1-1 AN ACT
1-2 relating to notification to certain health care providers of the
1-3 factors considered by a managed care entity in determining the
1-4 amount of reimbursement for an out-of-network provider.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.60 to read as follows:
1-8 Art. 21.60. AVAILABILITY OF CERTAIN REIMBURSEMENT GUIDELINES
1-9 USED BY MANAGED CARE ENTITY
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Health care provider" means:
1-12 (A) a hospital, emergency clinic, outpatient
1-13 clinic, or other facility providing health care; or
1-14 (B) an individual who is licensed in this state
1-15 to provide health care.
1-16 (2) "Managed care entity" means a health maintenance
1-17 organization, a preferred provider organization, an approved
1-18 nonprofit health corporation that holds a certificate of authority
1-19 issued by the commissioner under Article 21.52F of this code, and
1-20 any other entity that offers a managed care plan, including:
1-21 (A) an insurance company;
1-22 (B) a group hospital service corporation
1-23 operating under Chapter 20 of this code;
1-24 (C) a fraternal benefit society operating under
2-1 Chapter 10 of this code;
2-2 (D) a stipulated premium insurance company
2-3 operating under Chapter 22 of this code;
2-4 (E) a multiple employer welfare arrangement that
2-5 holds a certificate of authority under Article 3.95-2 of this code;
2-6 or
2-7 (F) any entity not licensed under this code or
2-8 another insurance law of this state that contracts directly for
2-9 health care services on a risk-sharing basis, including an entity
2-10 that contracts for health care services under a capitation method.
2-11 (3) "Managed care plan" means a health benefit plan:
2-12 (A) under which health care services are
2-13 provided through contracts with health care professionals or health
2-14 care facilities to persons enrolled in or insured under the plan;
2-15 and
2-16 (B) that provides financial incentives to
2-17 persons enrolled in or insured under the plan to use the
2-18 participating practitioners, participating health care facilities,
2-19 and procedures covered by the plan.
2-20 Sec. 2. PROVISION OF INFORMATION REQUIRED. (a) On the
2-21 written request of an out-of-network health care provider, a
2-22 managed care entity shall provide the provider with a written
2-23 description of the factors considered by the managed care entity in
2-24 determining the amount of reimbursement that the out-of-network
2-25 provider may receive for goods or services provided to a person
2-26 enrolled in or insured under the entity's managed care plan.
2-27 (b) This article does not require a managed care entity to
3-1 disclose proprietary information that a contract between the
3-2 managed care entity and a vendor who supplies payment or
3-3 statistical data to the managed care entity prohibits from
3-4 disclosure.
3-5 (c) A contract between the managed care entity and a vendor
3-6 who supplies payment or statistical data to the managed care entity
3-7 may not prohibit the managed care entity from disclosing under this
3-8 section:
3-9 (1) the name of the vendor; or
3-10 (2) the methodology and origin of information used to
3-11 compute the amount of reimbursement.
3-12 (d) A managed care entity that denies a request for
3-13 information under Subsection (b) of this section shall send a copy
3-14 of the request and the information requested to the department for
3-15 review.
3-16 Sec. 3. RULES. The commissioner shall adopt rules as
3-17 necessary to implement this article.
3-18 SECTION 2. This Act takes effect September 1, 2001.
_______________________________ _______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 2831 was passed by the House on May
5, 2001, by a non-record vote.
_______________________________
Chief Clerk of the House
I certify that H.B. No. 2831 was passed by the Senate on May
22, 2001, by the following vote: Yeas 30, Nays 0, 1 present, not
voting.
_______________________________
Secretary of the Senate
APPROVED: __________________________
Date
__________________________
Governor