes;
(2) peer review by physicians and other providers;
(3) systematic data collection on performance and
patient results; and
(4) procedures for taking appropriate remedial action.
(b) The quality improvement program shall identify important
areas for improvement. The monitoring and evaluation of important
aspects of care and service by the program shall include
high-volume, high-risk services and the care of acute and chronic
conditions. Through the program, the plan shall:
(1) adopt practice guidelines or explicit criteria
that are based on reasonable scientific evidence and reviewed by
plan providers;
(2) evaluate the continuity and coordination of care
that members receive; and
(3) establish mechanisms to detect underuse as well as
overuse.
Art. 20B.042. ORGANIZATIONAL DESCRIPTION. Each plan shall
specify within the quality improvement program its organizational
arrangements and responsibilities for quality improvement
processes, which must be clearly defined and assigned to
appropriate individuals. The plan shall maintain a written
description of the program that outlines the program structure and
design. The plan shall review the program description annually and
update the description as necessary.
Art. 20B.043. PROGRAM IMPLEMENTATION. (a) A designated
senior executive of the plan shall be responsible for
implementation of the program. The plan's medical director shall
have substantial involvement in quality improvement activities.
(b) If the plan delegates any quality improvement activities
to independent contractors, the quality improvement program must
require oversight of the delegated activities by the plan. The
required oversight must include periodic reporting by the
contractor, accountability for the delegated activities, and
establishment of a process by which the delegation is evaluated.
Art 20B.044. QUALITY IMPROVEMENT COMMITTEE. (a) Each plan
shall appoint a committee to oversee and support quality
improvement activities. The contracting providers shall
participate actively in the quality improvement committee.
(b) The committee shall maintain records reflecting the
actions of the committee. The committee shall adopt an annual
quality improvement work plan or schedule of activities that
includes:
(1) the objectives, scope, and planned projects or
activities for the year;
(2) planned monitoring of previously identified
issues, including tracking of those issues over time; and
(3) planned evaluation of the quality improvement
program.
(c) The committee shall be accountable to the governing body
of the plan or a committee of plan senior managers. The committee
shall demonstrate evidence of a formally designated structure,
accountability at the highest levels of the organization, and
ongoing and continuous oversight of quality improvement.
Art. 20B.045. REPORTS; COORDINATION OF ACTIVITIES. (a) The
quality improvement program shall document and report to
appropriate individuals within the plan organization the findings,
conclusions, recommendations, actions taken, and results of the
actions taken as a result of quality improvement activity. The
reports shall be made through the quality improvement program in
accordance with the plan organizational structure.
(b) The program shall coordinate quality improvement
activities with other performance-monitoring activities.
Art. 20B.046. DATA ANALYSIS. (a) The quality improvement
program shall analyze measurements of quality and quality
improvement data to evaluate quality improvement. The program
shall use quality indicators that are objective, measurable, and
based on current knowledge and clinical experience to monitor and
evaluate each important aspect of care and service identified by
the program.
(b) The program shall analyze all data collected through the
monitoring and evaluation activities.
Art. 20B.047. EVALUATION. (a) Each quality improvement
program shall ensure that the plan takes action as necessary to
improve quality and shall assess the effectiveness of that action
through systematic evaluations.
(b) The results of evaluations conducted under this article
shall be used by the plan to improve clinical care and service.
Art. 20B.048. ANNUAL ASSESSMENT BY PLAN; REPORT. Each plan
shall annually assess the overall effectiveness of its quality
improvement program and shall issue an annual written report on
quality improvement, including:
(1) completed quality improvement activities;
(2) trends in clinical and service indicators and
other performance data; and
(3) demonstrated improvements in quality.
Articles 20B.049-20B.060 reserved for expansion
SUBCHAPTER E. DELIVERY OF HEALTH CARE SERVICES TO MEMBERS
Art. 20B.061. SERVICE DELIVERY SYSTEM. (a) Each plan shall
provide or arrange for the provision of basic health services to
its members.
(b) The services provided by a plan shall be reasonably
accessible to its members with respect to geographic location,
hours of operation, and provision of after-hours services. This
subsection does not preclude the plan from providing or arranging
for the provision of member care within or outside the service area
of the plan for care that requires a higher level of skill or
specialty care than that which is available within the service
area.
(c) The plan shall cover emergency services at all times in
accordance with Article 20B.065 of this code.
(d) Each plan shall maintain appropriate systems as
necessary to monitor:
(1) member waiting time to get appointments with
participating providers;
(2) member telephone access to participating
providers; and
(3) the plan's arrangements for the provision of
emergency services.
Art. 20B.062. STANDARDS FOR DELIVERY OF CARE; MEMBER ACCESS.
(a) Each plan shall establish standards regarding the availability
of primary care providers to members and member access to services
provided through the plan, including access to:
(1) routine, urgent, and emergency care;
(2) a telephone appointment system;
(3) advice from providers; and
(4) other member telephone services.
(b) The plan's performance on member access to services
shall be assessed against the standards.
Art. 20B.063. HEALTH MANAGEMENT EFFORTS. (a) Each plan
shall take an active role in improving the health status of its
members and promoting effective health management by identifying
members with chronic illnesses and implementing appropriate
programmatic responses.
(b) The plan shall inform and educate each provider about
using the health management program for the members assigned to
that provider.
Art. 20B.064. MEDICAL RECORDS AND CONTINUITY OF CARE.
(a) A plan shall ensure continuity of care through:
(1) use of a health care professional who is primarily
responsible for coordinating the member's overall health care; and
(2) a system that maintains or ensures the maintenance
of necessary health and medical records that:
(A) accumulate pertinent information about each
member's health care; and
(B) are available to appropriate health care
professionals.
(b) A plan shall have policies and procedures governing the
maintenance of the health and medical records to ensure that those
records are maintained in a manner that:
(1) is current, detailed, and organized; and
(2) permits effective patient care and quality review.
(c) A plan shall ensure that:
(1) members' medical records are maintained so as to
ensure confidentiality, including written confidentiality policies
and procedures; and
(2) a member is afforded the opportunity to approve or
refuse the release of identifiable personal information except:
(A) to fulfill essential health plan functions
and obligations, including:
(i) quality improvement;
(ii) determining entitlement to health
care services;
(iii) administering payments; or
(iv) conducting approved, bona fide
medical education or research; or
(B) when the release is required by law.
Art. 20B.065. PAYMENT OF CERTAIN EMERGENCY SERVICES.
(a) The plan is financially responsible for, and shall provide
reasonable reimbursement for, necessary emergency services
required by a member, including services to treat and stabilize an
emergency medical condition that are obtained by a member from a
provider outside the plan, even if the services are provided
without prior authorization from the plan.
(b) The plan is financially responsible for the charges made
by a hospital emergency department for a medical screening
examination or other evaluation required by state or federal law
that is necessary to determine whether a medical emergency exists
for a member.
(c) After patient stabilization, the plan shall respond in a
timely manner appropriate to the circumstances of the case to
requests to provide additional services through the hospital
emergency department.
(d) On submission of written notice by a member of a valid
claim for medically necessary emergency care services, the plan
shall promptly reimburse the member for any amounts for which the
plan is obligated to pay.
Art. 20B.066. MEMBER RIGHTS AND RESPONSIBILITIES. (a) The
plan shall adopt written policies that recognize the rights of a
member to:
(1) voice grievances about the plan or the care
provided by the plan;
(2) be provided with information about the plan, its
services, the practitioners providing care, and members' rights and
responsibilities;
(3) participate in the decision-making regarding the
member's personal health care; and
(4) be treated with respect, recognizing the member's
dignity and need for privacy.
(b) The plan shall have written policies that address the
responsibility of a member to cooperate with providers providing
health care services. The written policy shall address the
member's responsibility to:
(1) provide, to the extent possible, information
needed by professional staff to care for the member; and
(2) follow instructions and guidelines given by those
providers.
(c) The plan shall provide a copy of its policies relating
to the rights and responsibilities of members on request to each
participating provider and directly to each subscriber.
Art. 20B.067. GRIEVANCE RESOLUTION. Each plan shall
establish, maintain, and inform each subscriber in writing of the
appeal and grievance procedures for each plan decision. The plan
shall have a formal system for resolving members' grievances that:
(1) establishes and monitors standards for timely
disposition of a grievance;
(2) documents the substance of a grievance and the
resulting actions taken;
(3) ensures a resolution of the grievance;
(4) establishes an appeals process:
(A) in which a member has the right to appear
before an appeals panel established by the plan and to request a
review of that panel's decision by different plan personnel; and
(B) that provides expedited procedures for
emergency situations;
(5) aggregates and analyzes information relating to
grievances and uses that information in its quality improvement
program; and
(6) ensures that a member who has filed a grievance or
an appeal is not the subject of retaliation or termination by the
plan solely because of that filing.
Art. 20B.068. DIRECT ACCESS. (a) The plan shall have a
written procedure to allow a member who has a chronic disabling or
life-threatening condition to apply to the plan's medical director
for direct access to specialty care appropriate to that member's
condition. The written procedure may include initial approval by
the member's primary care physician and the appropriate specialist.
(b) The medical director may set the conditions under which
the member may access the appropriate specialist directly.
(c) A member may appeal a denial of a request for direct
access through the appeals process required by this chapter.
Articles 20B.069-20B.080 reserved for expansion
SUBCHAPTER F. PROTECTION AGAINST INSOLVENCY
Art. 20B.081. NO PRIVATE INTEREST. No individual or other
person may own an interest in a plan.
Art. 20B.082. NET WORTH; RETAINED EARNINGS. (a) Each
plan's total net worth shall represent retained earnings and other
capital sources. Retained earnings shall be used to:
(1) serve the plan's health care purposes;
(2) meet the plan's financial obligations, excluding
surplus notes arrangements; and
(3) provide benefits to the community at large or
support medical education or research.
(b) Each plan shall maintain a total net worth and retained
earnings in amounts determined by the commissioner to be adequate
to provide services to its members.
(c) The commissioner shall accept a plan's total net worth
as adequate if the plan's average net worth for the three years
preceding the date on which the plan applied to the department for
a certificate of authority to operate as an integrated health plan,
as reported in the annual statement filed by the plan with the
department under Article 20A.10, Texas Health Maintenance
Organization Act (Article 20A.10, Vernon's Texas Insurance Code),
has been at least $10 million.
(d) The commissioner may not accept a plan's retained
earnings as adequate if the plan has:
(1) historically experienced losses resulting in a
negative balance in the plan's retained earnings account; or
(2) reported losses to the department under Article
20A.10, Texas Health Maintenance Organization Act (Article 20A.10,
Vernon's Texas Insurance Code), in either of the two calendar years
preceding the date on which the plan applied to the department for
a certificate of authority to operate as an integrated health plan.
Art. 20B.083. LIQUID ASSETS. Each plan shall maintain
sufficient cash or other liquid assets, or guarantee of liquid
assets, as necessary to meet the plan's financial obligations when
due.
Art. 20B.084. SOLVENCY PROTECTION PROGRAM. Each plan shall
adopt a solvency protection program that includes methods to
protect plan members from incurring liability for payment of fees
for health care services that are the legal obligation of the plan.
Articles 20B.085-20B.100 reserved for expansion
SUBCHAPTER G. UTILIZATION MANAGEMENT
Art. 20B.101. UTILIZATION MANAGEMENT PROGRAM. (a) Each
plan shall adopt and maintain a written health care utilization
management program to ensure that the care provided to members is
appropriate, of high quality, and not based solely on economic
criteria.
(b) The program at a minimum must provide for the
accumulation and review of information relating to:
(1) new medical procedures and technologies;
(2) provider performance;
(3) health care services utilization;
(4) procedures for pre-authorization, if
pre-authorization is used; and
(5) concurrent review.
(c) The program must require that any pre-authorization
requirements and concurrent review are supervised by qualified
medical professionals and that any denial of care must be reviewed
by a licensed physician.
Art. 20B.102. PROCEDURES FOR DENIAL OF TREATMENT. (a) The
program must provide that:
(1) utilization management decisions are made in a
timely manner, depending on the urgency of the situation;
(2) the reasons for denial of treatment are clearly
documented and made available to the member or physician; and
(3) procedures for the appeal of a denial of treatment
are communicated to the affected member.
(b) The program must include a process for an appeal of an
adverse determination. The process must include the presentation
of information by and the opinion of the treating physician
regarding the determination. If the decision to deny coverage was
based on a determination of lack of medical necessity, the appeal
must be decided by a physician.
(c) Unless the determination involves a life-threatening or
emergency situation, an appeal of an adverse determination must be
resolved not later than the 30th day after the date of receipt of
all necessary medical information. If the determination involves a
life-threatening or emergency situation, the appeal must be decided
on an expedited basis as provided by Subsection (d) of this
article.
(d) The program must include an expedited process for an
appeal of denial of treatment for a member with a life-threatening
condition. A complaint of denial of treatment that is subject to
this subsection must be resolved not later than the seventh day
after receipt of the complaint. An appeal of a determination made
under this subsection must be resolved not later than the seventh
day after the date of receipt of the appeal request.
Art. 20B.103. HOSPITAL STAY. (a) The program shall ensure
that the determination of the appropriate length of stay in a
hospital, including hospitalization provided under maternity
benefits, is made by the attending physician and the patient,
taking into consideration any special needs of the patient and, in
the case of maternity benefits, any special needs of the infant.
(b) The determination of the appropriate length of stay in a
hospital may not be based on economic criteria.
Articles 20B.104-20B.120 reserved for expansion
SUBCHAPTER H. OPERATION OF INTEGRATED HEALTH PLAN
Art. 20B.121. DETERMINATION OF MEDICAL NECESSITY. (a) An
integrated health plan shall have written policies and procedures
for making determinations as to whether a medical treatment is
medically necessary, experimental or investigational, or covered
under the terms of the health coverage provided by the plan. Those
policies and procedures must comply with this subchapter.
(b) The medical director of the integrated health plan, who
must be a physician licensed to practice medicine in this state and
employed by the applicable group medical practice, shall render or
approve a determination described by Subsection (a) of this
article. The medical director may delegate this responsibility to
one or more physicians who are licensed to practice medicine in
this state and are employed by or affiliated with the group medical
practice.
(c) The integrated health plan or group medical practice
shall subscribe or have access to an organized technology
assessment service that is independent from the plan and group
medical practice.
(d) The integrated health plan or group medical practice
shall have a committee composed of licensed physicians of the group
medical practice and, as necessary, other types of licensed medical
professionals that serve as an advisory body to the medical
director in making determinations of whether a medical treatment is
medically necessary or experimental or investigational.
(e) Before deciding that a medical treatment is not
medically necessary, is experimental or investigational, or is not
covered under the terms of the policy of health coverage, the
medical director, or the medical director's designee, shall perform
one or more of the following actions, as appropriate to the
circumstances and time constraints of the case:
(1) review the patient's medical record;
(2) review the patient's case with a physician of the
same or similar specialty as the physician recommending the
treatment in question;
(3) review relevant reports or findings of the
technology assessment service described under Subsection (c) of
this article; or
(4) consult with the advisory committee described
under Subsection (d) of this article.
(f) If the medical director or the medical director's
designee renders or approves a negative decision about a medical
treatment and the integrated health plan declines to provide
coverage for the treatment, the affected member may appeal the
decision through the grievance resolution procedure required under
this chapter.
Art. 20B.122. LIABILITY. (a) An integrated health plan
that complies with the policies and procedures required under
Article 20B.121 of this code is not liable for personal injury,
property damage, or death that arises as a result of the decision
by the plan to cover or not cover a treatment. If the member or
the member's provider fails to request approval from the plan for
the treatment until after the treatment is performed, the plan is
not liable for personal injury, property damage, or death that
arises as a result of the decision by the integrated health plan to
cover or not cover the treatment.
(b) An integrated health plan and the group medical practice
may indemnify the other with respect to a negligent act or
omission. The plan may not require any provider who is not
affiliated with the group medical practice to indemnify the plan
for its negligent act or omission.
(c) Notwithstanding Subsection (b) of this section, the
group medical practice assumes all liability for personal injury,
property damage, or death described by Subsection (a) of this
article to the exclusion of all liability of the integrated health
plan, except that the group medical practice may not be liable for
damages under both this article and the Medical Liability and
Insurance Improvement Act (Article 4590i, Vernon's Texas Civil
Statutes).
Art. 20B.123. APPLICATION OF INSURANCE LAWS. (a) Except as
provided by this article, an integrated health plan is exempt from
the operation and application of all insurance laws of this state,
including this code.
(b) An integrated health plan is subject to the following
laws as those laws existed on January 15, 1997:
(1) the Texas Health Maintenance Organization Act
(Chapter 20A, Vernon's Texas Insurance Code);
(2) Chapter 26, Insurance Code;
(3) Articles 1.04, 1.10, 1.10A, 1.10B, 1.10E, 1.11,
1.14-1, 1.15A, 1.19-1, 1.24C, 1.24D, 1.28, 1.31, 1.31A, 1.32, 1.33,
1.33B, 1.39, 1.41, 3.10, 3.51-5A, 3.51-6B, 3.51-6C, and 3.51-10,
Insurance Code;
(4) Section 1(F)(5), Chapter 397, Acts of the 54th
Legislature, Regular Session, 1955 (Article 3.70-1, Vernon's Texas
Insurance Code);
(5) Sections 2(F), (G), and (L), Chapter 397, Acts of
the 54th Legislature, Regular Session, 1955 (Article 3.70-2,
Vernon's Texas Insurance Code);
(6) Articles 3.72, 3.74, 3.77, 21.21-2, 21.21-4,
21.46, and 21.52C, Insurance Code;
(7) Article 21.21-6, Insurance Code, as added by
Chapter 522, Acts of the 74th Legislature, Regular Session, 1995;
(8) Article 21.52D, Insurance Code, as added by
Chapter 935, Acts of the 73rd Legislature, Regular Session, 1993;
(9) Articles 21.53A, 21.53C, 21.58A, 21.71, and
21.79D, Insurance Code;
(10) Sections 2(a) and 4(a), Article 1.36, Insurance
Code;
(11) Section 5(e), Texas Employees Uniform Group
Insurance Benefits Act (Article 3.50-2, Vernon's Texas Insurance
Code);
(12) Section 4(b)(4)(D), Texas State College and
University Employees Uniform Insurance Benefits Act (Article
3.50-3, Vernon's Texas Insurance Code);
(13) Section 3A, Article 3.51-6, Insurance Code;
(14) Section 3C, Article 3.51-6, as added by Chapter
1041, Acts of the 71st Legislature, Regular Session, 1989;
(15) Article 21.07-6, Insurance Code, except Sections
4, 5, 10, and 20(a)(1); and
(16) Section 5, Article 21.53, Insurance Code.
(c) An amendment to a law listed in Subsection (b) of this
article applies to an integrated health plan only if specifically
made applicable to an integrated health plan in its enactment.
(d) No provision of this code or other laws, other than
those listed by Subsection (b) of this article, whether existing
on or enacted after January 15, 1997, apply to an integrated health
plan unless that law is expressly added to that list.
(e) Unless this subsection is specifically amended to the
contrary, a law or rule, regardless of its effective date, may not
prohibit or in any way restrict an integrated health plan from:
(1) selectively contracting with or declining to
contract with any or all providers as the integrated health plan
considers necessary;
(2) contracting for or declining to contract for an
individual health care service or full range of health care
services as the integrated health plan considers necessary, if the
service or services may be legally provided by the contracting
provider; or
(3) requiring enrolled members of the integrated
health plan who wish to obtain the services covered by the
integrated health plan to use the providers specified by the
integrated health plan.
(2) On page 77, line 24, House Committee Report Printing,
strike "SECTION 27" and substitute "SECTION 28. (a)".
(3) On page 77, between lines 26 and 27, House Committee
Report Printing, insert the following:
(b) Chapter 20B, Insurance Code, as added by Section 27 of
this Act, takes effect September 1, 1997.
SECTION 29. Article 20B.122(c), Insurance Code, as added by
this Act, is contingent on the passage of S.B. 386, Acts of the
75th Legislature, Regular Session, 1997. If S.B. 386, Acts of the
75th Legislature, Regular Session, 1997, does not become law,
Article 20B.122(c), Insurance Code, as added by this Act, has no
effect.
(4) On page 77, line 27, House Committee Report Printing,
strike "SECTION 28. This Act applies" and substitute "SECTION 30.
Sections 1-26 of this Act apply".
(5) On page 78, House Committee Report Printing, strike line
6 and substitute "SECTION 31. Except as provided by Sections 28(a)
and 29 of this Act,".
(6) On page 78, line 8, House Committee Report Printing,
strike "SECTION 30" and substitute "SECTION 32".