88R12914 CJD-F

By: Oliverson H.B. No. 3848

A BILL TO BE ENTITLED

AN ACT

relating to health maintenance organization and preferred provider benefit plan minimum access standards for nonemergency ambulance transport services delivered by emergency medical services providers; providing administrative penalties.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 843.002(24), Insurance Code, is amended to read as follows:

(24) "Provider" means:

(A) a person, other than a physician, who is licensed or otherwise authorized to provide a health care service in this state, including:

(i) a chiropractor, registered nurse, pharmacist, optometrist, or acupuncturist; [or]

(ii) a pharmacy, hospital, or other institution or organization; or

(iii) an emergency medical services provider;

(B) a person who is wholly owned or controlled by a provider or by a group of providers who are licensed or otherwise authorized to provide the same health care service; or

(C) a person who is wholly owned or controlled by one or more hospitals and physicians, including a physician-hospital organization.

SECTION 2. Section 843.151, Insurance Code, is amended to read as follows:

Sec. 843.151. RULES. The commissioner may adopt reasonable rules as necessary and proper to:

(1) implement this chapter and Section 1367.053, Subchapter A, Chapter 1452, Subchapter B, Chapter 1507, Chapters 222, 251, and 258, as applicable to a health maintenance organization, and Chapters 1271 and 1272, including rules to:

(A) prescribe authorized investments for a health maintenance organization for all investments not otherwise addressed in this chapter;

(B) ensure that enrollees have adequate access to health care services; and

(C) establish minimum physician-to-patient ratios, mileage requirements for primary and specialty care, minimum access standards for nonemergency ambulance transport services delivered by an emergency medical services provider, maximum travel time, and maximum waiting time for obtaining an appointment; and

(2) meet the requirements of federal law and regulations.

SECTION 3. Section 843.304(c), Insurance Code, is amended to read as follows:

(c) This section does not require that a health maintenance organization:

(1) use a particular type of provider in its operation;

(2) accept each provider of a category or type, except as provided by Article 21.52B; [or]

(3) contract directly with providers of a particular category or type; or

(4) contract with an emergency medical services provider if that provider does not have the authority or ability to operate in the health maintenance organization's service area.

SECTION 4. Subchapter I, Chapter 843, Insurance Code, is amended by adding Section 843.3046 to read as follows:

Sec. 843.3046. NONEMERGENCY AMBULANCE TRANSPORT SERVICES. (a) A health maintenance organization offering a health care plan that covers a nonemergency ambulance transport service that is within the scope of an emergency medical services provider's license may not refuse to provide reimbursement to an in-network emergency medical services provider for the performance of the covered service solely because the service is provided by an emergency medical services provider.

(b) This section does not require a health maintenance organization to cover a particular health care or nonemergency ambulance transport service.

(c) This section does not affect the right of a health maintenance organization to determine whether a health care or nonemergency ambulance transport service is medically necessary.

(d) A health maintenance organization that violates this section is subject to an administrative penalty as provided by Chapter 84 of not more than $1,000 for each claim that remains unpaid in violation of this section. Each day the violation continues constitutes a separate violation.

SECTION 5. Section 843.305(d), Insurance Code, is amended to read as follows:

(d) This section does not require that a health maintenance organization:

(1) use a particular type of physician or provider in its operation;

(2) accept a physician or provider of a category or type that does not meet the practice standards and qualifications established by the health maintenance organization; [or]

(3) contract directly with physicians or providers of a particular category or type; or

(4) contract with an emergency medical services provider if that provider does not have the authority or ability to operate in the health maintenance organization's service area.

SECTION 6. Section 1301.001(1-a), Insurance Code, is amended to read as follows:

(1-a) "Health care provider" means a practitioner, institutional provider, or other person or organization that furnishes health care services and that is licensed or otherwise authorized to practice in this state. The term includes an emergency medical services provider, a pharmacist, and a pharmacy. The term does not include a physician.

SECTION 7. Section 1301.005, Insurance Code, is amended by adding Subsection (d) to read as follows:

(d) This section does not require that an insurer contract with an emergency medical services provider if that provider does not have the authority or ability to operate in the insurer's designated service area.

SECTION 8. Section 1301.007, Insurance Code, is amended to read as follows:

Sec. 1301.007. RULES. The commissioner shall adopt rules as necessary to:

(1) implement this chapter; [and]

(2) ensure reasonable accessibility and availability of preferred provider services to residents of this state; and

(3) establish minimum access standards for nonemergency ambulance transport services delivered by an emergency medical services provider.

SECTION 9. Section 1301.051, Insurance Code, is amended by adding Subsection (f) to read as follows:

(f) This section does not require that an insurer contract with an emergency medical services provider if that provider does not have the authority or ability to operate in the insurer's designated service area.

SECTION 10. Subchapter B, Chapter 1301, Insurance Code, is amended by adding Section 1301.0517 to read as follows:

Sec. 1301.0517. NONEMERGENCY AMBULANCE TRANSPORT SERVICES. (a) An insurer offering a preferred provider benefit plan that covers a nonemergency ambulance transport service that is within the scope of an emergency medical services provider's license may not refuse to provide reimbursement to an in-network emergency medical services provider for the performance of the covered service solely because the service is provided by an emergency medical services provider.

(b) This section does not require an insurer to cover a particular medical or health care service or nonemergency ambulance transport service.

(c) This section does not affect the right of an insurer to determine whether a medical or health care service or nonemergency ambulance transport service is medically necessary.

(d) An insurer that violates this section is subject to an administrative penalty as provided by Chapter 84 of not more than $1,000 for each claim that remains unpaid in violation of this section. Each day a violation continues constitutes a separate violation.

SECTION 11. The change in law made by this Act applies only to a health benefit plan that is delivered, issued for delivery, or renewed on or after January 1, 2024. A health benefit plan that is delivered, issued for delivery, or renewed before January 1, 2024, 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 12. 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, 2023.