By Haggerty, Oliveira, Gallego, Solis, H.B. No. 2498 A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to certain cross-border health care plans offered by 1-3 health maintenance organizations. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Title 1, Insurance Code, is amended by adding 1-6 Chapter 20B to read as follows: 1-7 CHAPTER 20B. CROSS-BORDER HEALTH CARE PLAN 1-8 Art. 20B.01. SHORT TITLE. This chapter may be cited as the 1-9 Cross-Border Health Care Plan Act. 1-10 Art. 20B.02. DEFINITIONS. In this chapter: 1-11 (1) "Basic health care services" means health care 1-12 services that the commissioner determines an enrolled population 1-13 might reasonably require in order to be maintained in good health, 1-14 including any services required by the applicable laws of the 1-15 United Mexican States. 1-16 (2) "Cross-border health care plan" means a health 1-17 care plan that is offered or made available to the categories of 1-18 persons described by Article 20B.03 of this code and that is 1-19 provided through a health maintenance organization delivery network 1-20 based exclusively on physicians, providers, or other health 1-21 maintenance organizations located in the United Mexican States. 1-22 (3) "Emergency care" means health care services 1-23 provided in a hospital emergency facility or comparable facility to 1-24 evaluate and stabilize medical conditions of a recent onset and 1-25 severity, including severe pain, that would lead a prudent 2-1 layperson, possessing an average knowledge of medicine and health, 2-2 to believe that the individual's condition, sickness, or injury is 2-3 of such a nature that failure to get immediate medical care could 2-4 result in: 2-5 (A) placing the patient's health in serious 2-6 jeopardy; 2-7 (B) serious impairment to bodily functions; 2-8 (C) serious dysfunction of any bodily organ or 2-9 part; 2-10 (D) serious disfigurement; or 2-11 (E) in the case of a pregnant woman, serious 2-12 jeopardy to the health of the fetus. 2-13 (4) "Enrollee" means an individual who is enrolled in 2-14 a health care plan, including covered dependents. 2-15 (5) "Health care plan" means a plan under which a 2-16 person undertakes to provide, arrange for, pay for, or reimburse 2-17 any part of the cost of any health care services if a part of the 2-18 plan consists of providing or arranging for health care services on 2-19 a prepaid basis through insurance or otherwise, as distinguished 2-20 from indemnification against the cost of the service. 2-21 (6) "Health care services" means services provided to 2-22 an individual to prevent, alleviate, cure, or heal human illness or 2-23 injury. The term includes: 2-24 (A) pharmaceutical services; 2-25 (B) medical, chiropractic, or dental care; 2-26 (C) hospitalization; and 2-27 (D) care or services incidental to the health 3-1 care services described by Paragraphs (A)-(C). 3-2 (7) "Health maintenance organization" means a person 3-3 or entity that arranges for or provides a health care plan to 3-4 enrollees on a prepaid basis. 3-5 (8) "Health maintenance organization delivery network" 3-6 means a health care delivery system in which a health maintenance 3-7 organization arranges for health care services directly or 3-8 indirectly through contracts and subcontracts with providers and 3-9 physicians. 3-10 Art. 20B.03. ELIGIBILITY FOR COVERAGE. A cross-border health 3-11 care plan may only be offered or made available to the following 3-12 persons and their dependents: 3-13 (1) a citizen of the United Mexican States who works 3-14 or resides within 62 miles of the border of this state and the 3-15 United Mexican States; or 3-16 (2) a resident of the United Mexican States who works 3-17 within 62 miles of the border of this state and the United Mexican 3-18 States. 3-19 Art. 20B.04. COVERAGE OFFERED. (a) A health maintenance 3-20 organization licensed to provide basic health care services under 3-21 the Texas Health Maintenance Organization Act (Chapter 20A, 3-22 Vernon's Texas Insurance Code) may offer a cross-border health care 3-23 plan to individuals or to small employers or large employers, as 3-24 those terms are defined by Article 26.02 of this code. In 3-25 arranging for or providing a cross-border health care plan, a 3-26 health maintenance organization has all of the powers and authority 3-27 granted under Section 6, Texas Health Maintenance Organization Act 4-1 (Article 20A.06, Vernon's Texas Insurance Code). 4-2 (b) A cross-border health care plan may limit its service 4-3 area to a geographic region within the United Mexican States and 4-4 may limit the coverage of out-of-area health care services 4-5 delivered in this state to emergency care services. The delivery 4-6 of emergency care services in this state under the plan is subject 4-7 to the requirements of Section 4(a)(16), Texas Health Maintenance 4-8 Organization Act (Article 20A.04, Vernon's Texas Insurance Code). 4-9 (c) The delivery of health care services through the health 4-10 maintenance organization delivery network located in the United 4-11 Mexican States must be based on and determined by the prevailing 4-12 community standards in the United Mexican States, and the licensing 4-13 of physicians and providers is governed by the applicable laws of 4-14 the United Mexican States. A physician or provider providing 4-15 health care services through the delivery network is not required 4-16 to be licensed in this state. The credentialing, peer review, and 4-17 quality of care standards used by a health maintenance organization 4-18 offering a cross-border health care plan is governed by the 4-19 standards that apply in the United Mexican States. 4-20 (d) A cross-border health care plan may be made available to 4-21 eligible employees of a small or large employer, and their 4-22 dependents, only when chosen by the employer as an option among two 4-23 or more health benefit plans, at least one of which provides 4-24 coverage for health care services delivered in this state. 4-25 (e) A health maintenance organization that offers a 4-26 cross-border health care plan must contract with sufficient 4-27 providers and physicians to assure that all health care services 5-1 for which coverage is provided will be reasonably available and 5-2 accessible. 5-3 Art. 20B.05. APPLICABILITY OF TEXAS HEALTH MAINTENANCE 5-4 ORGANIZATION ACT. (a) A cross-border health care plan must satisfy 5-5 the requirements of Section 9, Texas Health Maintenance 5-6 Organization Act (Article 20A.09, Vernon's Texas Insurance Code), 5-7 except that the provisions relating to state continuation of 5-8 coverage and conversion do not apply to a cross-border health care 5-9 plan. A health maintenance organization shall file the form of its 5-10 cross-border health care plan for information only with the 5-11 commissioner, accompanied by a certification on its behalf that on 5-12 best knowledge, information, and belief, the filed form complies in 5-13 all respects with the applicable provisions of this code, the Texas 5-14 Health Maintenance Organization Act, and the adopted rules and 5-15 regulations that are applicable to the form. 5-16 (b) A cross-border health care plan and the health 5-17 maintenance organization offering such a plan are exempt from the 5-18 requirements of Sections 9E, 9F, 11, 11A, 11B, 18A, as added by 5-19 Chapter 1026, Acts of the 75th Legislature, Regular Session, 1997, 5-20 18A, as added by Chapter 735, Acts of the 75th Legislature, Regular 5-21 Session, 1997, 18B, 18C, 29, 37, and 38, Texas Health Maintenance 5-22 Organization Act (Articles 20A.09E, 20A.09F, 20A.11, 20A.11A, 5-23 20A.11B, 20A.18A, as added by Chapter 1026, Acts of the 75th 5-24 Legislature, Regular Session, 1997, 20A.18A, as added by Chapter 5-25 735, Acts of the 75th Legislature, Regular Session, 1997, 20A.18B, 5-26 20A.18C, 20A.29, 20A.37, and 20A.38, Vernon's Texas Insurance 5-27 Code), and Article 26.09, Insurance Code, and any rules or 6-1 regulations adopted under those laws. The commissioner is not 6-2 required to examine a health maintenance organization with respect 6-3 to the quality of health care services delivered under a 6-4 cross-border health care plan by providers and physicians located 6-5 in the United Mexican States. 6-6 (c) Sections 12, 12A, and 12B, Texas Health Maintenance 6-7 Organization Act (Articles 20A.12, 20A.12A, and 20A.12B, Vernon's 6-8 Texas Insurance Code), apply to a cross-border health care plan 6-9 only to the extent that an enrollee under the plan receives health 6-10 care services delivered by a physician or provider located in this 6-11 state. 6-12 (d) Section 26, Texas Health Maintenance Organization Act 6-13 (Article 20A.26, Vernon's Texas Insurance Code), applies to a 6-14 cross-border health care plan, except that Subsection (i)(3) of 6-15 that section does not apply to a cross-border health care plan. 6-16 Articles 21.07-6 and 21.58A, Insurance Code, do not apply to the 6-17 activities of physicians, providers, and other persons doing 6-18 business in the United Mexican States. 6-19 Art. 20B.06. RULES AND REGULATIONS. The commissioner may 6-20 adopt reasonable rules and regulations to: 6-21 (1) prescribe the information to be provided to 6-22 prospective and current group contract holders and enrollees; and 6-23 (2) govern communications with providers and 6-24 physicians relating to the enrollee's medical condition or 6-25 treatment options. 6-26 SECTION 2. This Act takes effect September 1, 2001, and 6-27 applies only to a health care plan offered by a health maintenance 7-1 organization on or after that date. A health care plan that is 7-2 offered by a health maintenance organization before September 1, 7-3 2001, is governed by the law as it existed immediately before the 7-4 effective date of this Act, and that law is continued in effect for 7-5 that purpose.