75R14482 SAW-F
By Madla S.B. No. 976
Substitute the following for S.B. No. 976:
By Smithee C.S.S.B. No. 976
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to managed care plans issued by managed care organizations
1-3 under Medicare risk-sharing contracts; imposing administrative
1-4 penalties.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.52G to read as follows:
1-8 Art. 21.52G. REQUIREMENTS FOR MANAGED CARE ORGANIZATIONS
1-9 UNDER MEDICARE RISK-SHARING CONTRACTS
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Managed care organization" means an eligible
1-12 organization under 42 U.S.C. Section 1395mm.
1-13 (2) "Managed care plan" means a health benefit plan
1-14 issued by a managed care organization through which the
1-15 organization provides certain health care services.
1-16 (3) "Enrollee" means a person who receives certain
1-17 health care services through a managed care plan.
1-18 (4) "Participating provider" means a physician or
1-19 other health care provider who is under contract with a managed
1-20 care organization to provide certain health care services to
1-21 enrollees in a managed care plan issued by the organization.
1-22 (5) "Medicare" means the health insurance program for
1-23 the aged established under Parts A and B, Title XVIII, Social
1-24 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. PRE-ENROLLMENT REQUIREMENTS. (a) Not later than
2-9 the 10th day after the date on which the managed care organization
2-10 receives an application for enrollment, the organization shall
2-11 provide to the prospective enrollee a document that:
2-12 (1) describes the plan's procedure for selection of a
2-13 primary health care provider and other health care providers who
2-14 participate in the plan;
2-15 (2) describes the plan's referral requirements for
2-16 participating providers who are specialists; and
2-17 (3) lists all health care providers, including
2-18 hospitals, that participate in the plan.
2-19 (b) A managed care organization may not enroll a prospective
2-20 enrollee until the prospective enrollee signs a statement
2-21 described by Subsection (c) of this section and returns the
2-22 statement to the organization. The managed care organization shall
2-23 prepare the statement for the prospective enrollee and shall attach
2-24 to the statement an additional copy of the document provided to the
2-25 prospective enrollee under Subsection (a) of this section.
2-26 (c) The statement required by Subsection (b) of this section
2-27 must be printed in 12-point or larger type and state that the
3-1 prospective enrollee understands:
3-2 (1) that an enrollee in the plan is required to obtain
3-3 health care services from a participating provider to receive full
3-4 coverage under the plan;
3-5 (2) that the managed care plan may not fully or even
3-6 partially reimburse a health care provider for services provided to
3-7 an enrollee if the health care provider is not a participating
3-8 provider in the plan;
3-9 (3) that an enrollee is required to pay for services
3-10 provided by a health care provider who is not a participating
3-11 provider in the plan to the extent that the plan does not reimburse
3-12 the provider for the services;
3-13 (4) that an enrollee is required to obtain a referral
3-14 from the enrollee's primary health care provider under the plan
3-15 before obtaining the services of a specialist, even if the
3-16 specialist is a participating provider in the plan, and that the
3-17 enrollee is required to pay for services provided by a specialist
3-18 without a referral; and
3-19 (5) that the hospitals listed on the document attached
3-20 to the statement are the only hospitals that the plan will
3-21 reimburse for services provided to an enrollee.
3-22 (d) A managed care organization that violates this section
3-23 shall reimburse a health care provider for all health care services
3-24 provided to an enrollee, regardless of whether the provider is a
3-25 participating provider.
3-26 Sec. 4. DUTIES TO ENROLLEES. (a) A managed care
3-27 organization shall provide to a prospective enrollee who submits an
4-1 application for enrollment a sticker to attach to the prospective
4-2 enrollee's Medicare identification card that indicates possible
4-3 enrollment in the managed care plan. The sticker must include the
4-4 name of the plan and the plan's telephone number.
4-5 (b) A managed care organization shall ensure continuity of
4-6 care for all plan enrollees by ensuring the enrollee's timely
4-7 selection of a primary health care provider who is a participating
4-8 provider.
4-9 (c) A managed care organization that fails to provide for
4-10 the timely selection of a primary health care provider by an
4-11 enrollee shall reimburse a health care provider for all health care
4-12 services provided to the enrollee before the enrollee selects a
4-13 primary health care provider, regardless of whether the provider
4-14 who provides those services is a participating provider.
4-15 Sec. 5. OMBUDSMAN. The department shall provide an
4-16 ombudsman to assist Medicare recipients enrolled in managed care
4-17 plans and to ensure that managed care organizations subject to this
4-18 article comply with this article.
4-19 Sec. 6. MANAGED CARE PLAN FORMS. A managed care
4-20 organization may not use a printed form for enrollment in a managed
4-21 care plan unless the organization files a copy of the form with the
4-22 commissioner not later than the 60th day before the date on which
4-23 the organization proposes to use the form. The organization may
4-24 use the form unless the commissioner notifies the organization of
4-25 the commissioner's disapproval of the form not later than the 15th
4-26 day before the date of proposed use of the form.
4-27 Sec. 7. ADVERTISING. A managed care organization may not
5-1 advertise the availability of its managed care plan for Medicare
5-2 recipients unless the organization files a copy of the
5-3 advertisement with the commissioner not later than the 60th day
5-4 before the date the organization proposes to use the advertisement.
5-5 The organization may use the advertisement unless the commissioner
5-6 notifies the organization of the commissioner's disapproval of the
5-7 advertisement not later than the 15th day before the date of
5-8 proposed use of the advertisement.
5-9 Sec. 8. ADMINISTRATIVE PENALTY. A managed care organization
5-10 that violates this article is subject to administrative penalties
5-11 under Article 1.10E of this code.
5-12 Sec. 9. RULES. The commissioner shall adopt rules to
5-13 implement this article.
5-14 SECTION 2. Not later than January 1, 1998, the commissioner
5-15 shall adopt rules as required by Section 9, Article 21.52G,
5-16 Insurance Code, as added by this Act.
5-17 SECTION 3. (a) This Act takes effect September 1, 1997.
5-18 (b) This Act applies only to an evidence of coverage under a
5-19 managed care plan that is delivered, issued for delivery, or
5-20 renewed on or after January 1, 1998. An evidence of coverage under
5-21 a managed care plan that is delivered, issued for delivery, or
5-22 renewed before January 1, 1998, is governed by the law as it
5-23 existed immediately before the effective date of this Act, and that
5-24 law is continued in effect for that purpose.
5-25 (c) This Act applies to an advertisement for a managed care
5-26 plan used on or after January 1, 1998. An advertisement used
5-27 before January 1, 1998, is governed by the law as it existed
6-1 immediately before the effective date of this Act, and that law is
6-2 continued in effect for that purpose.
6-3 SECTION 4. The importance of this legislation and the
6-4 crowded condition of the calendars in both houses create an
6-5 emergency and an imperative public necessity that the
6-6 constitutional rule requiring bills to be read on three several
6-7 days in each house be suspended, and this rule is hereby suspended.