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A BILL TO BE ENTITLED
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AN ACT
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relating to the regulation of certain benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1273.001(4), Insurance Code, is amended |
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to read as follows: |
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(4) "Point-of-service plan" means an arrangement |
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under which: |
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(A) an enrollee chooses to obtain benefits or |
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services through: |
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(i) a health maintenance organization |
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delivery network, including a limited provider network; or |
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(ii) a non-network delivery system outside |
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the health maintenance organization delivery network, including an |
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exclusive provider benefit plan under Chapter 1301 or a limited |
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provider network, that is administered under an indemnity benefit |
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arrangement for the cost of health care services; or |
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(B) indemnity benefits for the cost of health |
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care services are provided by an insurer or group hospital service |
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corporation in conjunction with network benefits arranged or |
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provided by a health maintenance organization. |
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SECTION 2. Section 1301.001, Insurance Code, is amended by |
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amending Subdivision (1) and adding Subdivision (1-a) to read as |
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follows: |
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(1) "Exclusive provider benefit plan" means a benefit |
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plan in which an insurer excludes benefits to an insured for some or |
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all services, other than emergency care services required under |
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Section 1301.155, provided by a physician or health care provider |
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who is not a preferred provider. |
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(1-a) "Health care provider" means a practitioner, |
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institutional provider, or other person or organization that |
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furnishes health care services and that is licensed or otherwise |
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authorized to practice in this state. The term does not include a |
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physician. |
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SECTION 3. Section 1301.003, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.003. PREFERRED PROVIDER BENEFIT PLANS AND |
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EXCLUSIVE PROVIDER BENEFIT PLANS PERMITTED. A preferred provider |
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benefit plan or an exclusive provider benefit plan [health
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insurance policy that provides different benefits from the basic
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level of coverage for the use of preferred providers and] that meets |
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the requirements of this chapter is not: |
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(1) unjust under Chapter 1701; |
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(2) unfair discrimination under Subchapter A or B, |
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Chapter 544; or |
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(3) a violation of Subchapter B or C, Chapter 1451. |
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SECTION 4. Section 1301.0041, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.0041. APPLICABILITY. (a) Except as otherwise |
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specifically provided by this chapter, this [This] chapter applies |
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to each [any] preferred provider benefit plan in which an insurer |
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provides, through the insurer's health insurance policy, for the |
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payment of a level of coverage that is different depending on |
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whether an [from the basic level of coverage provided by the health
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insurance policy if the] insured uses a preferred provider or a |
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nonpreferred provider. |
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(b) Unless otherwise specified, an exclusive provider |
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benefit plan is subject to this chapter in the same manner as a |
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preferred provider benefit plan. |
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(c) This chapter does not apply to: |
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(1) the child health plan program under Chapter 62, |
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Health and Safety Code; or |
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(2) a Medicaid managed care program under Chapter 533, |
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Government Code. |
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SECTION 5. Subchapter A, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.0042 to read follows: |
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Sec. 1301.0042. APPLICABILITY OF INSURANCE LAW. (a) |
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Except as provided by Subsection (b), a provision of this code or |
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another insurance law of this state that applies to a preferred |
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provider benefit plan applies to an exclusive provider benefit plan |
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except to the extent that the commissioner determines the provision |
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to be inconsistent with the function and purpose of an exclusive |
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provider benefit plan. |
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(b) An exclusive provider benefit plan may not provide |
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dental care benefits. |
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SECTION 6. Section 1301.0045, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.0045. CONSTRUCTION OF CHAPTER. (a) Except as |
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provided by Section 1301.0046, this chapter may not be construed to |
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limit the level of reimbursement or the level of coverage, |
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including deductibles, copayments, coinsurance, or other |
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cost-sharing provisions, that are applicable to preferred |
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providers or, for plans other than exclusive provider benefit |
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plans, nonpreferred providers. |
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(b) Except as provided by Sections 1301.0052 and 1301.155, |
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this chapter may not be construed to require an exclusive provider |
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benefit plan to compensate a nonpreferred provider for services |
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provided to an insured. |
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SECTION 7. Section 1301.0046, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.0046. COINSURANCE REQUIREMENTS FOR SERVICES OF |
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NONPREFERRED PROVIDERS. The insured's coinsurance applicable to |
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payment to nonpreferred providers may not exceed 50 percent of the |
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total covered amount applicable to the medical or health care |
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services. This section does not apply to an exclusive provider |
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benefit plan. |
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SECTION 8. Sections 1301.005(a) and (b), Insurance Code, |
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are amended to read as follows: |
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(a) An insurer offering a preferred provider benefit plan |
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shall ensure that both preferred provider benefits and basic level |
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benefits are reasonably available to all insureds within a |
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designated service area. This subsection does not apply to an |
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exclusive provider benefit plan. |
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(b) If services are not available through a preferred |
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provider within a designated [the] service area under a preferred |
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provider benefit plan or an exclusive provider benefit plan, an |
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insurer shall reimburse a physician or health care provider who is |
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not a preferred provider at the same percentage level of |
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reimbursement as a preferred provider would have been reimbursed |
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had the insured been treated by a preferred provider. |
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SECTION 9. Subchapter A, Chapter 1301, Insurance Code, is |
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amended by adding Sections 1301.0051, 1301.0052, 1301.0053, and |
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1301.0056 to read as follows: |
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Sec. 1301.0051. EXCLUSIVE PROVIDER BENEFIT PLANS: QUALITY |
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IMPROVEMENT AND UTILIZATION MANAGEMENT. (a) An insurer that offers |
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an exclusive provider benefit plan shall establish procedures to |
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ensure that health care services are provided to insureds under |
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reasonable standards of quality of care that are consistent with |
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prevailing professionally recognized standards of care or |
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practice. The procedures must include: |
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(1) mechanisms to ensure availability, accessibility, |
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quality, and continuity of care; |
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(2) subject to Section 1301.059, a continuing quality |
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improvement program to monitor and evaluate services provided under |
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the plan, including primary and specialist physician services and |
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ancillary and preventive health care services, provided in |
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institutional or noninstitutional settings; |
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(3) a method of recording formal proceedings of |
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quality improvement program activities and maintaining quality |
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improvement program documentation in a confidential manner; |
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(4) subject to Section 1301.059, a physician review |
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panel to assist the insurer in reviewing medical guidelines or |
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criteria; |
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(5) a patient record system that facilitates |
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documentation and retrieval of clinical information for the |
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insurer's evaluation of continuity and coordination of services and |
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assessment of the quality of services provided to insureds under |
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the plan; |
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(6) a mechanism for making available to the |
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commissioner the clinical records of insureds for examination and |
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review by the commissioner on request of the commissioner; and |
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(7) a specific procedure for the periodic reporting of |
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quality improvement program activities to: |
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(A) the governing body and appropriate staff of |
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the insurer; and |
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(B) physicians and health care providers that |
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provide health care services under the plan. |
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(b) Minutes of a formal proceeding of the quality |
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improvement program established under Subsection (a) shall be made |
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available to the commissioner on request of the commissioner. |
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(c) Insured records made available to the commissioner |
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under Subsection (a)(6) are confidential and privileged, and are |
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not subject to Chapter 552, Government Code, or to subpoena, except |
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to the extent necessary for the commissioner to enforce this |
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chapter. |
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Sec. 1301.0052. EXCLUSIVE PROVIDER BENEFIT PLANS: |
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REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered |
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service is medically necessary and is not available through a |
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preferred provider, the issuer of an exclusive provider benefit |
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plan, on the request of a preferred provider, shall: |
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(1) approve the referral of an insured to a |
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nonpreferred provider within a reasonable period; and |
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(2) fully reimburse the nonpreferred provider at the |
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usual and customary rate or at a rate agreed to by the issuer and the |
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nonpreferred provider. |
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(b) An exclusive provider benefit plan must provide for a |
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review by a health care provider with expertise in the same |
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specialty as or a specialty similar to the type of health care |
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provider to whom a referral is requested under Subsection (a) |
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before the issuer of the plan may deny the referral. |
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Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS: |
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EMERGENCY CARE. If a nonpreferred provider provides emergency care |
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as defined by Section 1301.155 to an enrollee in an exclusive |
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provider benefit plan, the issuer of the plan shall reimburse the |
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nonpreferred provider at the usual and customary rate or at a rate |
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agreed to by the issuer and the nonpreferred provider for the |
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provision of the services. |
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Sec. 1301.0056. EXAMINATIONS AND FEES. (a) The |
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commissioner may examine an insurer to determine the quality and |
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adequacy of a network used by an exclusive provider benefit plan |
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offered by the insurer under this chapter. An insurer is subject to |
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a qualifying examination of the insurer's exclusive provider |
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benefit plans and subsequent quality of care examinations by the |
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commissioner at least once every five years. Documentation |
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provided to the commissioner during an examination conducted under |
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this section is confidential and is not subject to disclosure as |
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public information under Chapter 552, Government Code. |
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(b) An insurer examined under this section shall pay the |
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cost of the examination in an amount determined by the |
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commissioner. |
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(c) The department shall collect an assessment in an amount |
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determined by the commissioner from the insurer at the time of the |
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examination to cover all expenses attributable directly to the |
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examination, including the salaries and expenses of department |
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employees and all reasonable expenses of the department necessary |
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for the administration of this chapter. |
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(d) The department shall deposit an assessment collected |
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under this section to the credit of the Texas Department of |
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Insurance operating account. Money deposited under this subsection |
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shall be used to pay the salaries and expenses of examiners and all |
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other expenses relating to the examination of insurers under this |
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section. |
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SECTION 10. Subchapter D, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.1581 to read as follows: |
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Sec. 1301.1581. INFORMATION CONCERNING EXCLUSIVE PROVIDER |
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BENEFIT PLANS. (a) In this section, "prospective insured" has the |
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meaning assigned by Section 1301.158. |
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(b) In addition to the information required to be provided |
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under Section 1301.158, an insurer that offers an exclusive |
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provider benefit plan shall provide to a current or prospective |
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group contract holder or current or prospective insured notice that |
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the benefit plan includes limited coverage for services provided by |
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a physician or health care provider that is not a preferred |
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provider. |
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(c) An identification card or similar document issued by an |
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insurer to an insured in an exclusive provider benefit plan must |
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display: |
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(1) the first date on which the insured became insured |
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under the plan; |
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(2) a toll-free number that a physician or health care |
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provider may use to obtain the date on which the insured became |
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insured under the plan; and |
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(3) the acronym "EPO" or the phrase "Exclusive |
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Provider Organization" on the card in a location of the insurer's |
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choice. |
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SECTION 11. The change in law made by this Act applies only |
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to an exclusive provider benefit plan that is delivered, issued for |
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delivery, or renewed on or after January 1, 2012. An exclusive |
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provider benefit plan that is delivered, issued for delivery, or |
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renewed before January 1, 2012, is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 12. This Act takes effect September 1, 2011. |