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Amend CSHB 522 by striking all below the enacting clause and
substituting the following:
SECTION 1. Title 8, Insurance Code, is amended by adding
Subtitle J to read as follows:
SUBTITLE J. HEALTH INFORMATION TECHNOLOGY
CHAPTER 1660. ELECTRONIC DATA EXCHANGE
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1660.001. FINDINGS AND PURPOSE. (a) The legislature
finds that patients deserve accurate, instantaneous information
about coverage and financial responsibility to make well-informed
decisions about their treatment and spending.
(b) The legislature finds that the ability of health benefit
plan issuers and administrators to exchange eligibility and benefit
information with physicians, health care providers, hospitals, and
patients will ensure a more efficient and effective health care
delivery system.
(c) The legislature finds that electronic access to
eligibility information will reduce the amount of time and
resources spent on administrative functions, prevent abuse and
fraud, streamline and simplify processing of insurance claims, and
increase transparency in premium cost and health care cost.
(d) The legislature finds that patients often request
information about their health care coverage from their health care
providers and that health care providers therefore need access to
real-time information about their patients' eligibility to receive
health care under the health benefit plan, coverage of health care
under the health benefit plan, and the benefits associated with the
health benefit plan.
(e) The legislature finds that adoption of technology by
insurers, health maintenance organizations, and health care
providers to facilitate use of electronic data exchange standards
currently available will make coverage and health care electronic
transactions more predictable, reliable, and consistent.
Sec. 1660.002. DEFINITIONS. In this chapter:
(1) "Administrator" has the meaning assigned by
Section 4151.001.
(2) "Advisory committee" means the technical advisory
committee on electronic data exchange.
(3) "Enrollee" means an individual who is insured by
or enrolled in a health benefit plan.
(4) "Health benefit plan" means an individual, group,
blanket, or franchise insurance policy or insurance agreement, a
group hospital service contract, or an evidence of coverage that
provides health insurance or health care benefits.
(5) "Transaction standards" means the Health
Insurance Portability and Accountability Act of 1996 (Pub. L. No.
104-191) transaction standards of the Centers for Medicare and
Medicaid Services under 45 C.F.R. Part 162.
Sec. 1660.003. APPLICABILITY. (a) This chapter applies
only to a health benefit plan that provides benefits for medical or
surgical expenses incurred as a result of a health condition,
accident, or sickness, including an individual, group, blanket, or
franchise insurance policy or insurance agreement, a group hospital
service contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a fraternal benefit society operating under
Chapter 885;
(4) a stipulated premium insurance company operating
under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a health maintenance organization operating under
Chapter 843;
(7) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846; or
(8) an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
(b) This chapter does not apply to:
(1) a Medicaid managed care program operated under
Chapter 533, Government Code;
(2) a Medicaid program operated under Chapter 32,
Human Resources Code; or
(3) the state child health plan or any similar plan
operated under Chapter 62 or 63, Health and Safety Code.
Sec. 1660.004. GENERAL RULEMAKING. The commissioner may
adopt rules as necessary to implement this chapter, including rules
requiring the implementation and provision of the technology
recommended by the advisory committee.
[Sections 1660.005-1660.050 reserved for expansion]
SUBCHAPTER B. ADVISORY COMMITTEE
Sec. 1660.051. ADVISORY COMMITTEE; COMPOSITION. (a) The
commissioner shall appoint a technical advisory committee on
electronic data exchange.
(b) The advisory committee is composed of:
(1) at least one representative from each of the
following groups or entities:
(A) health benefit coverage consumers;
(B) physicians;
(C) hospital trade associations;
(D) representatives of medical units of
institutions of higher education;
(E) representatives of health benefit plan
issuers;
(F) health care providers; and
(G) administrators; and
(2) representatives from:
(A) the office of public insurance counsel;
(B) the Texas Health Insurance Risk Pool; and
(C) the Department of Information Resources.
(c) Members of the advisory committee serve without
compensation.
Sec. 1660.052. APPLICABILITY OF CERTAIN LAWS. The
following laws do not apply to the advisory committee:
(1) Section 39.003(a); and
(2) Chapter 2110, Government Code.
Sec. 1660.053. ADVISORY COMMITTEE POWERS AND DUTIES. The
advisory committee shall advise the commissioner on technical
aspects of using the transaction standards and the rules of the
Council for Affordable Quality Healthcare Committee on Operating
Rules for Information Exchange to require health benefit plan
issuers and administrators to provide access to information
technology that will enable physicians and other health care
providers, at the point of service, to generate a request for
eligibility information that is compliant with the transaction
standards.
Sec. 1660.054. DATA ELEMENTS. (a) The advisory committee
shall advise the commissioner on data elements required to be made
available by health benefit plan issuers and administrators. To
the extent possible, the committee shall use the framework adopted
by the Council for Affordable Quality Healthcare Committee on
Operating Rules for Information Exchange.
(b) The advisory committee shall consider inclusion in the
required information of the following data elements:
(1) the name, date of birth, member identification
number, and coverage status of the patient;
(2) identification of the payor, insurer, issuer, and
administrator, as applicable;
(3) the name and telephone number of the payor's
contact person;
(4) the payor's address;
(5) the name and address of the subscriber;
(6) the patient's relationship to the subscriber;
(7) the type of service;
(8) the type of health benefit plan or product;
(9) the effective date of the coverage;
(10) for professional services:
(A) copayment amounts;
(B) individual deductible amounts;
(C) family deductible amounts; and
(D) benefit limitations and maximums;
(11) for facility services:
(A) copayment and coinsurance amounts;
(B) individual deductible amounts;
(C) family deductible amounts; and
(D) benefit limitations and maximums;
(12) precertification or prior authorization
requirements;
(13) policy maximum limits;
(14) patient liability for a proposed service; and
(15) the health benefit plan coverage amount for a
proposed service.
Sec. 1660.055. RECOMMENDATIONS REGARDING ADOPTION OF
CERTAIN TECHNOLOGIES; REPORT. (a) The advisory committee shall:
(1) make recommendations regarding the use by health
benefit plan issuers or administrators of Internet website
technologies, smart card technologies, magnetic strip
technologies, biometric technologies, or other information
technologies to facilitate the generation of a request for
eligibility information that is compliant with the transaction
standards and the rules of the Council for Affordable Quality
Healthcare Committee on Operating Rules for Information Exchange;
(2) ensure that a recommendation made under
Subdivision (1) does not endorse or otherwise confine health
benefit plan issuers and administrators to any single product or
vendor; and
(3) recommend time frames for implementation of the
recommendations.
(b) The advisory committee shall:
(1) recommend specific provisions that could be
included in a department-issued request for information relating to
electronic data exchange, including identification card programs;
(2) provide those recommendations to the commissioner
not later than four months after the date on which the committee is
appointed; and
(3) issue a final report to the commissioner
containing the committee's recommendations for implementation by
September 1, 2009.
[Sections 1660.056-1660.100 reserved for expansion]
SUBCHAPTER C. IDENTIFICATION CARD PILOT PROGRAM
Sec. 1660.101. PILOT PROGRAM. (a) The commissioner shall
designate a county or counties for initial participation in an
identification card pilot program to begin not later than September
1, 2008.
(b) The commissioner shall require the issuer of a health
benefit plan that is offered in the county or counties selected for
initial participation in the identification card pilot program to
issue identification cards that comply with commissioner rules to
each enrollee of the plan.
(c) The commissioner may implement the identification card
pilot program before, during, or simultaneously with the
appointment and formation of the advisory committee.
Sec. 1660.102. PILOT PROGRAM RULES. (a) The commissioner
shall adopt rules as necessary to implement the identification card
pilot program, including the coordination of a testing phase and
incorporation of changes identified in the testing phase.
(b) The commissioner may consider the recommendations of
the advisory committee or any information provided in response to a
department-issued request for information relating to electronic
data exchange, including identification card programs, before
adopting rules regarding:
(1) information to be included on the identification
cards;
(2) technology to be used to implement the
identification card pilot program; and
(3) confidentiality and accuracy of the information
required to be included on the identification cards.
(c) The commissioner shall consider the requirements of any
federal program requiring health benefit plan issuers and
administrators to provide point-of-service access to physicians
and other health care providers regarding eligibility information
before adopting rules to implement this section.
Sec. 1660.103. REQUESTS FOR INFORMATION. The commissioner
may issue requests for information as needed to implement the
identification card pilot program under this subchapter.
Sec. 1660.104. HEALTH BENEFIT PLAN ISSUER COMPLIANCE. (a)
Each issuer of a health benefit plan that offers a health benefit
plan in a county or counties designated by the commissioner under
Section 1660.101 for initial participation in the identification
card pilot program shall comply with this subchapter and rules
adopted under this subchapter.
(b) To ensure timely compliance with the requirements of
this subchapter, the commissioner may require the issuer of a
health benefit plan to submit its procedures for implementation of
the requirements to the department in the form prescribed by the
commissioner.
SECTION 2. 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, 2007.