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S.B. No. 155
AN ACT
relating to the quality assurance accreditation process for certain
entities that offer health benefit plans and the provisional
credentialing process for health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 6, Insurance Code, is amended
by adding Chapter 847 to read as follows:
CHAPTER 847. HEALTH CARE QUALITY ASSURANCE
Sec. 847.001. SHORT TITLE. This chapter may be cited as the
Health Care Quality Assurance Act.
Sec. 847.002. LEGISLATIVE FINDINGS; PURPOSES. The
legislature finds that to ensure enrollees high quality care, many
health benefit plan issuers voluntarily undergo a rigorous
accreditation process conducted by nationally recognized
accreditation organizations. To maintain accreditation, these
health benefit plan issuers are subject to continuing review of
their processes and standards. The legislature recognizes that
many of these processes and standards are also reviewed by state
agencies, resulting in increased agency costs and increased health
benefit plan administrative costs. The purpose of this chapter is
to allow appropriate recognition of accreditation by nationally
recognized accreditation organizations and to foster coordination
among state agencies in order to:
(1) help make health benefit plan coverage more
affordable for consumers; and
(2) eliminate duplication of effort by both health
benefit plan issuers and state agencies.
Sec. 847.003. DEFINITIONS. In this chapter:
(1) "Commission" means the Health and Human Services
Commission.
(2) "Health benefit plan" means an individual, group,
blanket, or franchise insurance policy, a certificate issued under
a group policy, a group hospital service contract, or an individual
or group subscriber contract or evidence of coverage issued by a
health maintenance organization that provides benefits for health
care services. The term does not include:
(A) accident-only or disability income insurance
coverage or a combination of accident-only and disability income
insurance coverage;
(B) credit-only insurance coverage;
(C) disability insurance coverage;
(D) Medicare services under a federal contract;
(E) Medicare supplement and Medicare Select
benefit plans regulated in accordance with federal law;
(F) long-term care coverage or benefits, nursing
home care coverage or benefits, home health care coverage or
benefits, community-based care coverage or benefits, or any
combination of those coverages or benefits;
(G) workers' compensation insurance coverage or
similar insurance coverage;
(H) coverage provided through a jointly managed
trust authorized under 29 U.S.C. Section 141 et seq. that contains a
plan of benefits for employees that is negotiated in a collective
bargaining agreement governing wages, hours, and working
conditions of the employees that is authorized under 29 U.S.C.
Section 157;
(I) hospital indemnity or other fixed indemnity
insurance coverage;
(J) reinsurance contracts issued on a stop-loss,
quota-share, or similar basis;
(K) short-term major medical contracts;
(L) liability insurance coverage, including
general liability insurance coverage and automobile liability
insurance coverage, and coverage issued as a supplement to
liability insurance coverage, including automobile medical payment
insurance coverage;
(M) coverage for on-site medical clinics;
(N) coverage that provides other limited
benefits specified by federal regulations;
(O) coverage that provides limited scope dental
or vision benefits; or
(P) other coverage that:
(i) is similar to the coverage described by
this subdivision under which benefits for medical care are
secondary or incidental to other coverage benefits; and
(ii) is specified by federal regulations.
(3) "National accreditation organization" means:
(A) the Accreditation Association for Ambulatory
Health Care;
(B) the Joint Commission on Accreditation of
Healthcare Organizations;
(C) the National Committee for Quality
Assurance;
(D) the American Accreditation HealthCare
Commission ("URAC"); or
(E) any other national accreditation entity
recognized by rules jointly adopted by the commissioner of
insurance and the executive commissioner of the commission.
Sec. 847.004. APPLICABILITY OF CHAPTER. This chapter
applies only to an entity that issues a health benefit plan and that
holds a license or certificate of authority issued by the
commissioner and provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including:
(1) an insurance company;
(2) a group hospital service corporation operating
under Chapter 842;
(3) a health maintenance organization operating under
Chapter 843;
(4) an approved nonprofit health corporation that
holds a certificate of authority issued by the commissioner under
Chapter 844;
(5) a multiple employer welfare arrangement that holds
a certificate of authority under Chapter 846;
(6) a stipulated premium company operating under
Chapter 884;
(7) a fraternal benefit society operating under
Chapter 885; or
(8) a reciprocal exchange operating under Chapter 942.
Sec. 847.005. PRESUMED COMPLIANCE WITH CERTAIN STATUTORY
AND REGULATORY REQUIREMENTS. (a) A health benefit plan issuer is
presumed to be in compliance with state statutory and regulatory
requirements if:
(1) the health benefit plan issuer has received
nonconditional accreditation by a national accreditation
organization; and
(2) the national accreditation organization's
accreditation requirements are the same, substantially similar to,
or more stringent than the department's statutory or regulatory
requirements.
(b) A health benefit plan issuer that offers a Medicare
Advantage coordinated care plan under a contract with the federal
Centers for Medicare and Medicaid Services is presumed to be in
compliance with any state statutory and regulatory requirements
that are the same, substantially similar to, or more stringent than
the requirements for Medicare Advantage coordinated care plans, as
determined by the commissioner.
(c) If the department determines that a health benefit plan
issuer is in compliance with a state statutory or regulatory
requirement, the commission may presume that a Medicaid or state
child health plan program managed care plan offered by a health
benefit plan issuer under contract with the commission is in
compliance with any contractual Medicaid or state child health plan
program managed care plan requirement that is the same as,
substantially similar to, or more stringent than the state
statutory or regulatory requirement, as determined by the
commission.
(d) The commissioner may take appropriate action, including
imposition of sanctions under Chapter 82, against a health benefit
plan issuer who is presumed under Subsection (a), (b), or (c) to be
in compliance with state statutory and regulatory requirements but
does not maintain compliance with the same, substantially similar,
or more stringent requirements applicable to the issuer under
Subsection (a), (b), or (c).
(e) The department shall monitor and analyze periodically
as prescribed by rule by the commissioner updates and amendments
made to national accreditation standards as necessary to ensure
that those standards remain the same, substantially similar to, or
more stringent than the department's statutory or regulatory
requirements.
Sec. 847.006. FILING OF ACCREDITATION REPORT;
CONFIDENTIALITY REQUIREMENTS. (a) The commissioner may require a
health benefit plan issuer to submit to the commissioner the
accreditation report issued by the national accreditation
organization.
(b) An accreditation report submitted under Subsection (a)
is proprietary and confidential information under Chapter 552,
Government Code, and is not subject to subpoena. The commissioner
shall limit the disclosure of the accreditation report to those
department employees who need the accreditation report to perform
the duties of their job. A department employee may not further
disclose the accreditation report.
(c) The national accreditation organization
recommendations summary results are not proprietary information
and are subject to public disclosure under Chapter 552, Government
Code.
Sec. 847.007. DUTIES OF COMMISSIONER OF INSURANCE. (a) In
conducting an examination of a health benefit plan issuer, the
commissioner:
(1) shall accept the accreditation report submitted by
the health benefit plan issuer as a prima facie demonstration of the
issuer's compliance with the processes and standards for which the
issuer has received accreditation; and
(2) may adopt relevant findings in a health benefit
plan issuer's accreditation report in the examination report if the
accreditation report complies with applicable state and federal
requirements regarding the nondisclosure of proprietary and
confidential information and personal health information.
(b) Subsection (a) does not apply to any process or standard
of a health benefit plan issuer that is not covered as part of the
issuer's accreditation. This section does not set minimum quality
standards but operates only as a replacement of duplicate
requirements.
(c) The commissioner may by rule determine the application
of compliance with national accreditation requirements by a
delegated entity, delegated third party, or utilization review
agent to compliance by the health benefit plan issuer that
contracts with the delegated entity, delegated third party, or
agent.
Sec. 847.008. COMMISSION DUTIES. (a) The commission may
require the commissioner to submit to the commission the documents
reviewed by the department that substantiate the compliance of the
health benefit plan issuer with applicable state statutory and
regulatory requirements.
(b) Documents submitted under Subsection (a) are
proprietary and confidential information under Chapter 552,
Government Code, and are not subject to subpoena. The commission
shall limit disclosure of the documents to commission employees who
need the documentation to perform the duties of their job. A
commission employee may not further disclose the compliance
documents.
Sec. 847.009. MEMORANDUM OF UNDERSTANDING. The
commissioner and the commission must enter into a memorandum of
understanding to specify the responsibilities of the department and
the commission under this chapter.
Sec. 847.010. ENFORCEMENT. This chapter may not be
construed to prohibit the commissioner or the commission from
enforcing laws or rules relating to:
(1) the operation of a health benefit plan; or
(2) violation of a contract.
SECTION 2. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1457 to read as follows:
CHAPTER 1457. PROVISIONAL CREDENTIALING STATUS
Sec. 1457.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible to
receive health care services through a health benefit plan.
(2) "Physician" means an individual licensed to
practice medicine in this state under the authority of Subtitle B,
Title 3, Occupations Code.
(3) "Provider network" means a health benefit plan
under which health care services are provided to enrollees through
contracts with physicians and that requires those enrollees to use
physicians 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 organization; or
(C) another entity that issues a health benefit
plan, including an insurance company.
Sec. 1457.002. PROVISIONAL CREDENTIALING STATUS. (a) A
health benefit plan shall have a process for provisional
credentialing status in compliance with the requirements of the
National Committee for Quality Assurance.
(b) A health benefit plan may grant provisional
credentialing status to a physician who:
(1) submits a completed standard credentialing
application to the health benefit plan;
(2) meets the health plan's requirements for
provisional credentialing; and
(3) joins as a partner, shareholder, or employee of
another physician who is contracted with a health benefit plan to
provide medical or health care services to enrollees.
(c) A health benefit plan must complete the credentialing
process within 60 calendar days of the date a physician is granted
provisional status. In the event the physician does not meet the
health plan's credentialing standards, the physician must be
provided the same appeal process as any other physician applying
for participation with the health benefit plan.
SECTION 3. This Act takes effect June 1, 2005, 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 effect on that
date, this Act takes effect September 1, 2005.
______________________________ ______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 155 passed the Senate on
March 30, 2005, by the following vote: Yeas 30, Nays 0; and that
the Senate concurred in House amendments on May 27, 2005, by the
following vote: Yeas 29, Nays 0.
______________________________
Secretary of the Senate
I hereby certify that S.B. No. 155 passed the House, with
amendments, on May 25, 2005, by the following vote: Yeas 145,
Nays 0, two present not voting.
______________________________
Chief Clerk of the House
Approved:
______________________________
Date
______________________________
Governor