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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 exclusive provider benefit |
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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 from the basic |
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level of coverage provided by the health insurance policy if the |
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insured uses a preferred 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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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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provision of this code or another insurance law of this state that |
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applies to a preferred provider benefit plan applies to an |
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exclusive provider benefit plan to the extent that the commissioner |
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determines the provision to be consistent with the function and |
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purpose of an exclusive provider benefit plan. |
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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 Section 1301.155, this chapter may |
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not be construed to require an exclusive provider benefit plan to |
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compensate a nonpreferred provider for services provided to an |
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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. Section 1301.005, Insurance Code, is amended by |
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adding Subsection (d) to read as follows: |
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(d) This section does not apply to an exclusive provider |
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benefit plan. |
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SECTION 9. 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 10. This Act takes effect September 1, 2011. |