By: Harris, Nelson S.B. No. 387
Madla, Cain, Sibley
97S0228/1
A BILL TO BE ENTITLED
AN ACT
1-1 relating to the creation of a rating system and consumer report
1-2 cards for the comparison of health care plans.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Chapter 1, Insurance Code, is amended by adding
1-5 Article 1.35A-1 to read as follows:
1-6 Art. 1.35A-1. HEALTH CARE PLAN REPORT CARDS
1-7 Sec. 1. RATING SYSTEM. (a) On or before September 1, 1998,
1-8 the office of public insurance counsel shall establish and
1-9 implement a rating system to compare and evaluate the quality of
1-10 care provided by, and the performance of, health maintenance
1-11 organization benefit plans and services on an objective basis.
1-12 (b) The rating system, where appropriate, shall solicit
1-13 performance information, through a survey or other means, from
1-14 enrollees of health maintenance organizations licensed in this
1-15 state under the Texas Health Maintenance Organization Act (Article
1-16 20A.01 et seq., Vernon's Texas Insurance Code). The survey may
1-17 include responses from enrollees regarding satisfaction with the
1-18 benefits of plans and the cost and quality of the health care
1-19 services received.
1-20 (c) In performing its duties under this section, the office
1-21 of public insurance counsel may enter into contracts as necessary
1-22 to implement this section.
1-23 (d) The office of public insurance counsel shall have access
2-1 to data collected by the Texas Health Care Information Council
2-2 under Chapter 108, Health and Safety Code, and information provided
2-3 by health maintenance organizations to the commissioner under the
2-4 Texas Health Maintenance Organization Act (Article 20A.01 et seq.,
2-5 Vernon's Texas Insurance Code), except for documents deemed
2-6 confidential under:
2-7 (1) Section 27, Texas Health Maintenance Organization
2-8 Act (Article 20A.27, Vernon's Texas Insurance Code); or
2-9 (2) the open records law, Chapter 552, Government
2-10 Code.
2-11 Sec. 2. CONSUMER REPORT CARDS. (a) The office of public
2-12 insurance counsel shall develop consumer report cards on health
2-13 maintenance organizations licensed in this state under the Texas
2-14 Health Maintenance Organization Act (Article 20A.01 et seq.,
2-15 Vernon's Texas Insurance Code) that include:
2-16 (1) a uniform rating of the performance of health
2-17 maintenance organizations; and
2-18 (2) information to aid purchasers and consumers in
2-19 making health benefit enrollment and contract decisions when
2-20 selecting a health care plan.
2-21 (b) Consumer report cards shall include uniform rating
2-22 information including but not limited to ratings on benefit
2-23 structures, complaint and appeal records, utilization of health
2-24 care services, financial soundness, premium costs and co-payments,
2-25 enrollee satisfaction surveys, quality of care measures, and other
3-1 measures on health maintenance organizations that may assist
3-2 purchasers and consumers in making informed choices about medical
3-3 care.
3-4 (c) Consumer report cards shall also include an explanation
3-5 of the following:
3-6 (1) the types of health care plans available in the
3-7 market including but not limited to indemnity plans, health
3-8 maintenance organizations, preferred provider organizations, point
3-9 of service health maintenance organizations, and self-funded or
3-10 self-insured plans, and how they operate;
3-11 (2) federal and state regulation of health maintenance
3-12 organizations;
3-13 (3) factors to consider when choosing a health
3-14 maintenance organization including but not limited to premium and
3-15 co-pay requirements, benefits, access to care, quality of care, and
3-16 the administrative and financial operations of health maintenance
3-17 organizations; and
3-18 (4) any other information determined by the office of
3-19 public insurance counsel to be useful to the public.
3-20 (d) Consumer report cards shall be updated annually.
3-21 (e) Consumer report cards shall be composed of comprehensive
3-22 and comparable information in a concise and easily understandable
3-23 format and shall be readily available to the public.
3-24 Sec. 3. CONFIDENTIALITY OF DATA AND INFORMATION. (a) The
3-25 data and information collected or received by the office of public
4-1 insurance counsel shall be used for the benefit of the public. The
4-2 office of public insurance counsel is subject to the open records
4-3 law, Chapter 552, Government Code. Subject to specific limitations
4-4 established by this section, the office of public insurance counsel
4-5 shall make determinations on requests for information in favor of
4-6 access.
4-7 (b) Unless specifically authorized by this section, the
4-8 office of public insurance counsel may not release and a person or
4-9 entity may not gain access to any data:
4-10 (1) that could reasonably be expected to reveal the
4-11 identity of a patient or physician or that reveals the zip code of
4-12 a patient's primary residence;
4-13 (2) disclosing provider discounts or differentials
4-14 between payments and billed charges; or
4-15 (3) relating to actual payments to an identified
4-16 provider made by a payer.
4-17 (c) All data and information collected and used by the
4-18 office of public insurance counsel under this section is subject to
4-19 the confidentiality provisions and criminal penalties of:
4-20 (1) Section 311.037, Health and Safety Code;
4-21 (2) Section 81.103, Health and Safety Code; and
4-22 (3) Section 5.08, Medical Practice Act (Article 4495b,
4-23 Vernon's Texas Civil Statutes).
4-24 (d) Data on patients and physicians and compilations,
4-25 reports, or analyses produced from the data collected or received
5-1 that identify patients and physicians are not:
5-2 (1) subject to discovery, subpoena, or other means of
5-3 legal compulsion for release to any person or entity except as
5-4 provided by this section; or
5-5 (2) admissible in any civil, administrative, or
5-6 criminal proceeding.
5-7 (e) Notwithstanding Subsection (b)(1) of this section, the
5-8 office of public insurance counsel may use zip code information to
5-9 analyze data on a geographic basis.
5-10 Sec. 4. ADVISORY COMMITTEE. (a) The public counsel shall
5-11 appoint an 11-member advisory committee to assist and advise the
5-12 office of public insurance counsel in developing a rating system
5-13 and consumer report cards. The committee may consult with other
5-14 professionals, as necessary. The committee shall include:
5-15 (1) the commissioner as the ex officio member; and
5-16 (2) one representative for each of the following:
5-17 consumers, employers, health maintenance organizations, health
5-18 insurers, hospitals, physicians, and other health care providers.
5-19 (b) The advisory committee's deliberations shall be subject
5-20 to the open meetings law, Chapter 551, Government Code.
5-21 (c) A member of the advisory committee may not receive
5-22 compensation or reimbursement for service on the committee or for
5-23 any expense incurred while serving on the committee.
5-24 Sec. 5. AUTHORITY. The public counsel, as executive
5-25 director of the office of public insurance counsel, shall have the
6-1 powers, duties, and responsibilities provided under Article 1.35A
6-2 of this code to administer, enforce, and carry out the provisions
6-3 of this article.
6-4 Sec. 6. REPORT TO LEGISLATURE. The public counsel shall by
6-5 January 1, 1999, provide to the governor and the legislature a
6-6 written report on the effectiveness of the office of public
6-7 insurance counsel in carrying out the legislative intent of this
6-8 article and, if applicable, any needed changes in the law.
6-9 SECTION 2. This Act takes effect September 1, 1997.
6-10 SECTION 3. The importance of this legislation and the
6-11 crowded condition of the calendars in both houses create an
6-12 emergency and an imperative public necessity that the
6-13 constitutional rule requiring bills to be read on three several
6-14 days in each house be suspended, and this rule is hereby suspended.