By: Lucio S.B. No. 1826
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to certain cross-border health care plans offered by
1-3 health maintenance organizations.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. The Texas Insurance Code is amended by adding
1-6 Chapter 20B to read as follows:
1-7 CHAPTER 20B - CROSS BORDER HEALTH CARE PLAN
1-8 Art. 20B.01 Short Title
1-9 This chapter may be cited as the Cross Border Health Care
1-10 Plan Act.
1-11 Art. 20B.02 Definitions
1-12 In this chapter:
1-13 (a) "Cross border health care plan" means a health care plan
1-14 offered or made available to the categories of persons listed below
1-15 and which is provided through a health maintenance organization
1-16 delivery network based exclusively on physicians, providers, or
1-17 other health maintenance organizations located in the United
1-18 Mexican States. The cross border health care plan may only be
1-19 offered or made available to the following persons and their
1-20 dependents:
1-21 (1) a citizen of the United Mexican States who works
1-22 or resides within 62 miles of the border of this state and the
1-23 United Mexican States; or
2-1 (2) a resident of the United Mexican States who works
2-2 within 62 miles of the border of this state and the United Mexican
2-3 States.
2-4 (b) "Basic health care services" means health care services
2-5 which the commissioner determines an enrolled population might
2-6 reasonably require in order to be maintained in good health,
2-7 including any services required by the applicable laws of the
2-8 United Mexican States.
2-9 (c) "Commissioner" means the commissioner of insurance.
2-10 (d) "Emergency care" means health care services provided in
2-11 a hospital emergency facility or comparable facility to evaluate
2-12 and stabilize medical conditions of a recent onset and severity,
2-13 including but not limited to severe pain, that would lead a prudent
2-14 layperson, possessing an average knowledge of medicine and health,
2-15 to believe that his or her condition, sickness, or injury is of
2-16 such a nature that failure to get immediate medical care could
2-17 result in:
2-18 (1) placing the patient's health in serious jeopardy;
2-19 (2) serious impairment to bodily functions;
2-20 (3) serious dysfunction of any bodily organ or part;
2-21 (4) serious disfigurement; or
2-22 (5) in the case of a pregnant woman, serious jeopardy
2-23 to the health of the fetus.
2-24 (e) "Enrollee" means an individual who is enrolled in a
2-25 health care plan, including covered dependents.
2-26 (f) "Health care plan" means any plan whereby any person
3-1 undertakes to provide, arrange for, pay for, or reimburse any part
3-2 of the cost of any health care services; provided, however, a part
3-3 of such plan consists of arranging for or the provision of health
3-4 care services, as distinguished from indemnification against the
3-5 cost of such service, on a prepaid basis through insurance or
3-6 otherwise.
3-7 (g) "Health care services" means any services, including the
3-8 furnishing to any individual of pharmaceutical services, medical,
3-9 chiropractic, or dental care, or hospitalization or incident to the
3-10 furnishing of such services, care, or hospitalization, as well as
3-11 the furnishing to any person of any and all other services for the
3-12 purpose of preventing, alleviating, curing or healing human illness
3-13 or injury.
3-14 (h) "Health maintenance organization" means any person who
3-15 arranges for or provides a health care plan to enrollees on a
3-16 prepaid basis.
3-17 (i) "Health maintenance organization delivery network" means
3-18 a health care delivery system in which a health maintenance
3-19 organization arranges for health care services directly or
3-20 indirectly through contracts and subcontracts with providers and
3-21 physicians, which providers and physicians may be licensed under
3-22 the laws of the United Mexican States.
3-23 Art. 20B.03 Coverage Offered
3-24 (a) A health maintenance organization licensed to provide
3-25 basic health care services under chapter 20A, Insurance Code, may
3-26 offer a cross border health care plan to individuals or to small
4-1 employers or large employers, as such terms are defined in the
4-2 Health Insurance Portability and Accountability Act (Chapter 26,
4-3 Vernon's Texas Insurance Code). In arranging for or providing a
4-4 cross border health care plan, a health maintenance organization
4-5 shall have all of the powers and authority granted under article
4-6 20A.06, Insurance Code.
4-7 (b) A cross border health care plan may limit its service
4-8 area to a geographic region within the United Mexican States and
4-9 may limit the coverage of out-of-area health care services
4-10 delivered in this state to emergency care services. The delivery
4-11 of emergency care services in this state under such a plan shall be
4-12 subject to the requirements of article 20A.04(a)(16), Insurance
4-13 Code.
4-14 (c) The delivery of health care services through the health
4-15 maintenance organization delivery network located in the United
4-16 Mexican States must be based on and determined by the prevailing
4-17 community standards in the United Mexican States, and the licensing
4-18 of physicians and providers is governed by the applicable laws of
4-19 the United Mexican States. A physician or provider providing
4-20 health care services through the delivery network is not required
4-21 to be licensed in this state. The credentialing, peer review, and
4-22 quality of care standards used by a health maintenance organization
4-23 offering a cross border health care plan is governed by the
4-24 standards that apply in the United Mexican States.
4-25 (d) A cross border health care plan may be made available to
4-26 eligible employees of a small or large employer, and their
5-1 dependents, only when chosen by the employer as an option among two
5-2 or more health benefit plans, at least one of which provides
5-3 coverage for health care services delivered in Texas.
5-4 (e) A health maintenance organization which offers a cross
5-5 border health care plan must contract with sufficient providers and
5-6 physicians to assure that all health care services for which
5-7 coverage is provided will be reasonably available and accessible.
5-8 Art. 20B.04 Applicability of Texas Health Maintenance
5-9 Organization Act
5-10 (a) A cross border health care plan must satisfy the
5-11 requirements of article 20A.09, Insurance Code; provided, however,
5-12 the provisions relating to state continuation of coverage and
5-13 conversion shall not be applicable to such health care plan. A
5-14 health maintenance organization shall file the form of its cross
5-15 border health care plan for information only with the commissioner,
5-16 accompanied by a certification on its behalf that upon best
5-17 knowledge, information and belief, such filed form complies in all
5-18 respects with the applicable provisions of this Code and the
5-19 adopted rules and regulations that are applicable to such form
5-20 being filed.
5-21 (b) A cross border health care plan and the health
5-22 maintenance organization offering such a plan is exempt from the
5-23 requirements of articles 20A.09E, 20A.09F, 20A.11, 20A.11A,
5-24 20A.11B, 20A.18A, 20A.18B, 20A.18C, 20A.29, 20A.37, 20A.38, and
5-25 26.09, Insurance Code, and any rules or regulations promulgated
5-26 pursuant thereto. The commissioner shall not be charged with the
6-1 responsibility of examining a health maintenance organization with
6-2 respect to the quality of health care services delivered under a
6-3 cross border health care plan by providers and physicians located
6-4 in the United Mexican States.
6-5 (c) Articles 20A.12, 20A.12A, 20A.12B, Insurance Code, shall
6-6 apply to a cross border health care plan only to the extent that an
6-7 enrollee under such a plan receives health care services delivered
6-8 by a physician or provider located in this state.
6-9 (d) The provisions of article 20A.26, Insurance Code, other
6-10 than subsection (i)(3), shall apply to a cross border health care
6-11 plan. Articles 21.07-6 and 21.58A, Insurance Code, shall not apply
6-12 to the activities of physicians, providers, and other persons doing
6-13 business in the United Mexican States.
6-14 Art. 20B.05 Rules and Regulations
6-15 The commissioner is authorized to promulgate such reasonable
6-16 rules and regulations to prescribe the information to be provided
6-17 to prospective and current group contract holders and enrollees;
6-18 and communications with providers and physicians relating to the
6-19 enrollee's medical condition or treatment options.
6-20 Art. 20B.06 Severability
6-21 If any provision of this Act or the application thereof to
6-22 any person or circumstance is held invalid for any reason, the
6-23 invalidity shall not affect the other provisions or any other
6-24 application of this Act which can be given effect without the
6-25 invalid provisions or application. To this end, all provisions of
6-26 the Texas Cross Border Health Care Plan Act are declared to be
7-1 severable.
7-2 SECTION 2. This Act takes effect September 1, 2001, and
7-3 applies only to a health care plan offered by a health maintenance
7-4 organization on or after that date. A health care plan that is
7-5 offered by a health maintenance organization before September 1,
7-6 2001, is governed by the law as it existed immediately before the
7-7 effective date of this Act, and that law is continued in effect for
7-8 that purpose.