By Haggerty, Oliveira, Gallego, Solis, H.B. No. 2498
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. Title 1, 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. This chapter may be cited as the
1-9 Cross-Border Health Care Plan Act.
1-10 Art. 20B.02. DEFINITIONS. In this chapter:
1-11 (1) "Basic health care services" means health care
1-12 services that the commissioner determines an enrolled population
1-13 might reasonably require in order to be maintained in good health,
1-14 including any services required by the applicable laws of the
1-15 United Mexican States.
1-16 (2) "Cross-border health care plan" means a health
1-17 care plan that is offered or made available to the categories of
1-18 persons described by Article 20B.03 of this code and that is
1-19 provided through a health maintenance organization delivery network
1-20 based exclusively on physicians, providers, or other health
1-21 maintenance organizations located in the United Mexican States.
1-22 (3) "Emergency care" means health care services
1-23 provided in a hospital emergency facility or comparable facility to
1-24 evaluate and stabilize medical conditions of a recent onset and
1-25 severity, including severe pain, that would lead a prudent
2-1 layperson, possessing an average knowledge of medicine and health,
2-2 to believe that the individual's condition, sickness, or injury is
2-3 of such a nature that failure to get immediate medical care could
2-4 result in:
2-5 (A) placing the patient's health in serious
2-6 jeopardy;
2-7 (B) serious impairment to bodily functions;
2-8 (C) serious dysfunction of any bodily organ or
2-9 part;
2-10 (D) serious disfigurement; or
2-11 (E) in the case of a pregnant woman, serious
2-12 jeopardy to the health of the fetus.
2-13 (4) "Enrollee" means an individual who is enrolled in
2-14 a health care plan, including covered dependents.
2-15 (5) "Health care plan" means a plan under which a
2-16 person undertakes to provide, arrange for, pay for, or reimburse
2-17 any part of the cost of any health care services if a part of the
2-18 plan consists of providing or arranging for health care services on
2-19 a prepaid basis through insurance or otherwise, as distinguished
2-20 from indemnification against the cost of the service.
2-21 (6) "Health care services" means services provided to
2-22 an individual to prevent, alleviate, cure, or heal human illness or
2-23 injury. The term includes:
2-24 (A) pharmaceutical services;
2-25 (B) medical, chiropractic, or dental care;
2-26 (C) hospitalization; and
2-27 (D) care or services incidental to the health
3-1 care services described by Paragraphs (A)-(C).
3-2 (7) "Health maintenance organization" means a person
3-3 or entity that arranges for or provides a health care plan to
3-4 enrollees on a prepaid basis.
3-5 (8) "Health maintenance organization delivery network"
3-6 means a health care delivery system in which a health maintenance
3-7 organization arranges for health care services directly or
3-8 indirectly through contracts and subcontracts with providers and
3-9 physicians.
3-10 Art. 20B.03. ELIGIBILITY FOR COVERAGE. A cross-border health
3-11 care plan may only be offered or made available to the following
3-12 persons and their dependents:
3-13 (1) a citizen of the United Mexican States who works
3-14 or resides within 62 miles of the border of this state and the
3-15 United Mexican States; or
3-16 (2) a resident of the United Mexican States who works
3-17 within 62 miles of the border of this state and the United Mexican
3-18 States.
3-19 Art. 20B.04. COVERAGE OFFERED. (a) A health maintenance
3-20 organization licensed to provide basic health care services under
3-21 the Texas Health Maintenance Organization Act (Chapter 20A,
3-22 Vernon's Texas Insurance Code) may offer a cross-border health care
3-23 plan to individuals or to small employers or large employers, as
3-24 those terms are defined by Article 26.02 of this code. In
3-25 arranging for or providing a cross-border health care plan, a
3-26 health maintenance organization has all of the powers and authority
3-27 granted under Section 6, Texas Health Maintenance Organization Act
4-1 (Article 20A.06, Vernon's Texas Insurance Code).
4-2 (b) A cross-border health care plan may limit its service
4-3 area to a geographic region within the United Mexican States and
4-4 may limit the coverage of out-of-area health care services
4-5 delivered in this state to emergency care services. The delivery
4-6 of emergency care services in this state under the plan is subject
4-7 to the requirements of Section 4(a)(16), Texas Health Maintenance
4-8 Organization Act (Article 20A.04, Vernon's Texas Insurance Code).
4-9 (c) The delivery of health care services through the health
4-10 maintenance organization delivery network located in the United
4-11 Mexican States must be based on and determined by the prevailing
4-12 community standards in the United Mexican States, and the licensing
4-13 of physicians and providers is governed by the applicable laws of
4-14 the United Mexican States. A physician or provider providing
4-15 health care services through the delivery network is not required
4-16 to be licensed in this state. The credentialing, peer review, and
4-17 quality of care standards used by a health maintenance organization
4-18 offering a cross-border health care plan is governed by the
4-19 standards that apply in the United Mexican States.
4-20 (d) A cross-border health care plan may be made available to
4-21 eligible employees of a small or large employer, and their
4-22 dependents, only when chosen by the employer as an option among two
4-23 or more health benefit plans, at least one of which provides
4-24 coverage for health care services delivered in this state.
4-25 (e) A health maintenance organization that offers a
4-26 cross-border health care plan must contract with sufficient
4-27 providers and physicians to assure that all health care services
5-1 for which coverage is provided will be reasonably available and
5-2 accessible.
5-3 Art. 20B.05. APPLICABILITY OF TEXAS HEALTH MAINTENANCE
5-4 ORGANIZATION ACT. (a) A cross-border health care plan must satisfy
5-5 the requirements of Section 9, Texas Health Maintenance
5-6 Organization Act (Article 20A.09, Vernon's Texas Insurance Code),
5-7 except that the provisions relating to state continuation of
5-8 coverage and conversion do not apply to a cross-border health care
5-9 plan. A health maintenance organization shall file the form of its
5-10 cross-border health care plan for information only with the
5-11 commissioner, accompanied by a certification on its behalf that on
5-12 best knowledge, information, and belief, the filed form complies in
5-13 all respects with the applicable provisions of this code, the Texas
5-14 Health Maintenance Organization Act, and the adopted rules and
5-15 regulations that are applicable to the form.
5-16 (b) A cross-border health care plan and the health
5-17 maintenance organization offering such a plan are exempt from the
5-18 requirements of Sections 9E, 9F, 11, 11A, 11B, 18A, as added by
5-19 Chapter 1026, Acts of the 75th Legislature, Regular Session, 1997,
5-20 18A, as added by Chapter 735, Acts of the 75th Legislature, Regular
5-21 Session, 1997, 18B, 18C, 29, 37, and 38, Texas Health Maintenance
5-22 Organization Act (Articles 20A.09E, 20A.09F, 20A.11, 20A.11A,
5-23 20A.11B, 20A.18A, as added by Chapter 1026, Acts of the 75th
5-24 Legislature, Regular Session, 1997, 20A.18A, as added by Chapter
5-25 735, Acts of the 75th Legislature, Regular Session, 1997, 20A.18B,
5-26 20A.18C, 20A.29, 20A.37, and 20A.38, Vernon's Texas Insurance
5-27 Code), and Article 26.09, Insurance Code, and any rules or
6-1 regulations adopted under those laws. The commissioner is not
6-2 required to examine a health maintenance organization with respect
6-3 to the quality of health care services delivered under a
6-4 cross-border health care plan by providers and physicians located
6-5 in the United Mexican States.
6-6 (c) Sections 12, 12A, and 12B, Texas Health Maintenance
6-7 Organization Act (Articles 20A.12, 20A.12A, and 20A.12B, Vernon's
6-8 Texas Insurance Code), apply to a cross-border health care plan
6-9 only to the extent that an enrollee under the plan receives health
6-10 care services delivered by a physician or provider located in this
6-11 state.
6-12 (d) Section 26, Texas Health Maintenance Organization Act
6-13 (Article 20A.26, Vernon's Texas Insurance Code), applies to a
6-14 cross-border health care plan, except that Subsection (i)(3) of
6-15 that section does not apply to a cross-border health care plan.
6-16 Articles 21.07-6 and 21.58A, Insurance Code, do not apply to the
6-17 activities of physicians, providers, and other persons doing
6-18 business in the United Mexican States.
6-19 Art. 20B.06. RULES AND REGULATIONS. The commissioner may
6-20 adopt reasonable rules and regulations to:
6-21 (1) prescribe the information to be provided to
6-22 prospective and current group contract holders and enrollees; and
6-23 (2) govern communications with providers and
6-24 physicians relating to the enrollee's medical condition or
6-25 treatment options.
6-26 SECTION 2. This Act takes effect September 1, 2001, and
6-27 applies only to a health care plan offered by a health maintenance
7-1 organization on or after that date. A health care plan that is
7-2 offered by a health maintenance organization before September 1,
7-3 2001, is governed by the law as it existed immediately before the
7-4 effective date of this Act, and that law is continued in effect for
7-5 that purpose.