By Bailey H.B. No. 1123
75R4589 SAW-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 21.52G to read as follows:
1-6 Art. 21.52G. MANAGED CARE PLANS
1-7 Sec. 1. DEFINITIONS. In this article:
1-8 (1) "Managed care plan" means a plan offered by a
1-9 health maintenance organization, a preferred provider organization,
1-10 or another organization that:
1-11 (A) provides health care benefits or arranges
1-12 for health care benefits to be provided to a participant in the
1-13 plan; and
1-14 (B) requires or encourages plan participants to
1-15 use practitioners under contract with the plan.
1-16 (2) "Practitioner" means a pharmacist, dentist,
1-17 optometrist, psychologist, advanced nurse practitioner, podiatrist,
1-18 or chiropractor licensed to practice in this state.
1-19 Sec. 2. DUTIES TO PARTICIPANTS. A managed care plan shall:
1-20 (1) demonstrate to the department that the plan has
1-21 contracted with an adequate number of practitioners to ensure that
1-22 a participant:
1-23 (A) receives health care services covered by the
1-24 plan in a timely manner; and
2-1 (B) has freedom in choosing a particular type of
2-2 practitioner to provide health care services covered by the plan;
2-3 (2) establish a mechanism for each practitioner who
2-4 has contracted to provide health care services under the plan to
2-5 comment on and provide information relating to:
2-6 (A) the payment of benefits for procedures based
2-7 on new medical technology;
2-8 (B) utilization review criteria and procedures;
2-9 (C) quality of care and credentialing criteria;
2-10 and
2-11 (D) medical management procedures; and
2-12 (3) provide prospective participants with sufficient
2-13 information on the terms and conditions of the plan to enable them
2-14 to make informed decisions about accepting coverage under the
2-15 managed care plan.
2-16 Sec. 3. PRACTITIONER CONTRACTS. (a) Any qualified
2-17 practitioner who agrees to comply with reasonable terms and
2-18 conditions may contract to provide services under a managed care
2-19 plan. A managed care plan may not limit the plan's number of
2-20 practitioners.
2-21 (b) This section does not apply to a managed care plan that
2-22 provides all medical services to participants through practitioners
2-23 who are:
2-24 (1) employed by the managed care plan; or
2-25 (2) contractually prohibited from treating individuals
2-26 who are not participants in the plan.
2-27 Sec. 4. TERMINATION OF PRACTITIONER CONTRACTS. (a) Before
3-1 terminating a contract with a practitioner, the managed care plan
3-2 shall provide the practitioner with notice, an opportunity for
3-3 discussion, and an opportunity to enter into and complete a
3-4 corrective action program to cure any deficiency in performance
3-5 under the contract.
3-6 (b) This section does not apply to termination of a
3-7 practitioner contract in a case in which there is risk of imminent
3-8 harm to a participant's health or in which the practitioner's
3-9 license has been suspended, revoked, or limited by a state
3-10 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 practitioner makes the
3-14 request and shall employ qualified personnel for same-day telephone
3-15 responses to inquiries about medical necessity, including
3-16 certification of continued length of stay. This section does not
3-17 authorize a managed care plan to require prior authorization for
3-18 emergency 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 that applies to all
4-1 practitioners under contract with the plan.
4-2 SECTION 2. This Act takes effect September 1, 1997, and
4-3 applies only to a contract with a practitioner into which a managed
4-4 care plan enters on or after that date. A contract into which a
4-5 managed care plan enters before the effective date of this Act is
4-6 governed by the law as it existed immediately before that date, and
4-7 that law is 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.