By West S.B. No. 1424
76R7233 AJA-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the creation of a consumer assistance ombudsman program
1-3 for health insurance consumers.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. The Insurance Code is amended by adding Chapter
1-6 28 to read as follows:
1-7 CHAPTER 28. INDEPENDENT CONSUMER ASSISTANCE
1-8 OMBUDSMAN PROGRAM FOR HEALTH CARE CONSUMERS
1-9 Art. 28.01. DEFINITIONS. In this chapter:
1-10 (1) "Consumer" means a person entitled to coverage
1-11 under a health care plan or attempting to obtain coverage under a
1-12 health care plan.
1-13 (2) "Health care plan" means:
1-14 (A) a health benefit plan that provides benefits
1-15 for medical, surgical, or other treatment expenses incurred as a
1-16 result of a health or mental health condition, accident, sickness,
1-17 or condition involving substance abuse, including an individual,
1-18 group, blanket, or franchise insurance policy or insurance
1-19 agreement, a group hospital service contract, or an individual or
1-20 group evidence of coverage or similar coverage document that is
1-21 offered by:
1-22 (i) an insurance company;
1-23 (ii) a group hospital service corporation
1-24 operating under Chapter 20 of this code;
2-1 (iii) a fraternal benefit society
2-2 operating under Chapter 10 of this code;
2-3 (iv) a stipulated premium insurance
2-4 company operating under Chapter 22 of this code;
2-5 (v) a reciprocal exchange operating under
2-6 Chapter 19 of this code;
2-7 (vi) a health maintenance organization
2-8 operating under the Texas Health Maintenance Organization Act
2-9 (Chapter 20A, Vernon's Texas Insurance Code);
2-10 (vii) a multiple employer welfare
2-11 arrangement as defined by Section 3, Employee Retirement Income
2-12 Security Act of 1974 (29 U.S.C. Section 1002), as amended;
2-13 (viii) an approved nonprofit health
2-14 corporation that holds a certificate of authority issued by the
2-15 commissioner under Article 21.52F of this code;
2-16 (ix) a small employer health benefit plan
2-17 written under Chapter 26 of this code; or
2-18 (x) a Medicare supplemental policy as
2-19 defined by Section 1882(g)(1), Social Security Act (42 U.S.C.
2-20 Section 1395ss), as amended;
2-21 (B) the state medical assistance program,
2-22 including Medicaid managed care; or
2-23 (C) the federal Medicare program.
2-24 (3) "Program" means the Independent Consumer
2-25 Assistance Ombudsman Program for Health Care Consumers.
2-26 Art. 28.02. PROGRAM ESTABLISHED BY CONTRACT. (a) The
2-27 Independent Consumer Assistance Ombudsman Program for Health Care
3-1 Consumers is established. The office of public insurance counsel
3-2 shall contract, through a request for proposals, with a nonprofit
3-3 organization to operate the program.
3-4 (b) To be eligible for selection to operate the program, the
3-5 nonprofit organization must not be involved in providing health
3-6 care or health care plans and must demonstrate that it has
3-7 expertise in providing direct assistance to consumers with respect
3-8 to their concerns and problems with health care plans.
3-9 (c) The nonprofit organization operating the program may
3-10 establish an advisory committee composed of consumers, health care
3-11 providers, and health care plan representatives.
3-12 Art. 28.03. POWERS AND DUTIES. (a) The program shall:
3-13 (1) assist individual consumers with:
3-14 (A) understanding:
3-15 (i) their rights and responsibilities with
3-16 respect to obtaining timely, good quality health care; and
3-17 (ii) how to assert their rights; and
3-18 (B) filing and pursuing complaints, grievances,
3-19 and appeals;
3-20 (2) represent individual consumers in:
3-21 (A) grievances or appeals within the operation
3-22 of a health care plan, including the plan's utilization review
3-23 process;
3-24 (B) grievances or appeals outside of the
3-25 operation of a health care plan, including appeals to an
3-26 independent review organization under Article 21.58A of this code
3-27 or in Medicaid and Medicare fair hearings; or
4-1 (C) mediations and arbitrations with health care
4-2 plans;
4-3 (3) serve as a statewide clearinghouse for objective
4-4 consumer information about health care coverage;
4-5 (4) operate a statewide toll-free assistance telephone
4-6 number; and
4-7 (5) assist consumers in understanding their options
4-8 for obtaining health care coverage.
4-9 (b) The program shall supplement and not duplicate the
4-10 functions provided by existing programs or state agencies,
4-11 including the department and the office of public insurance
4-12 counsel, and shall refer consumers to other programs or agencies if
4-13 appropriate.
4-14 (c) The program shall collect and maintain information,
4-15 including statistical information, and submit a quarterly report to
4-16 the public and the media and an annual report to the legislature
4-17 regarding the problems reported by consumers. The report to the
4-18 legislature may include recommendations on how those problems might
4-19 be resolved.
4-20 (d) The program shall study the feasibility of providing
4-21 program services throughout the state on a regional basis and
4-22 submit its findings to the legislature.
4-23 Art. 28.04. NOTICE TO CONSUMERS. (a) A health care plan
4-24 regulated under this code or the other insurance laws of this state
4-25 shall provide in its membership information materials information
4-26 regarding the availability of the program and the services provided
4-27 by the program. The information must include the telephone number
5-1 for the program and a notice that a consumer can call the program
5-2 for information or assistance in resolving a problem or filing a
5-3 complaint. The information shall be provided in writing to any
5-4 consumer making an oral or written complaint.
5-5 (b) If the department receives a complaint relating to a
5-6 health care plan not subject to the department's jurisdiction from
5-7 a consumer enrolled in the plan, the department shall inform the
5-8 consumer about the program.
5-9 Art. 28.05. IMMUNITY. An organization operating the program
5-10 or a representative of that organization is not liable for any
5-11 action taken in good faith to fulfill the duties of the
5-12 organization under this chapter.
5-13 Art. 28.06. FUNDING. (a) The office of public insurance
5-14 counsel or the nonprofit organization operating the program may
5-15 accept gifts, grants, or donations from any source for the purpose
5-16 of operating the program.
5-17 (b) The contract between the office of public insurance
5-18 counsel and the nonprofit organization operating the program may
5-19 allow the nonprofit organization to charge reasonable fees to
5-20 consumers to support the program.
5-21 SECTION 2. This Act takes effect September 1, 1999.
5-22 SECTION 3. The importance of this legislation and the
5-23 crowded condition of the calendars in both houses create an
5-24 emergency and an imperative public necessity that the
5-25 constitutional rule requiring bills to be read on three several
5-26 days in each house be suspended, and this rule is hereby suspended.