77R13011 AJA-D By Smithee H.B. No. 2831 Substitute the following for H.B. No. 2831: By Smithee C.S.H.B. No. 2831 A BILL TO BE ENTITLED 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.