|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to health insurance. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Section 542.051, Insurance Code, is amended by |
|
adding Subdivision (5) to read as follows: |
|
(5) "Provider network" means a health benefit plan |
|
under which health care services are provided to enrollees through |
|
contracts with health care providers and that requires those |
|
enrollees to use health care providers participating in the plan |
|
and procedures covered by the plan. The term includes a network |
|
operated by: |
|
(A) a health maintenance organization; |
|
(B) a preferred provider benefit plan issuer; or |
|
(C) another entity that issues a health benefit |
|
plan, including an insurance company. |
|
SECTION 2. Section 542.052, Insurance Code, is amended to |
|
read as follows: |
|
Sec. 542.052. APPLICABILITY OF SUBCHAPTER. (a) This |
|
subchapter applies to any insurer authorized to engage in business |
|
as an insurance company or to provide insurance in this state, |
|
including: |
|
(1) a stock life, health, or accident insurance |
|
company; |
|
(2) a mutual life, health, or accident insurance |
|
company; |
|
(3) a stock fire or casualty insurance company; |
|
(4) a mutual fire or casualty insurance company; |
|
(5) a Mexican casualty insurance company; |
|
(6) a Lloyd's plan; |
|
(7) a reciprocal or interinsurance exchange; |
|
(8) a fraternal benefit society; |
|
(9) a stipulated premium company; |
|
(10) a nonprofit legal services corporation; |
|
(11) a statewide mutual assessment company; |
|
(12) a local mutual aid association; |
|
(13) a local mutual burial association; |
|
(14) an association exempt under Section 887.102; |
|
(15) a nonprofit hospital, medical, or dental service |
|
corporation, including a corporation subject to Chapter 842; |
|
(16) a county mutual insurance company; |
|
(17) a farm mutual insurance company; |
|
(18) a risk retention group; |
|
(19) a purchasing group; |
|
(20) an eligible surplus lines insurer; and |
|
(21) except as provided by Section 542.053(b), a |
|
guaranty association operating under Chapter 462 or 463. |
|
(b) This subchapter applies to a claim of a health care |
|
provider who: |
|
(1) is in the provider network of an enrollee's |
|
insurer; or |
|
(2) is not in the provider network of an enrollee's |
|
insurer. |
|
SECTION 3. Chapter 1274, Insurance Code, is amended by |
|
adding Section 1274.006 to read as follows: |
|
Sec. 1274.006. A health benefit plan issuer shall establish |
|
a secure website that provides an enrollee with real-time |
|
information concerning: |
|
(1) any applicable deductibles; and |
|
(2) physician or health care provider network |
|
participation. |
|
SECTION 4. Section 1369.153(a), Insurance Code, is amended |
|
to read as follows: |
|
(a) An issuer of a health benefit plan that provides |
|
pharmacy benefits to enrollees shall include on the identification |
|
card of each enrollee: |
|
(1) the name or logo of the entity administering the |
|
pharmacy benefits if the entity is different from the health |
|
benefit plan issuer; |
|
(2) the group number applicable to the enrollee; |
|
(3) the identification number of the enrollee; |
|
(4) [(3)] the effective date and expected expiration |
|
date of the coverage evidenced by the card; |
|
(5) [(4)] a telephone number for contacting an |
|
appropriate person to obtain information relating to the pharmacy |
|
benefits provided under the plan; [and] |
|
(6) [(5)] copayment and deductible information for |
|
generic and brand-name prescription drugs; and |
|
(7) any other information required by the commission |
|
by rule. |
|
SECTION 5. Chapter 1456, Insurance Code, is amended by |
|
adding Section 1456.0066 to read as follows: |
|
Sec. 1456.0066. NETWORK ADEQUACY STANDARDS. The |
|
commissioner shall by rule adopt network adequacy standards that |
|
are adapted to local markets in which the health benefit plan |
|
operates. The rules must include standards that ensure |
|
availability of, and accessibility to, a full range of health care |
|
practitioners to provide health care services to enrollees. |
|
SECTION 6. Subtitle F, Title 8, Insurance Code, is amended |
|
by adding Chapter 1458 to read as follows: |
|
CHAPTER 1458. PAYMENT OF OUT-OF-NETWORK PROVIDERS |
|
Sec. 1458.001. DEFINITIONS. In this chapter: |
|
(1) "Balance billing" has the meaning assigned by |
|
Section 1456.001. |
|
(2) "Enrollee" means an individual who is eligible to |
|
receive health care services under a managed care plan. |
|
(3) "Health care provider" means: |
|
(A) an individual who is licensed to provide |
|
health care services; or |
|
(B) a hospital, emergency clinic, outpatient |
|
clinic, or other facility providing health care services. |
|
(4) "Managed care plan" means a health benefit plan |
|
under which health care services are provided to enrollees through |
|
contracts with health care providers and that requires those |
|
enrollees to use health care providers participating in the plan |
|
and procedures covered by the plan. The term includes a health |
|
benefit plan issued by: |
|
(A) a health maintenance organization; |
|
(B) a preferred provider benefit plan issuer; or |
|
(C) any other entity that issues a health benefit |
|
plan, including an insurance company. |
|
(5) "Out-of-network provider" means a health care |
|
provider who is not a participating provider. |
|
(6) "Participating provider" means a health care |
|
provider who has contracted with a health benefit plan issuer to |
|
provide services to enrollees. |
|
Sec. 1458.002. PAYMENT AT IN-NETWORK RATE. A managed care |
|
plan must pay an out-of-network health care provider that provides |
|
a service to an enrollee at the rate the plan pays a participating |
|
provider for the health care service. |
|
Sec. 1458.003. NO BALANCE BILLING. An out-of-network |
|
health care provider may not balance bill. |
|
Sec. 1458.004. RULES. The commissioner shall adopt rules |
|
necessary to implement this chapter. |
|
SECTION 7. This Act applies only to an insurance policy or |
|
contract or evidence of coverage that is delivered, issued for |
|
delivery, or renewed on or after January 1, 2010. An insurance |
|
policy or contract or evidence of coverage delivered, issued for |
|
delivery, or renewed before January 1, 2010, is governed by the law |
|
as it existed immediately before the effective date of this Act, and |
|
that law is continued in effect for that purpose. |
|
SECTION 8. This Act takes effect September 1, 2009. |