By: Madla S.B. No. 976
A BILL TO BE ENTITLED
AN ACT
1-1 relating to managed care plans issued by managed care organizations
1-2 under Medicare risk-sharing contracts; providing administrative
1-3 penalties.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.52G to read as follows:
1-7 Art. 21.52G. REQUIREMENTS FOR MANAGED CARE ORGANIZATIONS
1-8 UNDER MEDICARE RISK-SHARING CONTRACTS
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Managed care organization" means an eligible
1-11 organization under 42 U.S.C. Section 1395mm.
1-12 (2) "Managed care plan" means a health benefit plan
1-13 issued by a managed care organization through which the
1-14 organization provides certain health care services.
1-15 (3) "Enrollee" means a person who receives certain
1-16 health care services through a managed care plan.
1-17 (4) "Participating provider" means a physician or
1-18 other health care provider who is under contract with a managed
1-19 care organization to provide certain health care services to
1-20 enrollees in a managed care plan issued by the organization.
1-21 (5) "Medicare" means the health insurance program for
1-22 the aged established under Parts A and B, Title XVIII, Social
1-23 Security Act (42 U.S.C. Section 1395 et seq.).
2-1 (6) "Risk-sharing contract" has the meaning assigned
2-2 by 42 U.S.C. Section 1395mm.
2-3 Sec. 2. SCOPE OF ARTICLE. This article applies only to
2-4 enrollment of a Medicare recipient in a managed care plan issued by
2-5 a managed care organization that enters into a risk-sharing
2-6 contract to provide certain health care services to Medicare
2-7 recipients through that managed care plan.
2-8 Sec. 3. NOTICE TO PROVIDERS. Not later than the 10th day
2-9 after the date on which a managed care organization enrolls an
2-10 enrollee in a managed care plan, the organization shall provide to
2-11 each health care provider listed by the enrollee under Section 3(a)
2-12 of this article written notice of the enrollment and notice of the
2-13 extent to which the plan will reimburse the provider for services
2-14 provided to the new enrollee.
2-15 Sec. 4. DUTIES TO ENROLLEES. (a) A managed care
2-16 organization shall provide to an enrollee a sticker to attach to
2-17 the enrollee's Medicare identification card that indicates
2-18 enrollment in the managed care plan. The sticker must include the
2-19 name of the plan and the plan's telephone number.
2-20 (b) A managed care organization shall ensure continuity of
2-21 care for all plan enrollees by ensuring the enrollee's timely
2-22 selection of a primary health care provider who is a participating
2-23 provider.
2-24 (c) A managed care organization that fails to provide for
2-25 the timely selection of a primary health care provider by an
3-1 enrollee shall reimburse a health care provider for all health care
3-2 services provided to the enrollee before the enrollee selects a
3-3 primary health care provider, regardless of whether the provider
3-4 who provides those services is a participating provider.
3-5 Sec. 5. OMBUDSMAN. The department shall provide an
3-6 ombudsman to assist Medicare recipients enrolled in managed care
3-7 plans and to ensure that managed care organizations subject to this
3-8 article comply with this article.
3-9 Sec. 6. MANAGED CARE PLAN FORMS. A managed care
3-10 organization may not use a printed form for enrollment in a managed
3-11 care plan unless the organization files a copy of the form with the
3-12 commissioner not later than the 60th day before the date on which
3-13 the organization proposes to use the form. The organization may
3-14 use the form unless the commissioner notifies the organization of
3-15 the commissioner's disapproval of the form not later than the 15th
3-16 day before the date of proposed use of the form.
3-17 Sec. 7. ADVERTISING. A managed care organization may not
3-18 advertise the availability of its managed care plan for Medicare
3-19 recipients unless the organization files a copy of the
3-20 advertisement with the commissioner not later than the 60th day
3-21 before the date the organization proposes to use the advertisement.
3-22 The organization may use the advertisement unless the commissioner
3-23 notifies the organization of the commissioner's disapproval of the
3-24 advertisement not later than the 15th day before the date of
3-25 proposed use of the advertisement.
4-1 Sec. 8. ADMINISTRATIVE PENALTY. A managed care organization
4-2 that violates this article is subject to administrative penalties
4-3 under Article 1.10E of this code.
4-4 Sec. 9. RULES. The commissioner shall adopt rules to
4-5 implement this article.
4-6 SECTION 2. Not later than January 1, 1998, the commissioner
4-7 of insurance shall adopt rules as required by Section 10, Article
4-8 21.52G, Insurance Code, as added by this Act.
4-9 SECTION 3. (a) This Act takes effect September 1, 1997.
4-10 (b) This Act applies only to an evidence of coverage under a
4-11 managed care plan that is delivered, issued for delivery, or
4-12 renewed on or after January 1, 1998. An evidence of coverage under
4-13 a managed care plan that is delivered, issued for delivery, or
4-14 renewed before January 1, 1998, is governed by the law as it
4-15 existed immediately before the effective date of this Act, and that
4-16 law is continued in effect for that purpose.
4-17 (c) This Act applies to an advertisement for a managed care
4-18 plan used on or after January 1, 1998. An advertisement used
4-19 before January 1, 1998, is governed by the law as it existed
4-20 immediately before the effective date of this Act, and that law is
4-21 continued in effect for that purpose.
4-22 SECTION 4. The importance of this legislation and the
4-23 crowded condition of the calendars in both houses create an
4-24 emergency and an imperative public necessity that the
4-25 constitutional rule requiring bills to be read on three several
5-1 days in each house be suspended, and this rule is hereby suspended.