By: Harris S.B. No. 1149
A BILL TO BE ENTITLED
AN ACT
relating to the electronic transmission of health benefit
information between a health benefit plan issuer and a physician or
health care provider.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
by adding Chapter 1274 to read as follows:
CHAPTER 1274. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND PAYMENT
STATUS
Sec. 1274.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible for
coverage under a health benefit plan, including a covered
dependent.
(2) "Health benefit plan issuer" means a health
maintenance organization operating under Chapter 843, a preferred
provider organization operating under Chapter 1301, an approved
nonprofit health corporation that holds a certificate of authority
under Chapter 844, and any other entity that issues a health benefit
plan, including:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885; or
(D) a stipulated premium company operating under
Chapter 884.
(3) "Health care provider" means:
(A) a person, other than a physician, who is
licensed or otherwise authorized to provide a health care service
in this state, including:
(i) a pharmacist or dentist; or
(ii) a pharmacy, hospital, or other
institution or organization;
(B) a person who is wholly owned or controlled by
a provider or by a group of providers who are licensed or otherwise
authorized to provide the same health care service; or
(C) a person who is wholly owned or controlled by
one or more hospitals and physicians, including a
physician-hospital organization.
(4) "Participating provider" means:
(A) a physician or health care provider who
contracts with a health benefit plan issuer to provide medical care
or health care to enrollees in a health benefit plan; or
(B) a physician or health care provider who
accepts and treats a patient on a referral from a physician or
provider described by Paragraph (A).
(5) "Physician" means:
(A) an individual licensed to practice medicine
in this state under Subtitle B, Title 3, Occupations Code;
(B) a professional association organized under
the Texas Professional Association Act (Article 1528f, Vernon's
Texas Civil Statutes);
(C) a nonprofit health corporation certified
under Chapter 162, Occupations Code;
(D) a medical school or medical and dental unit,
as defined or described by Section 61.003, 61.501, or 74.601,
Education Code, that employs or contracts with physicians to teach
or provide medical services or employs physicians and contracts
with physicians in a practice plan; or
(E) another entity wholly owned by physicians.
Sec. 1274.002. TRANSMISSION OF ENROLLEE ELIGIBILITY AND
PAYMENT STATUS. Each health benefit plan issuer shall 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 an enrollee's visit
information concerning:
(1) the enrollee, including:
(A) the enrollee's identification number
assigned by the health benefit plan issuer;
(B) the name of the enrollee and all covered
dependents, if appropriate;
(C) the birth date of the enrollee and the birth
dates of all covered dependents, if appropriate;
(D) the gender of the enrollee and the gender of
each covered dependent, if appropriate; and
(E) the current enrollment and eligibility
status of the enrollee under the health benefit plan;
(2) the enrollee's benefits, including:
(A) whether a specific type or category of
service is a covered benefit; and
(B) excluded benefits or limitations, both group
and individual; and
(3) the enrollee's financial information, including:
(A) copayment requirements, if any; and
(B) the unmet amount of the enrollee's deductible
or enrollee financial responsibility.
Sec. 1274.003. CERTAIN CHARGES PROHIBITED. A health
benefit plan issuer may not directly or indirectly charge or hold a
physician, health care provider, or enrollee responsible for a fee
for making available or accessing information under this chapter.
Sec. 1274.004. RULES. (a) The commissioner shall adopt
rules as necessary to implement this chapter.
(b) Before adopting rules under this section, the
commissioner shall consult and receive advice from the technical
advisory committee on claims processing established under Article
21.52Y.
Sec. 1274.005. WAIVER OF CERTAIN PROVISIONS FOR
CERTAIN FEDERAL PLANS. If the commissioner, in consultation with
the commissioner of health and human services, determines 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.), the commissioner of insurance by rule shall waive
the application of that provision to the providing of those
benefits or services.
SECTION 2. (a) Except as provided by Subsection (b) of
this section, the commissioner of insurance shall adopt rules
necessary to implement Chapter 1274, Insurance Code, as added by
this Act, not later than January 1, 2006.
(b) As soon as practicable, but not later than the 90th day
after the effective date of this Act, the commissioner of insurance
shall adopt rules necessary to implement Section 1274.005,
Insurance Code, as added by this Act. The commissioner may use the
procedures under Section 2001.034, Government Code, for adopting
emergency rules under this subsection. The commissioner is not
required to make the finding described by Subsection (a), Section
2001.034, Government Code, to adopt emergency rules under this
subsection.
SECTION 3. (a) The change in law made by this Act applies
only to a contract between a health benefit plan issuer and a
physician or health care provider that is entered into or renewed on
or after January 31, 2006. For the purposes of this section, a
contract renewed includes a contract that renews from one term to
the next in the absence of contrary notice by one of the parties.
(b) A contract entered into or renewed before January 31,
2006, is, until a renewal date for that contract that occurs on or
after January 31, 2006, governed by the law in effect immediately
before the effective date of this Act, and that law is continued in
effect for that purpose.
SECTION 4. This Act takes effect immediately 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 immediate effect, this
Act takes effect September 1, 2005.