79R9146 T
By: Harris S.B. No. 1149
A BILL TO BE ENTITLED
AN ACT
relating to the regulation of electronic transmissions of health
benefit information between a health care insurer and a physician
or health care provider.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Title 6, Subtitle C, Insurance Code, is amended
by adding a new Chapter 847, to read as follows:
CHAPTER 847. ELECTRONIC TRANSMISSION OF ELIGIBILITY AND PAYMENT
STATUS.
Section 847.001. Definitions. In this Chapter:
(1) "Enrollee" means an individual who is covered by a
policy of insurance for health care or enrolled in a health care
plan and includes covered dependents.
(2) "Health Care Insurer" means a health maintenance
organization operating under Chapter 843 of this code, a preferred
provider operating under Chapter 1301 of this Code, an approved
nonprofit health corporation that holds a certificate of authority
under Chapter 844 of this Code, and any other entity that issues a
health care plan including:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842 of this Code;
(C) a fraternal benefit society operating under
Chapter 885 of this Code; or
(D) a stipulated premium company operating under
Chapter 884 of this Code.
(2) "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, 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.
(3) "Participating provider" means a physician or
health care provider who contracts with an insurer to provide
medical care or health care to insureds covered by a health
insurance policy, certificate or contract.
(4) "Physician" means:
(A) an individual licensed to practice medicine
in this state under the authority of Title 3, Subtitle B,
Occupations Code;
(B) a professional association organized under
the Texas Professional Association Act (Article 1528f, Vernon's
Texas Civil Statutes);
(C) an approved 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 person wholly owned by physicians.
Section 847.002. Real Time Transmission of Enrollee
Eligibility and Payment Status. Each health care insurer must make
available, telephonically or electronically, to each participating
provider information sufficient for the provider to determine at
the time of an enrollee's visit:
(a) Information concerning the enrollee including:
(A) subscriber identification number;
(B) name of enrollee and all covered dependents;
(C) birth date of enrollee and birthdates of all
covered dependents;
(D) gender of enrollee and gender of each covered
dependent;
(E) marital status of enrollee and of each
covered dependent;
(F) current enrollment and eligibility status
with the insurer.
(b) Information concerning enrollee benefits including:
(A) covered benefits;
(B) excluded benefits, both group and
individual;
(C) hospitals and participating providers; and
(D) a listing of physicians with hospital
privileges by hospital.
(c) Information concerning enrollee financial information
including
(A) co-payment requirements and current status
applicable to the enrollee's coverage policy; and
(B) the amount of the enrollee's deductible or
co-insurance balance owing at the time of the visit.
847.003. CERTAIN CHARGES PROHIBITED. A health care insurer
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.
847.004. RULES. The commissioner shall adopt rules to
implement the provisions of this section by January 31, 2006.
Before adopting the rules, the commissioner shall create and
receive advice from an advisory committee comprised as follows:
(1) one person representing managers of group
practices for physicians;
(2) two persons representing physicians;
(3) two persons representing hospitals;
(4) one person representing pharmacists;
(5) one person representing dentists; and
(6) two persons representing health care insurers.
Members of the advisory committee serve without compensation and
such committee is not subject to Chapter 551, Government Code.
SECTION 2. The provisions of this act shall apply shall to
any contract between a health care insurer and a physician or health
care provider that is signed or any contract that renews on or after
January 31, 2006. "Any contract that renews" includes, but is not
limited to, a contract that renews from one term to the next in the
absence of contrary notice by one of the parties.
SECTION 3. 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.