1-1 By: Smithee (Senate Sponsor - Sibley) H.B. No. 2831 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 favorably by the following 1-5 vote: Yeas 5, Nays 0; May 10, 2001, sent to printer.) 1-6 A BILL TO BE ENTITLED 1-7 AN ACT 1-8 relating to notification to certain health care providers of the 1-9 factors considered by a managed care entity in determining the 1-10 amount of reimbursement for an out-of-network provider. 1-11 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-12 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is 1-13 amended by adding Article 21.60 to read as follows: 1-14 Art. 21.60. AVAILABILITY OF CERTAIN REIMBURSEMENT GUIDELINES 1-15 USED BY MANAGED CARE ENTITY 1-16 Sec. 1. DEFINITIONS. In this article: 1-17 (1) "Health care provider" means: 1-18 (A) a hospital, emergency clinic, outpatient 1-19 clinic, or other facility providing health care; or 1-20 (B) an individual who is licensed in this state 1-21 to provide health care. 1-22 (2) "Managed care entity" means a health maintenance 1-23 organization, a preferred provider organization, an approved 1-24 nonprofit health corporation that holds a certificate of authority 1-25 issued by the commissioner under Article 21.52F of this code, and 1-26 any other entity that offers a managed care plan, including: 1-27 (A) an insurance company; 1-28 (B) a group hospital service corporation 1-29 operating under Chapter 20 of this code; 1-30 (C) a fraternal benefit society operating under 1-31 Chapter 10 of this code; 1-32 (D) a stipulated premium insurance company 1-33 operating under Chapter 22 of this code; 1-34 (E) a multiple employer welfare arrangement that 1-35 holds a certificate of authority under Article 3.95-2 of this code; 1-36 or 1-37 (F) any entity not licensed under this code or 1-38 another insurance law of this state that contracts directly for 1-39 health care services on a risk-sharing basis, including an entity 1-40 that contracts for health care services under a capitation method. 1-41 (3) "Managed care plan" means a health benefit plan: 1-42 (A) under which health care services are 1-43 provided through contracts with health care professionals or health 1-44 care facilities to persons enrolled in or insured under the plan; 1-45 and 1-46 (B) that provides financial incentives to 1-47 persons enrolled in or insured under the plan to use the 1-48 participating practitioners, participating health care facilities, 1-49 and procedures covered by the plan. 1-50 Sec. 2. PROVISION OF INFORMATION REQUIRED. (a) On the 1-51 written request of an out-of-network health care provider, a 1-52 managed care entity shall provide the provider with a written 1-53 description of the factors considered by the managed care entity in 1-54 determining the amount of reimbursement that the out-of-network 1-55 provider may receive for goods or services provided to a person 1-56 enrolled in or insured under the entity's managed care plan. 1-57 (b) This article does not require a managed care entity to 1-58 disclose proprietary information that a contract between the 1-59 managed care entity and a vendor who supplies payment or 1-60 statistical data to the managed care entity prohibits from 1-61 disclosure. 1-62 (c) A contract between the managed care entity and a vendor 1-63 who supplies payment or statistical data to the managed care entity 1-64 may not prohibit the managed care entity from disclosing under this 2-1 section: 2-2 (1) the name of the vendor; or 2-3 (2) the methodology and origin of information used to 2-4 compute the amount of reimbursement. 2-5 (d) A managed care entity that denies a request for 2-6 information under Subsection (b) of this section shall send a copy 2-7 of the request and the information requested to the department for 2-8 review. 2-9 Sec. 3. RULES. The commissioner shall adopt rules as 2-10 necessary to implement this article. 2-11 SECTION 2. This Act takes effect September 1, 2001. 2-12 * * * * *