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A BILL TO BE ENTITLED
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AN ACT
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relating to requirements for contracts between physicians, |
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hospitals, and health benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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by adding Chapter 1461 to read as follows: |
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CHAPTER 1461. IN-NETWORK PROVIDER REQUIREMENTS |
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Sec. 1461.001. DEFINITIONS. In this chapter: |
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(1) "Enrollee" has the meaning assigned by Section |
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1456.001. |
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(2) "Health care facility" has the meaning assigned by |
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Section 1456.001. |
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(3) "Health care practitioner" has the meaning |
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assigned by Section 1456.001. |
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(4) "Medical specialty" means a medical specialty |
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offered by the American Board of Medical Specialties. |
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(5) "Physician" means a person licensed to practice |
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medicine in this state. |
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(6) "Provider network" has the meaning assigned by |
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Section 1456.001. |
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Sec. 1461.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies to: |
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(1) each health benefit plan or person described by |
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Subsection (b) or (c); |
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(2) a health care facility; and |
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(3) a provider network. |
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(b) This chapter applies to any health benefit plan that: |
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(1) provides benefits for medical or surgical expenses |
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incurred as a result of a health condition, accident, or sickness, |
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including an individual, group, blanket, or franchise insurance |
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policy or insurance agreement, a group hospital service contract, |
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or an individual or group evidence of coverage that is offered by: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a fraternal benefit society operating under |
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Chapter 885; |
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(D) a stipulated premium company operating under |
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Chapter 884; |
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(E) a health maintenance organization operating |
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under Chapter 843; |
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(F) a multiple employer welfare arrangement that |
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holds a certificate of authority under Chapter 846; |
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(G) an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844; or |
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(H) an entity not authorized under this code or |
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another insurance law of this state that contracts directly for |
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health care services on a risk-sharing basis, including a |
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capitation basis; or |
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(2) provides health and accident coverage through a |
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risk pool created under Chapter 172, Local Government Code, |
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notwithstanding Section 172.014, Local Government Code, or any |
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other law. |
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(c) This chapter applies to a person to whom a health |
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benefit plan contracts to: |
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(1) process or pay claims; |
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(2) obtain the services of physicians or other |
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providers to provide health care services to enrollees; or |
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(3) issue verifications or preauthorizations. |
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(d) This chapter does not apply to: |
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(1) Medicaid managed care programs operated under |
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Chapter 533, Government Code; |
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(2) Medicaid programs operated under Chapter 32, Human |
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Resources Code; or |
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(3) the state child health plan operated under Chapter |
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62 or 63, Health and Safety Code. |
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Sec. 1461.003. GENERAL REQUIREMENTS. (a) A health benefit |
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plan must make available in its provider network at least one |
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physician for each medical specialty. |
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(b) A health care facility must make available to an |
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enrollee at least one health care provider in the provider network |
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of an enrollee's health benefit plan for each medical specialty. |
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Sec. 1461.004. EXCLUSIVE CONTRACTS PROHIBITED; EXCEPTION. |
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(a) A hospital may not enter into an exclusive contract or grant |
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exclusive privileges to a specific physician group, including a |
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professional association of physicians authorized under Chapter |
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162, Occupations Code. |
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(b) A health benefit plan may not enter into exclusive |
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contracts with specific hospitals. A health benefit plan may not |
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enter into an exclusive contract with a specific physician group, |
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including a professional association of physicians authorized |
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under Chapter 162, Occupations Code. |
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(c) Notwithstanding Subsection (a), a hospital may enter |
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into an exclusive contract or grant exclusive privileges to a |
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specific physician group that is a member of the provider network of |
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each health benefit plan that has contracted with the hospital. |
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Sec. 1461.005. NETWORK ADEQUACY STANDARDS. The |
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commissioner shall by rule adopt network adequacy standards that |
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are adapted to local markets in which the health benefit plan |
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operates. The rules must include standards that ensure |
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availability of, and accessibility to, a full range of health care |
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practitioners to provide health care services to enrollees. |
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Sec. 1461.006. REIMBURSEMENT REPORTING. (a) A health |
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benefit plan must submit to the department, as prescribed by the |
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commissioner, information regarding: |
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(1) the methods used by the health benefit plan to |
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compute out-of-network reimbursements, such as a maximum allowable |
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amount; and |
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(2) the effect of the computation described by |
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Subdivision (1) on the out-of-pocket expenses of an enrollee. |
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(b) The commissioner shall establish by rule the |
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information required under Subsection (a). |
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SECTION 2. This Act applies only to an insurance policy or |
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contract or evidence of coverage that is delivered, issued for |
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delivery, or renewed on or after January 1, 2010. An insurance |
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policy or contract or evidence of coverage delivered, issued for |
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delivery, or renewed before January 1, 2010, is governed by the law |
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as it existed immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 3. This Act takes effect September 1, 2009. |