By Smithee                                            H.B. No. 2831
         77R7556 AJA-D                           
                                A BILL TO BE ENTITLED
 1-1                                   AN ACT
 1-2     relating to notification to certain health care providers of the
 1-3     standards used by a managed care entity to determine the amount of
 1-4     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 to enrollees through contracts with health care
2-14     professionals  or health care facilities; and
2-15                       (B)  that provides financial incentives to
2-16     enrollees in the plan to use the participating practitioners,
2-17     participating health care facilities, and procedures covered by the
2-18     plan.
2-19           Sec. 2.  PROVISION OF INFORMATION REQUIRED. On the request of
2-20     a health care provider, a managed care entity shall provide the
2-21     provider with a written description of the standards used by the
2-22     managed care entity to determine the amount of reimbursement that
2-23     an out-of-network provider may receive for goods or services
2-24     provided to an enrollee in the entity's managed care plan.
2-25           Sec. 3.  RULES. The commissioner shall adopt rules as
2-26     necessary to implement this article.
2-27           SECTION 2. This Act takes effect September 1, 2001.