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. 3-24 * * * * *