BILL ANALYSIS
Senate Research Center S.B. 1149
By: Harris
AUTHOR'S/SPONSOR'S STATEMENT OF INTENT
Current Texas law does not require health plans to provide real-time information. Most health plans issue enrollee information cards that provide some of this information. The information on these cards is dynamic and changes frequently, such as an enrollee's deductible, the health plan's contracted network of physicians and hospitals, and the contracted physicians with privileges at contracted hospitals.
S.B. 1149 requires that health plans make available to participating providers, by telephone or electronically, information relating to enrollee demographics, enrollment and eligibility status, benefits, and financial responsibility. It also requires health plans to provide a list of hospitals and participating providers and a listing of physicians with hospital privileges at each hospital.
RULEMAKING AUTHORITY
Rulemaking authority is expressly granted to the commissioner of insurance in SECTION 1 (Sections 1247.004 and 1274.005, Insurance Code) of this bill.
SECTION BY SECTION ANALYSIS
SECTION 1. Amends Subtitle C, Title 8, Insurance Code, by adding Chapter 1274, as follows:
CHAPTER 1274. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND
PAYMENT STATUS
Sec. 1274.001. DEFINITIONS. Defines "enrollee," "health benefit plan," "health benefit plan issuer," "health care provider," "participating provider," and "physician."
Sec. 1274.0015. EXEMPTION. Provides that this chapter does not apply to a single-service health maintenance organization that provides coverage only for dental or vision benefits.
Sec. 1274.002. TRANSMISSION OF ENROLLEE ELIGIBILITY AND PAYMENT STATUS. (a) Requires each health benefit plan issuer to, upon the participating provider's submission of specific patient information, make available telephonically, electronically, or by an Internet website portal to each participating provider, information maintained in the ordinary course of business and sufficient for the provider to determine at the time of the enrollee's visit specific information concerning the enrollee, the enrollee's benefits, and the enrollee's financial information.
(b) Provides that information required to be made available under this section may be made available only to a participating provider who is authorized under state and federal law to receive personally identifiable information on an enrollee or dependent.
Sec. 1274.003. CERTAIN CHARGES PROHIBITED. Prohibits a health benefit plan issuer from directly or indirectly charging or holding a physician, health care provider, or enrollee responsible for a fee for making available or accessing information under this chapter.
Sec. 1274.004. RULES. Requires the commissioner of insurance (commissioner) to adopt rules to implement the provisions of this chapter. Requires the commissioner to consult and receive advice from the Technical Advisory Committee on Claims Processing established under Article 21.52Y (Technical Advisory Committee on Claims Processing), before adopting the rules.
Sec. 1274.005. WAIVER OF CERTAIN PROVISIONS FOR CERTAIN FEDERAL PLANS. Requires the commissioner, by rule, in consultation with the commissioner of health and human services, upon determining that a provision of Section 1274.002 will cause a negative fiscal impact on the state with respect to providing benefits or services under Subchapter XIX, Social Security Act (42 U.S.C. Section 1396 et seq.) or Subchapter XXI, Social Security Act (42 U.S.C. Section 1397aa et seq.), to waive the application of that provision to the providing of those benefits or services.
SECTION 2. (a) Requires the commissioner, except as provided by Subsection (b) of this section, to adopt rules necessary to implement Chapter 1274, Insurance Code, as added by this Act, not later than January 1, 2006.
(b) Requires the commissioner, as soon as practicable, but not later than the 90th day after the effective date of this Act, to adopt rules necessary to implement Section 1274.005, Insurance Code, as added by this Act. Authorizes the commissioner to use the procedures under Section 2001.034 (Emergency Rulemaking), Government Code, for adopting emergency rules under this subsection. Provides that the commissioner is not required to make the finding described by Section 2001.034(a), Government Code, to adopt emergency rules under this subsection.
SECTION 3. Makes application of this Act prospective to January 31, 2006.
SECTION 4. Effective date: upon passage or September 1, 2005.