1-1     By:  Haggerty, et al. (Senate Sponsor - Lucio)        H.B. No. 2498
 1-2           (In the Senate - Received from the House May 7, 2001;
 1-3     May 7, 2001, read first time and referred to Committee on Business
 1-4     and Commerce; May 10, 2001, reported adversely, with favorable
 1-5     Committee Substitute by the following vote:  Yeas 4, Nays 1;
 1-6     May 10, 2001, sent to printer.)
 1-7     COMMITTEE SUBSTITUTE FOR H.B. No. 2498                   By:  Lucio
 1-8                            A BILL TO BE ENTITLED
 1-9                                   AN ACT
1-10     relating to certain cross-border health care plans offered by
1-11     health maintenance organizations.
1-12           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13           SECTION 1.  Title 1, Insurance Code, is amended by adding
1-14     Chapter 20B to read as follows:
1-15                 CHAPTER 20B.  CROSS-BORDER HEALTH CARE PLAN
1-16           Art. 20B.01.  SHORT TITLE. This chapter may be cited as the
1-17     Cross-Border Health Care Plan Act.
1-18           Art. 20B.02.  DEFINITIONS. In this chapter:
1-19                 (1)  "Basic health care services" means health care
1-20     services that the commissioner determines an enrolled population
1-21     might reasonably require in order to be maintained in good health,
1-22     including any services required by the applicable laws of the
1-23     United Mexican States.
1-24                 (2)  "Cross-border health care plan" means a health
1-25     care plan that is offered or made available to the categories of
1-26     persons described by Article 20B.03 of this code and that is
1-27     provided through a health maintenance organization delivery network
1-28     based exclusively on physicians, providers, or other health
1-29     maintenance organizations located in the United Mexican States.
1-30                 (3)  "Emergency care" means health care services
1-31     provided in a hospital emergency facility or comparable facility to
1-32     evaluate and stabilize medical conditions of a recent onset and
1-33     severity, including severe pain, that would lead a prudent
1-34     layperson, possessing an average knowledge of medicine and health,
1-35     to believe that the individual's condition, sickness, or injury is
1-36     of such a nature that failure to get immediate medical care could
1-37     result in:
1-38                       (A)  placing the patient's health in serious
1-39     jeopardy;
1-40                       (B)  serious impairment to bodily functions;
1-41                       (C)  serious dysfunction of any bodily organ or
1-42     part;
1-43                       (D)  serious disfigurement; or
1-44                       (E)  in the case of a pregnant woman, serious
1-45     jeopardy to the health of the fetus.
1-46                 (4)  "Enrollee" means an individual who is enrolled in
1-47     a health care plan, including covered dependents.
1-48                 (5)  "Health care plan" means a plan under which a
1-49     person undertakes to provide, arrange for, pay for, or reimburse
1-50     any part of the cost of any health care services if a part of the
1-51     plan consists of providing or arranging for health care services on
1-52     a prepaid basis through insurance or otherwise, as distinguished
1-53     from indemnification against the cost of the service.
1-54                 (6)  "Health care services" means services provided to
1-55     an individual to prevent, alleviate, cure, or heal human illness or
1-56     injury. The term includes:
1-57                       (A)  pharmaceutical services;
1-58                       (B)  medical, chiropractic, or dental care;
1-59                       (C)  hospitalization; and
1-60                       (D)  care or services incidental to the health
1-61     care services described by Paragraphs (A)-(C).
1-62                 (7)  "Health maintenance organization" means a person
1-63     or entity that arranges for or provides a health care plan to
1-64     enrollees on a prepaid basis.
 2-1                 (8)  "Health maintenance organization delivery network"
 2-2     means a health care delivery system in which a health maintenance
 2-3     organization arranges for health care services directly or
 2-4     indirectly through contracts and subcontracts with providers and
 2-5     physicians.
 2-6           Art. 20B.03.  ELIGIBILITY FOR COVERAGE. A cross-border health
 2-7     care plan may only be offered or made available to the following
 2-8     persons and their dependents:
 2-9                 (1)  a citizen of the United Mexican States who works
2-10     or resides within 62 miles of the border of this state and the
2-11     United Mexican States; or
2-12                 (2)  a resident of the United Mexican States who works
2-13     within 62 miles of the border of this state and the United Mexican
2-14     States.
2-15           Art. 20B.04.  COVERAGE OFFERED. (a)  A health maintenance
2-16     organization licensed to provide basic health care services under
2-17     the Texas Health Maintenance Organization Act (Chapter 20A,
2-18     Vernon's Texas Insurance Code) may offer a cross-border health care
2-19     plan to individuals or to small employers or large employers, as
2-20     those terms are defined by Article 26.02 of this code.  In
2-21     arranging for or providing a cross-border health care plan, a
2-22     health maintenance organization has all of the powers and authority
2-23     granted under Section 6, Texas Health Maintenance Organization Act
2-24     (Article 20A.06, Vernon's Texas Insurance Code).
2-25           (b)  A cross-border health care plan may limit its service
2-26     area to a geographic region within the United Mexican States and
2-27     may limit the coverage of out-of-area health care services
2-28     delivered in this state to emergency care services.  The delivery
2-29     of emergency care services in this state under the plan is subject
2-30     to the requirements of Section 4(a)(16), Texas Health Maintenance
2-31     Organization Act (Article 20A.04, Vernon's Texas Insurance Code).
2-32           (c)  The delivery of health care services through the health
2-33     maintenance organization delivery network located in the United
2-34     Mexican States must be based on and determined by the prevailing
2-35     community standards in the United Mexican States, and the licensing
2-36     of physicians and providers is governed by the applicable laws of
2-37     the United Mexican States.  A physician or provider providing
2-38     health care services through the delivery network is not required
2-39     to be licensed in this state.  The credentialing, peer review, and
2-40     quality of care standards used by a health maintenance organization
2-41     offering a cross-border health care plan is governed by the
2-42     standards that apply in the United Mexican States.
2-43           (d)  A cross-border health care plan may be made available to
2-44     eligible employees of a small or large employer, and their
2-45     dependents, only when chosen by the employer as an option among two
2-46     or more health benefit plans, at least one of which provides
2-47     coverage for health care services delivered in this state.
2-48           (e)  A health maintenance organization that offers a
2-49     cross-border health care plan must contract with sufficient
2-50     providers and physicians to assure that all health care services
2-51     for which coverage is provided will be reasonably available and
2-52     accessible.
2-53           Art. 20B.05.  APPLICABILITY OF TEXAS HEALTH MAINTENANCE
2-54     ORGANIZATION ACT. (a)  A cross-border health care plan must satisfy
2-55     the requirements of Section 9, Texas Health Maintenance
2-56     Organization Act (Article 20A.09, Vernon's Texas Insurance Code),
2-57     except that the provisions relating to state continuation of
2-58     coverage and conversion do not apply to a cross-border health care
2-59     plan.  A health maintenance organization shall file the form of its
2-60     cross-border health care plan for information only with the
2-61     commissioner, accompanied by a certification on its behalf that on
2-62     best knowledge, information, and belief, the filed form complies in
2-63     all respects with the applicable provisions of this code, the Texas
2-64     Health Maintenance Organization Act, and the adopted rules and
2-65     regulations that are applicable to the form.
2-66           (b)  Sections 12, 12A, and 12B, Texas Health Maintenance
2-67     Organization Act (Articles 20A.12, 20A.12A, and 20A.12B, Vernon's
2-68     Texas Insurance Code), apply to a cross-border health care plan
2-69     only to the extent that an enrollee under the plan receives health
 3-1     care services delivered by a physician or provider located in this
 3-2     state.
 3-3           (c)  Section 26, Texas Health Maintenance Organization Act
 3-4     (Article 20A.26, Vernon's Texas Insurance Code), applies to a
 3-5     cross-border health care plan, except that Subsection (i)(3) of
 3-6     that section does not apply to a cross-border health care plan.
 3-7     Articles 21.07-6 and 21.58A, Insurance Code, do not apply to the
 3-8     activities of physicians, providers, and other persons doing
 3-9     business in the United Mexican States.
3-10           Art. 20B.06.  RULES AND REGULATIONS. The commissioner may
3-11     adopt reasonable rules and regulations to:
3-12                 (1)  prescribe the information to be provided to
3-13     prospective and current group contract holders and enrollees; and
3-14                 (2)  govern communications with providers and
3-15     physicians relating to the enrollee's medical condition or
3-16     treatment options.
3-17           SECTION 2.  This Act takes effect September 1, 2001, and
3-18     applies only to a health care plan offered by a health maintenance
3-19     organization on or after that date.  A health care plan that is
3-20     offered by a health maintenance organization before September 1,
3-21     2001, is governed by the law as it existed immediately before the
3-22     effective date of this Act, and that law is continued in effect for
3-23     that purpose.
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