By Smithee H.B. No. 2828
77R7075 AJA-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to delegation of certain functions by a health maintenance
1-3 organization; providing penalties.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 11(b), Texas Health Maintenance
1-6 Organization Act (Article 20A.11, Vernon's Texas Insurance Code),
1-7 is amended to read as follows:
1-8 (b) A health maintenance organization shall provide an
1-9 accurate written description of health care plan terms and
1-10 conditions, including an explanation of delegated networks and
1-11 restrictions or limitations related to limited provider networks or
1-12 delegated networks within a health care plan, to allow any current
1-13 or prospective group contract holder and current or prospective
1-14 enrollee eligible for enrollment in a health care plan to make
1-15 comparisons and informed decisions before selecting among health
1-16 care plans. The written description must be in a readable and
1-17 understandable format as prescribed by the commissioner and shall
1-18 include a current list of physicians and providers, including
1-19 delineation of limited provider networks and delegated networks.
1-20 The health maintenance organization may provide its handbook to
1-21 satisfy this requirement provided the handbook's content is
1-22 substantially similar to and achieves the same level of disclosure
1-23 as the written description prescribed by the commissioner and the
1-24 current list of physicians and providers is also provided. Not
2-1 later than the 30th day after the date a person enrolls in a health
2-2 maintenance organization health care plan, the health maintenance
2-3 organization shall provide the person with the descriptions
2-4 required by this subsection relating to limited provider networks
2-5 and delegated networks. When a health maintenance organization
2-6 issues an identification card to an enrollee, the health
2-7 maintenance organization shall provide the enrollee with
2-8 standardized information relating to limited provider networks.
2-9 Duties under this subsection may not be delegated by a health
2-10 maintenance organization and may not be waived or eliminated by
2-11 contract.
2-12 SECTION 2. Section 12(q), Texas Health Maintenance
2-13 Organization Act (Article 20A.12, Vernon's Texas Insurance Code),
2-14 is amended to read as follows:
2-15 (q) Each health maintenance organization shall maintain
2-16 documentation on each complaint received and the action taken on
2-17 the complaint until the third anniversary of the date of receipt of
2-18 the complaint and shall provide copies of the complaint to the
2-19 Texas Department of Insurance in a format prescribed by rule by the
2-20 commissioner. The department shall periodically issue a report on
2-21 the complaints received by the department under this subsection
2-22 that includes a list of complaints by category, by action taken on
2-23 the complaint, and by network name and type. The department shall
2-24 make the report available to the public and shall include
2-25 information to assist the public in evaluating the information
2-26 contained in the report. The department [Texas Department of
2-27 Insurance] may review documentation maintained under this
3-1 subsection, including original documentation, during any
3-2 investigation of the health maintenance organization.
3-3 SECTION 3. Section 18C, Texas Health Maintenance Organization
3-4 Act (Article 20A.18C, Vernon's Texas Insurance Code), is amended by
3-5 adding a new Subsection (o) and redesignating existing Subsection
3-6 (o) as Subsection (p) to read as follows:
3-7 (o) The commissioner by rule shall establish a system to
3-8 ensure that the information required by Subsections (b) and (c) of
3-9 this section is complete, accurate, and provided in a timely
3-10 manner. The commissioner may impose sanctions or penalties under
3-11 Chapters 82, 83, and 84, Insurance Code, on a health maintenance
3-12 organization that violates this section.
3-13 (p) [(o)] The commissioner may adopt rules as necessary to
3-14 interpret, implement, and enforce this section.
3-15 SECTION 4. The Texas Health Maintenance Organization Act
3-16 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding
3-17 Sections 18D and 18E to read as follows:
3-18 Sec. 18D. CONTINUITY OF CARE IN LIMITED PROVIDER NETWORKS OR
3-19 DELEGATED NETWORKS. (a) A health maintenance organization whose
3-20 plan includes limited provider networks or delegated networks shall
3-21 permit an enrollee to complete an episode of care without changing
3-22 the enrollee's primary care physician or specialist physician when
3-23 the physician moves from one limited provider network or delegated
3-24 care network to another network included in the plan if:
3-25 (1) the physician's move occurs during the contract
3-26 year of the plan; and
3-27 (2) at the time of the enrollee's enrollment the
4-1 physician was a member or provider of the limited provider network
4-2 or delegated network from which the physician is moving.
4-3 (b) A move by a physician described by Subsection (a) of
4-4 this section does not release the health maintenance organization
4-5 from the obligation to reimburse the primary care physician or
4-6 specialist physician involved with the care and treatment of the
4-7 patient.
4-8 Sec. 18E. CONSIDERATION OF REQUEST FOR CARE OUTSIDE
4-9 DELEGATED NETWORK. (a) A delegated network that enters into a
4-10 delegation agreement with a health maintenance organization shall
4-11 establish and provide to the health maintenance organization in
4-12 writing a process under which enrollee requests that specific
4-13 health care services be provided outside the delegated network will
4-14 be considered.
4-15 (b) A denial by a delegated network of a request by an
4-16 enrollee under this section shall be sent by the delegated network
4-17 to the health maintenance organization for second review.
4-18 (c) A review or decision by a delegated network under this
4-19 section must comply with all medical necessity determinations
4-20 required under this Act or any other law.
4-21 (d) This section does not apply to a review or determination
4-22 subject to appeal under a statute, including Section 12A of this
4-23 Act and Article 21.58C, Insurance Code.
4-24 SECTION 5. Section 5, Chapter 621, Acts of the 76th
4-25 Legislature, Regular Session, 1999, is repealed.
4-26 SECTION 6. The change in law made by Section 18D, Texas
4-27 Health Maintenance Organization Act (Chapter 20A, Vernon's Texas
5-1 Insurance Code), and Section 18E, Texas Health Maintenance
5-2 Organization Act (Chapter 20A, Vernon's Texas Insurance Code), as
5-3 added by this Act, applies only to a health maintenance
5-4 organization contract entered into or renewed on or after January
5-5 1, 2002. A health maintenance organization contract entered into
5-6 before January 1, 2002, is governed by the law in effect
5-7 immediately before the effective date of this Act, and that law is
5-8 continued in effect for that purpose.
5-9 SECTION 7. This Act takes effect September 1, 2001.