By: Lucio S.B. No. 1826 Line and page numbers may not match official copy. Bill not drafted by TLC or Senate E&E. A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to certain cross-border health care plans offered by 1-3 health maintenance organizations. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. The Texas Insurance Code is amended by adding 1-6 Chapter 20B to read as follows: 1-7 CHAPTER 20B - CROSS BORDER HEALTH CARE PLAN 1-8 Art. 20B.01 Short Title 1-9 This chapter may be cited as the Cross Border Health Care 1-10 Plan Act. 1-11 Art. 20B.02 Definitions 1-12 In this chapter: 1-13 (a) "Cross border health care plan" means a health care plan 1-14 offered or made available to the categories of persons listed below 1-15 and which is provided through a health maintenance organization 1-16 delivery network based exclusively on physicians, providers, or 1-17 other health maintenance organizations located in the United 1-18 Mexican States. The cross border health care plan may only be 1-19 offered or made available to the following persons and their 1-20 dependents: 1-21 (1) a citizen of the United Mexican States who works 1-22 or resides within 62 miles of the border of this state and the 1-23 United Mexican States; or 2-1 (2) a resident of the United Mexican States who works 2-2 within 62 miles of the border of this state and the United Mexican 2-3 States. 2-4 (b) "Basic health care services" means health care services 2-5 which the commissioner determines an enrolled population might 2-6 reasonably require in order to be maintained in good health, 2-7 including any services required by the applicable laws of the 2-8 United Mexican States. 2-9 (c) "Commissioner" means the commissioner of insurance. 2-10 (d) "Emergency care" means health care services provided in 2-11 a hospital emergency facility or comparable facility to evaluate 2-12 and stabilize medical conditions of a recent onset and severity, 2-13 including but not limited to severe pain, that would lead a prudent 2-14 layperson, possessing an average knowledge of medicine and health, 2-15 to believe that his or her condition, sickness, or injury is of 2-16 such a nature that failure to get immediate medical care could 2-17 result in: 2-18 (1) placing the patient's health in serious jeopardy; 2-19 (2) serious impairment to bodily functions; 2-20 (3) serious dysfunction of any bodily organ or part; 2-21 (4) serious disfigurement; or 2-22 (5) in the case of a pregnant woman, serious jeopardy 2-23 to the health of the fetus. 2-24 (e) "Enrollee" means an individual who is enrolled in a 2-25 health care plan, including covered dependents. 2-26 (f) "Health care plan" means any plan whereby any person 3-1 undertakes to provide, arrange for, pay for, or reimburse any part 3-2 of the cost of any health care services; provided, however, a part 3-3 of such plan consists of arranging for or the provision of health 3-4 care services, as distinguished from indemnification against the 3-5 cost of such service, on a prepaid basis through insurance or 3-6 otherwise. 3-7 (g) "Health care services" means any services, including the 3-8 furnishing to any individual of pharmaceutical services, medical, 3-9 chiropractic, or dental care, or hospitalization or incident to the 3-10 furnishing of such services, care, or hospitalization, as well as 3-11 the furnishing to any person of any and all other services for the 3-12 purpose of preventing, alleviating, curing or healing human illness 3-13 or injury. 3-14 (h) "Health maintenance organization" means any person who 3-15 arranges for or provides a health care plan to enrollees on a 3-16 prepaid basis. 3-17 (i) "Health maintenance organization delivery network" means 3-18 a health care delivery system in which a health maintenance 3-19 organization arranges for health care services directly or 3-20 indirectly through contracts and subcontracts with providers and 3-21 physicians, which providers and physicians may be licensed under 3-22 the laws of the United Mexican States. 3-23 Art. 20B.03 Coverage Offered 3-24 (a) A health maintenance organization licensed to provide 3-25 basic health care services under chapter 20A, Insurance Code, may 3-26 offer a cross border health care plan to individuals or to small 4-1 employers or large employers, as such terms are defined in the 4-2 Health Insurance Portability and Accountability Act (Chapter 26, 4-3 Vernon's Texas Insurance Code). In arranging for or providing a 4-4 cross border health care plan, a health maintenance organization 4-5 shall have all of the powers and authority granted under article 4-6 20A.06, Insurance Code. 4-7 (b) A cross border health care plan may limit its service 4-8 area to a geographic region within the United Mexican States and 4-9 may limit the coverage of out-of-area health care services 4-10 delivered in this state to emergency care services. The delivery 4-11 of emergency care services in this state under such a plan shall be 4-12 subject to the requirements of article 20A.04(a)(16), Insurance 4-13 Code. 4-14 (c) The delivery of health care services through the health 4-15 maintenance organization delivery network located in the United 4-16 Mexican States must be based on and determined by the prevailing 4-17 community standards in the United Mexican States, and the licensing 4-18 of physicians and providers is governed by the applicable laws of 4-19 the United Mexican States. A physician or provider providing 4-20 health care services through the delivery network is not required 4-21 to be licensed in this state. The credentialing, peer review, and 4-22 quality of care standards used by a health maintenance organization 4-23 offering a cross border health care plan is governed by the 4-24 standards that apply in the United Mexican States. 4-25 (d) A cross border health care plan may be made available to 4-26 eligible employees of a small or large employer, and their 5-1 dependents, only when chosen by the employer as an option among two 5-2 or more health benefit plans, at least one of which provides 5-3 coverage for health care services delivered in Texas. 5-4 (e) A health maintenance organization which offers a cross 5-5 border health care plan must contract with sufficient providers and 5-6 physicians to assure that all health care services for which 5-7 coverage is provided will be reasonably available and accessible. 5-8 Art. 20B.04 Applicability of Texas Health Maintenance 5-9 Organization Act 5-10 (a) A cross border health care plan must satisfy the 5-11 requirements of article 20A.09, Insurance Code; provided, however, 5-12 the provisions relating to state continuation of coverage and 5-13 conversion shall not be applicable to such health care plan. A 5-14 health maintenance organization shall file the form of its cross 5-15 border health care plan for information only with the commissioner, 5-16 accompanied by a certification on its behalf that upon best 5-17 knowledge, information and belief, such filed form complies in all 5-18 respects with the applicable provisions of this Code and the 5-19 adopted rules and regulations that are applicable to such form 5-20 being filed. 5-21 (b) A cross border health care plan and the health 5-22 maintenance organization offering such a plan is exempt from the 5-23 requirements of articles 20A.09E, 20A.09F, 20A.11, 20A.11A, 5-24 20A.11B, 20A.18A, 20A.18B, 20A.18C, 20A.29, 20A.37, 20A.38, and 5-25 26.09, Insurance Code, and any rules or regulations promulgated 5-26 pursuant thereto. The commissioner shall not be charged with the 6-1 responsibility of examining a health maintenance organization with 6-2 respect to the quality of health care services delivered under a 6-3 cross border health care plan by providers and physicians located 6-4 in the United Mexican States. 6-5 (c) Articles 20A.12, 20A.12A, 20A.12B, Insurance Code, shall 6-6 apply to a cross border health care plan only to the extent that an 6-7 enrollee under such a plan receives health care services delivered 6-8 by a physician or provider located in this state. 6-9 (d) The provisions of article 20A.26, Insurance Code, other 6-10 than subsection (i)(3), shall apply to a cross border health care 6-11 plan. Articles 21.07-6 and 21.58A, Insurance Code, shall not apply 6-12 to the activities of physicians, providers, and other persons doing 6-13 business in the United Mexican States. 6-14 Art. 20B.05 Rules and Regulations 6-15 The commissioner is authorized to promulgate such reasonable 6-16 rules and regulations to prescribe the information to be provided 6-17 to prospective and current group contract holders and enrollees; 6-18 and communications with providers and physicians relating to the 6-19 enrollee's medical condition or treatment options. 6-20 Art. 20B.06 Severability 6-21 If any provision of this Act or the application thereof to 6-22 any person or circumstance is held invalid for any reason, the 6-23 invalidity shall not affect the other provisions or any other 6-24 application of this Act which can be given effect without the 6-25 invalid provisions or application. To this end, all provisions of 6-26 the Texas Cross Border Health Care Plan Act are declared to be 7-1 severable. 7-2 SECTION 2. This Act takes effect September 1, 2001, and 7-3 applies only to a health care plan offered by a health maintenance 7-4 organization on or after that date. A health care plan that is 7-5 offered by a health maintenance organization before September 1, 7-6 2001, is governed by the law as it existed immediately before the 7-7 effective date of this Act, and that law is continued in effect for 7-8 that purpose.