Amend CSHB 2498 by striking all below the enacting clause and
substituting the following:
SECTION 1. Title 1, Insurance Code, is amended by adding
Chapter 20B to read as follows:
CHAPTER 20B. CROSS-BORDER HEALTH CARE PLAN
Art. 20B.01. SHORT TITLE. This chapter may be cited as the
Cross-Border Health Care Plan Act.
Art. 20B.02. DEFINITIONS. In this chapter:
(1) "Basic health care services" means health care
services that the commissioner determines an enrolled population
might reasonably require in order to be maintained in good health,
including any services required by the applicable laws of the
United Mexican States.
(2) "Cross-border health care plan" means a health
care plan that is offered or made available to the categories of
persons described by Article 20B.03 of this code and that is
provided through a health maintenance organization delivery network
based exclusively on physicians, providers, or other health
maintenance organizations located in the United Mexican States.
(3) "Emergency care" means health care services
provided in a hospital emergency facility or comparable facility to
evaluate and stabilize medical conditions of a recent onset and
severity, including severe pain, that would lead a prudent
layperson, possessing an average knowledge of medicine and health,
to believe that the individual's condition, sickness, or injury is
of such a nature that failure to get immediate medical care could
result in:
(A) placing the patient's health in serious
jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or
part;
(D) serious disfigurement; or
(E) in the case of a pregnant woman, serious
jeopardy to the health of the fetus.
(4) "Enrollee" means an individual who is enrolled in
a health care plan, including covered dependents.
(5) "Health care plan" means a plan under which a
person undertakes to provide, arrange for, pay for, or reimburse
any part of the cost of any health care services if a part of the
plan consists of providing or arranging for health care services on
a prepaid basis through insurance or otherwise, as distinguished
from indemnification against the cost of the service.
(6) "Health care services" means services provided to
an individual to prevent, alleviate, cure, or heal human illness or
injury. The term includes:
(A) pharmaceutical services;
(B) medical, chiropractic, or dental care;
(C) hospitalization; and
(D) care or services incidental to the health
care services described by Paragraphs (A)-(C).
(7) "Health maintenance organization" means a person
or entity that arranges for or provides a health care plan to
enrollees on a prepaid basis.
(8) "Health maintenance organization delivery network"
means a health care delivery system in which a health maintenance
organization arranges for health care services directly or
indirectly through contracts and subcontracts with providers and
physicians.
Art. 20B.03. ELIGIBILITY FOR COVERAGE. A cross-border health
care plan may only be offered or made available to the following
persons and their dependents:
(1) a citizen of the United Mexican States who works
or resides within 62 miles of the border of this state and the
United Mexican States; or
(2) a resident of the United Mexican States who works
within 62 miles of the border of this state and the United Mexican
States.
Art. 20B.04. COVERAGE OFFERED. (a) A health maintenance
organization licensed to provide basic health care services under
the Texas Health Maintenance Organization Act (Chapter 20A,
Vernon's Texas Insurance Code) may offer a cross-border health care
plan to individuals or to small employers or large employers, as
those terms are defined by Article 26.02 of this code. In
arranging for or providing a cross-border health care plan, a
health maintenance organization has all of the powers and authority
granted under Section 6, Texas Health Maintenance Organization Act
(Article 20A.06, Vernon's Texas Insurance Code).
(b) A cross-border health care plan may limit its service
area to a geographic region within the United Mexican States and
may limit the coverage of out-of-area health care services
delivered in this state to emergency care services. The delivery
of emergency care services in this state under the plan is subject
to the requirements of Section 4(a)(16), Texas Health Maintenance
Organization Act (Article 20A.04, Vernon's Texas Insurance Code).
(c) The delivery of health care services through the health
maintenance organization delivery network located in the United
Mexican States must be based on and determined by the prevailing
community standards in the United Mexican States, and the licensing
of physicians and providers is governed by the applicable laws of
the United Mexican States. A physician or provider providing
health care services through the delivery network is not required
to be licensed in this state. The credentialing, peer review, and
quality of care standards used by a health maintenance organization
offering a cross-border health care plan is governed by the
standards that apply in the United Mexican States.
(d) A cross-border health care plan may be made available to
eligible employees of a small or large employer, and their
dependents, only when chosen by the employer as an option among two
or more health benefit plans, at least one of which provides
coverage for health care services delivered in this state.
(e) A health maintenance organization that offers a
cross-border health care plan must contract with sufficient
providers and physicians to assure that all health care services
for which coverage is provided will be reasonably available and
accessible.
Art. 20B.05. APPLICABILITY OF TEXAS HEALTH MAINTENANCE
ORGANIZATION ACT. (a) A cross-border health care plan must satisfy
the requirements of Section 9, Texas Health Maintenance
Organization Act (Article 20A.09, Vernon's Texas Insurance Code),
except that the provisions relating to state continuation of
coverage and conversion do not apply to a cross-border health care
plan. A health maintenance organization shall file the form of its
cross-border health care plan for information only with the
commissioner, accompanied by a certification on its behalf that on
best knowledge, information, and belief, the filed form complies in
all respects with the applicable provisions of this code, the Texas
Health Maintenance Organization Act, and the adopted rules and
regulations that are applicable to the form.
(b) A cross-border health care plan and the health
maintenance organization offering such a plan are exempt from the
requirements of Sections 9E, 9F, 11, 11A, 11B, 18A, as added by
Chapter 1026, Acts of the 75th Legislature, Regular Session, 1997,
18A, as added by Chapter 735, Acts of the 75th Legislature, Regular
Session, 1997, 18B, 18C, 29, 37, and 38, Texas Health Maintenance
Organization Act (Articles 20A.09E, 20A.09F, 20A.11, 20A.11A,
20A.11B, 20A.18A, as added by Chapter 1026, Acts of the 75th
Legislature, Regular Session, 1997, 20A.18A, as added by Chapter
735, Acts of the 75th Legislature, Regular Session, 1997, 20A.18B,
20A.18C, 20A.29, 20A.37, and 20A.38, Vernon's Texas Insurance
Code), and Article 26.09, Insurance Code, and any rules or
regulations adopted under those laws. The commissioner is not
required to examine a health maintenance organization with respect
to the quality of health care services delivered under a
cross-border health care plan by providers and physicians located
in the United Mexican States.
(c) Sections 12, 12A, and 12B, Texas Health Maintenance
Organization Act (Articles 20A.12, 20A.12A, and 20A.12B, Vernon's
Texas Insurance Code), apply to a cross-border health care plan
only to the extent that an enrollee under the plan receives health
care services delivered by a physician or provider located in this
state.
(d) Section 26, Texas Health Maintenance Organization Act
(Article 20A.26, Vernon's Texas Insurance Code), applies to a
cross-border health care plan, except that Subsection (i)(3) of
that section does not apply to a cross-border health care plan.
Articles 21.07-6 and 21.58A, Insurance Code, do not apply to the
activities of physicians, providers, and other persons doing
business in the United Mexican States.
Art. 20B.06. RULES AND REGULATIONS. The commissioner may
adopt reasonable rules and regulations to:
(1) prescribe the information to be provided to
prospective and current group contract holders and enrollees; and
(2) govern communications with providers and
physicians relating to the enrollee's medical condition or
treatment options.
SECTION 2 This Act takes effect September 1, 2001, and
applies only to a health care plan offered by a health maintenance
organization on or after that date. A health care plan that is
offered by a health maintenance organization before September 1,
2001, is governed by the law as it existed immediately before the
effective date of this Act, and that law is continued in effect for
that purpose.