79R1928 PB-F
By: Eiland H.B. No. 978
A BILL TO BE ENTITLED
AN ACT
relating to the quality assurance accreditation process for certain
entities that offer health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 6, Insurance Code, is amended
by adding Chapter 847 to read as follows:
CHAPTER 847. HEALTH CARE QUALITY ASSURANCE
Sec. 847.001. SHORT TITLE. This chapter may be cited as the
Health Care Quality Assurance Act.
Sec. 847.002. LEGISLATIVE FINDINGS; PURPOSES. The
legislature finds that to ensure enrollees high quality care, many
health benefit plans voluntarily undergo a rigorous accreditation
process conducted by nationally recognized accreditation
organizations. To maintain accreditation, these health benefit
plans are subject to continuing review of their processes and
standards. The legislature recognizes that many of these processes
and standards are also reviewed by state agencies, resulting in
increased agency costs and increased health benefit plan
administrative costs. The purpose of this chapter is to allow
appropriate recognition of accreditation by nationally recognized
accreditation organizations and to foster coordination among state
agencies in order to:
(1) help make health benefit plan coverage more
affordable for consumers; and
(2) eliminate duplication of effort by both health
benefit plans and state agencies.
Sec. 847.003. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services
Commission.
(2) "Health benefit plan" means an individual, group,
blanket, or franchise insurance policy, a certificate issued under
a group policy, a group hospital service contract, or an individual
or group subscriber contract or evidence of coverage issued by a
health maintenance organization that provides benefits for health
care services. The term does not include:
(A) accident-only or disability income insurance
coverage or a combination of accident-only and disability income
insurance coverage;
(B) credit-only insurance coverage;
(C) disability insurance coverage;
(D) Medicare services under a federal contract;
(E) Medicare supplement and Medicare Select
benefit plans regulated in accordance with federal law;
(F) long-term care coverage or benefits, nursing
home care coverage or benefits, home health care coverage or
benefits, community-based care coverage or benefits, or any
combination of those coverages or benefits;
(G) workers' compensation insurance coverage or
similar insurance coverage;
(H) coverage provided through a jointly managed
trust authorized under 29 U.S.C. Section 141 et seq. that contains a
plan of benefits for employees that is negotiated in a collective
bargaining agreement governing wages, hours, and working
conditions of the employees that is authorized under 29 U.S.C.
Section 157;
(I) hospital indemnity or other fixed indemnity
insurance coverage;
(J) reinsurance contracts issued on a stop-loss,
quota-share, or similar basis;
(K) short-term major medical contracts;
(L) liability insurance coverage, including
general liability insurance coverage and automobile liability
insurance coverage, and coverage issued as a supplement to
liability insurance coverage, including automobile medical payment
insurance coverage;
(M) coverage for on-site medical clinics;
(N) coverage that provides other limited
benefits specified by federal regulations; or
(O) other coverage that:
(i) is similar to the coverage described by
this subdivision under which benefits for medical care are
secondary or incidental to other coverage benefits; and
(ii) is specified by federal regulations.
(3) "National accreditation organization" means:
(A) the Accreditation Association for Ambulatory
Health Care;
(B) the Joint Commission on Accreditation of
Healthcare Organizations;
(C) the National Committee for Quality
Assurance;
(D) the American Accreditation HealthCare
Commission ("URAC"); or
(E) any other national accreditation entity
recognized by rule by the commissioner.
Sec. 847.004. APPLICABILITY OF CHAPTER. This chapter
applies only to an entity that issues a health benefit plan and that
holds a license or certificate of authority issued by the
commissioner and provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority issued by the commissioner under
Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885; or
(8) a reciprocal exchange operating under Chapter 942.
Sec. 847.005. DEEMED COMPLIANCE WITH CERTAIN STATUTORY AND
REGULATORY REQUIREMENTS. (a) Notwithstanding any provision of
this code, the Health and Safety Code, or any other law, a health
benefit plan issuer is deemed to be in compliance with state
statutory and regulatory accreditation requirements if:
(1) the health benefit plan issuer has been accredited
at any level by a national accreditation organization; and
(2) the national accreditation organization's
accreditation requirements are the same or substantially similar to
the department's statutory or regulatory accreditation
requirements, as determined by the commissioner.
(b) Notwithstanding this code, the Health and Safety Code,
or any other law, a health benefit plan issuer that offers a
Medicare Advantage coordinated care plan under a contract with the
federal Centers for Medicare and Medicaid Services is deemed to be
in compliance with any state statutory and regulatory requirements
that are the same or substantially similar to the requirements for
Medicare Advantage coordinated care plans, as determined by the
commissioner.
(c) Notwithstanding Sections 533.005 and 533.007,
Government Code, or any other law, a Medicaid managed care plan
offered by a health benefit plan issuer under a contract with the
commission is deemed to be in compliance with any contractual
Medicaid managed care plan requirements that are the same or
substantially similar to any statutory and regulatory
requirements, as determined by the commissioner.
Sec. 847.006. FILING OF ACCREDITATION REPORT;
CONFIDENTIALITY REQUIREMENTS. (a) The commissioner may require a
health benefit plan issuer to submit to the commissioner the
accreditation report issued by the national accreditation
organization.
(b) An accreditation report submitted under Subsection (a)
is proprietary and confidential and is not subject to subpoena.
The commissioner shall limit the disclosure of the accreditation
report to those department employees who need the accreditation
report to perform the duties of their job. A department employee
may not further disclose the accreditation report.
Sec. 847.007. COMMISSIONER DUTIES. (a) In conducting an
examination of a health benefit plan, the commissioner:
(1) shall accept the accreditation report submitted by
the health benefit plan issuer as demonstrating the issuer's
compliance with the processes and standards for which the issuer
has received accreditation; and
(2) may adopt relevant findings in a health benefit
plan issuer's accreditation report in the examination report if the
accreditation report complies with applicable state and federal
requirements regarding the nondisclosure of proprietary and
confidential information and personal health information.
(b) Subsection (a) does not apply to any process or standard
of a health benefit plan issuer that is not covered as part of the
issuer's accreditation. This section does not set minimum quality
standards but operates only as a replacement of duplicate
requirements.
Sec. 847.008. COMMISSION DUTIES. (a) The commission may
require the commissioner to submit to the commission the documents
reviewed by the department that substantiate the compliance of the
health benefit plan issuer with applicable state statutory and
regulatory requirements.
(b) Documents submitted under Subsection (a) are
proprietary and confidential and are not subject to subpoena. The
commission shall limit disclosure of the documents to commission
employees who need the documentation to perform the duties of their
job. A commission employee may not further disclose the compliance
documents.
Sec. 847.009. MEMORANDUM OF UNDERSTANDING. The
commissioner and the commission may enter into a memorandum of
understanding to specify the responsibilities of the department and
the commission under this chapter.
SECTION 2. This Act takes effect June 1, 2005, if it
receives a vote of two-thirds of all the members elected to each
house, as provided by Section 39, Article III, Texas Constitution.
If this Act does not receive the vote necessary for effect on that
date, this Act takes effect September 1, 2005.