Commissioner’s Bulletin # Summary of Health Care Coverage/Life Related Legislation Enacted - 75th Legislative Session (House Bills Only)

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2063 (HB 2063) relating to Diagnosis and Treatment of Conditions Affecting the Temporomandibular Joint (TMJ) and Dental Services SECTION 1 amends Article 21.53A, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Scope of Article - This article applies to a group health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including a group, blanket, or franchise insurance policy/agreement, a group hospital service contract or group evidence of coverage that is offered by an insurance company, a group hospital service corporation, a fraternal benefit society, a stipulated premium insurance company, an HMO (including an approved nonprofit health corporation under Article 21.52F) or to the extent permitted by the Employee Retirement Income Security Act, a multiple employer welfare arrangement, any other entity that contracts directly for health care services or another analogous benefit arrangement - Article 21.53A, Sec. 2(a).

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2063 - Continued

Effective Date of Statute

Requirements of Statute

This article does NOT apply to a plan that provides coverage only for a specified disease or other limited benefit; accidental death or dismemberment; disability income; as a supplement to liability insurance; credit insurance; vision care only; indemnity for hospital confinement; a Medicare supplemental policy; workers' compensation insurance coverage; a small employer health plan under Chapter 26; medical payment insurance issued as part of a motor vehicle insurance policy; or a long term care policy. - Article 21.53A, Sec. 2(b).

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2063 - Continued

Effective Date of Statute

Requirements of Statute

Required Benefit for Diagnosis and Treatment Affecting TMJ - Each group health benefit plan that provides benefits for the medically necessary diagnostic or surgical treatment of skeletal joints must provide comparable coverage for the medically necessary diagnostic or surgical treatment of conditions affecting the TMJ. TMJ includes the jaw and the craniomandibular joint - Article 21.53A, Sec. 3(a).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Articles 20A and 21.58A, (c) summary plan descriptions and submit in accordance with 28 TAC 7.1901-7.1910; and (d) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop and propose rules. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

Applies to group health benefit plans, issued, delivered or renewed on or after 1/1/98 - SECTION 2 of HB 2063.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2063 - Continued

Effective Date of Statute

Requirements of Statute

Each health benefit plan subject to this law shall provide coverage for diagnosis or surgical treatment that is medically necessary as a result of an accident, a trauma, a congenital defect, a developmental defect, or a pathology - Article 21.53A, Sec. 3(b). All other provisions generally applicable to surgical treatment under the plan may be applied to the benefits required, including precertification - Article 21.53A, Sec. 3(c).

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2063 - Continued

Effective Date of Statute

Requirements of Statute

Dental Services - A group health benefit plan (a) is not required to provide dental services if the plan does not otherwise provide dental benefits and (b) may not exclude from coverage an individual who is unable to undergo dental treatment in an office setting or under local anesthesia (due to a documented physical, mental, or medical reason as determined by the individual s physician/dentist providing the dental care) - Article 21.53A, Sec. 4.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2180 (HB 2180) relating to the Review of Mandated Coverage in Health Benefit Plans SECTIONS 1 and 2 repeal Article 21.52D, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Article 21.52D relating to review of mandated coverage in health benefit plans by a Mandated Review Panel is repealed. (Note: HB 1 requires TDI to review and prepare a report on mandates in health benefit plans.)

Responsibility of and/or Action Needed by Carriers

Inform staff.

Responsibility of and/or Action Needed by TDI

Inform staff. Revise checklists and other educational materials/brochures.

Applicable Date of Compliance

Statute and panel repealed/ abolished 9/1/97 - SECTIONS 1 and 2 of HB 2180.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2221 (HB 2221) relating to Life Insurance Written by Certain Agents or Assumed by Stipulated Premium Insurance Companies SECTIONS 1, 2 and, 3 amend Article 21.07 Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Agents Licenses - The statute was amended to raise the dollar limit requiring an individual desiring to sell life insurance over a certain amount submit to an examination. The limiting amount was increased from $7,500 to $10,000 - Article 21.07 Secs. 3(b) and 4A. A person or corporation that holds a license under Article 21.07-1 is entitled to write life insurance under that license for a stipulated premium company without obtaining a license under Article 21.07. A stipulated premium company may appoint as its agent a person/corporation that holds a license under Article 21.07-1 - Article 21.07, Sec. 15A.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Amend procedures.

Responsibility of and/or Action Needed by TDI

Inform staff. Proposed rules published in Texas Register on 8/15/97. Revise forms. Take any other necessary action.

Applicable Date of Compliance

9/1/97 - SECTION 7 of HB 2221.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2221 - Continued SECTION 4 adds Sec. 3 to Article 22.07, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Reinsurance - If the surplus of stipulated premium company is at least $50,000 but less than $200,000, the stipulated premium company shall reinsure the life insurance amount that exceeds $10,000 on any one life - Article 22.07, Sec. 3.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Review life risks and obtain reinsurance.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise forms/ checklists/procedures and other educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2221 - Continued SECTION 5 amends Article 22.13, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

This article was amended to provide an exception to the provision that limited stipulated premium insurance companies from assuming liability on a life insurance risk in an amount in excess of $10,000. The statute now states that if a stipulated premium insurance company assumes a life insurance risk , the initial death benefit of $10,000 or less may increase to an amount greater than $10,000. For a policy in which the death benefit (subsequent to issuance) exceeds $10,000 the death benefit at the end of each policy year may not exceed the greater of (a) the maximum increase as specified in the policy (compounded annually) or (b) the CPI-U (compounded annually). The CPI-U for a calendar year is the consumer price index for all urban consumers for all items and all regions of the U.S. (combined as determined by the U.S. Dept. of Labor, Bureau of Labor Statistics) on 9/30 of the prior calendar year. The maximum increase that may be specified in a life insurance policy under this article is 5% (compounded annually) - Article 22.13, Sec. 1(b).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Revise or develop as applicable (a) Life forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) any other internal documents

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

Applies to a policy delivered issued for delivery or renewed on or after 9/1/97. A policy is considered renewed on the date the policyholder makes a payment of a premium - SECTION 7 of HB 2221.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2221 - Continued SECTION 6 amends Article 22.23, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Language addressing the $10,000 limitation on any one life was amended to reference the exceptions provided for in Articles 23.13 and 22.23A.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2274 (HB 2274) relating to the Exemption of Insurance Benefits and Certain Annuity Proceeds from Seizure under Process SECTION 1 adds Sec. 7 to Article 21.22, Texas Insurance Code.

Effective Date of Statute 9/1/97

Requirements of Statute

Exemptions and protections from seizure - Exemptions and protections from seizure under Article 21.22 are in addition to the exemptions from garnishment, attachment, execution, or other seizure under Chapter 42, Property Code - Article 21.22, Sec. 7.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Develop/amend applicable procedures.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise checklists and other educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

Applies to money or benefits paid or rendered to an insured/ beneficiary under an insurance policy or annuity contract without regard to whether the policy or contract was issued on, entered into before, on or after 9/1/97 - SECTION 2 of HB 2274.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2644 (HB 2644) relating to Systems and Programs Administered by the Teacher Retirement System of Texas SECTIONS 33-36 amend Article 3.50-4, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Alternative Health Benefit Plan - Alternative health benefit plan may be offered by a school district to its active employees during the period of its participation in the program if the trustee approves the plan as providing contributions, participation and a design that are in accordance with sound group benefit underwriting principles - Article 3.50-4, Sec. 7A(a). Contributions - Each participating school district shall contribute for each district employee covered by the program an amount equal to not less that 75% of the cost of the employee only coverage. The district shall certify to the trustee the amount the district will contribute. The trustee shall determine if the amount is sufficient to underwrite the plan for the district based on sound group benefit underwriting principles. A determination by the trustee is final - Article 3.50-4, Sec. 7A(e).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Inform staff (including agents). Revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Article 20A; and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise checklists and other educational materials/brochures. Inform staff. Develop/revise and propose rules, if necessary. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

9/1/97 - SECTION 42 of HB 2644.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2644 - Continued

Effective Date of Statute

Requirements of Statute

Purchase of Group Health Care Benefits - The statute was amended by (a) giving the trustee the authority to establish one or more plans that are self-insured; (b) adding long-term care to the list of coverages that may be included in the plan; (c) deleting certain language pertaining to contracting; and (d) adding language requiring rules on the bidding process to require prospective bidders to provide information (for each area consisting of a county and all adjacent counties) on the number and types of qualified providers willing to participate in the coverage for which the bid is made. Additionally, the rules may provide criteria to determine qualified providers. The trustee shall consider this information before awarding a contract but may not require a bidder to demonstrate a minimum standard of provider participation. The statute was also amended by adding language modifying the entities with which trustee may contract to provide benefits (HMOs, preferred provider organizations, carriers, administrators and other qualified vendors) - Article 3.50-4, Sec. 8.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules by the trustee.

Responsibility of and/or Action Needed by TDI

Inform staff. Provide assistance to the trustee in development of rules, if necessary. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2644 - Continued

Effective Date of Statute

Requirements of Statute

Miscellaneous - Other changes were made to the language of Article 3.50-4 including, but not limited to, deletion of the amount the state shall pay for active employees for the years 1986-1998.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2644 - Continued SECTION 37 amends Sec. 22.004 of the Education Code

Effective Date of Statute

Requirements of Statute

The board of trustees of the Teacher Retirement System (TRS) shall adopt rules to determine whether a school district s health care coverage is comparable to the basic health coverage specified. The statute requires rules be adopted and lists 7 factors that must be considered in determining if the school district s coverage is comparable. - Sec. 22.004, Education Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules by the trustee. If applicable, revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Article 20A; and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

Applies beginning with the 1998-1999 school year - SECTION 42 of HB 2644.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2795 (HB 2795) relating to the Composition and Powers of the Texas Health Benefits Purchasing Cooperative (THBPC) and miscellaneous changes to Chapter 26, Texas Insurance Code SECTION 1 amends Article 26.11, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Definitions - The definition of "Texas cooperative" is amended to clarify that the cooperative is a nonprofit corporation - Article 26.11(4).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents).

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise checklists and other educational materials/brochures.

Applicable Date of Compliance

9/1/97 - SECTION 8 of HB 2795.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2795 - Continued SECTIONS 2, 3 and 4 amend Article 26.13, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Texas Department of Commerce - The requirement that the executive director of the Texas Department of Commerce shall serve as a nonvoting ex-officio member of the THBPC has been deleted - Article 26.13(b). Immunity from Liability - The THBPC is not liable for (a) acts performed in good faith or (b) independent action of a small employer carrier or a person who provides health care services under a health benefit plan - Article 26.13(h).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents and persons who provide health care services).

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2795 - Continued SECTIONS 5 and 6 amend Article 26.15.

Effective Date of Statute

Requirements of Statute

Powers and Duties of the THBPC and Private Purchasing Cooperatives - A cooperative s power has been expanded to allow for the offering of ancillary products and services to its members that are customarily offered in conjunction with health benefit plans - Article 26.15(a)(10).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Revise or develop as applicable (a) A&H/Life forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Article 20A; and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Evaluate and propose rules, if necessary. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2795 - Continued

Effective Date of Statute

Requirements of Statute

A cooperative shall comply with (a) federal and state law or rules and (b) state laws applicable to cooperatives and health benefit plans issued - Article 26.15(d).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Develop/amend procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2795 - Continued SECTION 7 amends Article 26.16, Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Cooperative Not an Insurer - The statute was amended to state that (a) a cooperative is considered an employer solely for the purpose of benefit elections under the code and (b) a licensed agent used and compensated by a cooperative need NOT be appointed by each small employer carrier participating in the cooperative. A licensed agent may not market any other non-sponsored product or service of a participating small employer carrier without first being appointed by the small employer carrier - Article 21.16(b) and (d).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Develop/amend procedures.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise procedures and educational materials/brochures. Take any other necessary action.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 2846 (HB 2846) relating to Health Care Services by Advanced Practice Nurses and Physician Assistants SECTION 4 amends Article 20A.14, Texas Insurance Code and SECTION 5 adds Article 3.70-3C to the Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

HMOs or Preferred Provider Benefit Plans (PPO) and Advance Practice Nurses (APN) and Physician Assistances (PA) - If an APN or PA is authorized to provide care under the Medical Practice Act by a physician participating in a HMO or PPO, the HMO or PPO may NOT refuse a request made by the physician and PA or APN to have the PA or APN identified as a provider (unless the PA or APN fails to meet the quality of care standards previously established by the HMO or PPO for participation in the plan by APNs and PAs) - Articles 20A.14(i) and 3.70-3(C), Sec. 2. A HMO or PPO may not refuse to contract with an APN or PA, refuse to reimburse the APN or PA for covered services or otherwise discriminate against the APN or PA solely because the APN or PA is not identified under Article 21.52 - Articles 20A.14(j) and 3.70-3(C), Sec. 3.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Revise or develop as applicable (a) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; (b) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Article 20A; and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop/revise checklists and other educational materials/brochures. Review form filings. Take any other necessary action.

Applicable Date of Compliance

Applies to an insurance policy or evidence of coverage that is delivered, issued for delivery or renewed on or after 1/1/98 - SECTION 7 of HB 2846.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 2846 - Continued SECTION 6 amends Article 3.70-2(B), Texas Insurance Code

Effective Date of Statute

Requirements of Statute

Designation of Practitioners - The list of practitioners has been amended to define and include Advance Practice Nurse and Physician Assistance - Article 3.70-2(B).

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 3054 (HB 3054) relating to Reporting of Immunizations SECTION 1 amends Chapter 161 of the Health and Safety Code

Effective Date of Statute 9/1/97

Requirements of Statute

The Texas Department of Health (TDH) shall establish and maintain a childhood immunization registry. Rules are to be adopted. Insurance companies, HMOs or another organizations that pay or reimburse a claim for an immunization of a person younger than 18 years of age shall provide an immunization history to the TDH. Reporting is not required for a person from whom consent has not been obtained in accordance with guidelines adopted by the department or for whom consent has been withdrawn - Sec. 161.007, Health and Safety Code.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules by TDH. Establish procedures/systems to collect data and submit to TDH as required.

Responsibility of and/or Action Needed by TDI

Inform staff. Provide assistance to TDH as necessary.

Applicable Date of Compliance

Sections 161.007(c) & (d) are effective 1/1/99 - SECTION 3 of HB 3054.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 3197 (HB 3197) relating to Utilization Review of Certain Health Care Services Provided to a Person who Sustains a Compensable Injury. SECTION 1 amends Article 21.58A, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Utilization Review for Workers' Compensation Medical Benefits - Utilization review of health care services provided to persons eligible for workers' compensation medical benefits under Title 5, Labor Code is subject to the provisions of Article 21.58A. The commissioner shall regulate in the manner provided by Article 21.58A a person who performs review of a medical benefit provided under Chapter 408, Labor Code. This does not affect the authority of the Texas Workers' Compensation Commission (TWCC) to exercise the powers granted to that commission under Title 5, Labor Code. If there is a conflict between Article 21.58A and Title 5, Labor Code, Title 5 of the Labor Code prevails. The Commissioner of Insurance and the TWCC may adopt rules and enter into memoranda of understanding as necessary to implement this statute - Article 21.58A, Sec. 14(c).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Submit certificate of registration for review by the department in accordance with Article 21.58A.

Responsibility of and/or Action Needed by TDI

Inform staff. Coordinate with the TWCC in the development of rules. Develop/revise checklists and other education materials/brochures. Review filings. Take any other necessary action. Develop memorandum of understanding with the TWCC.

Applicable Date of Compliance

Applies to utilization review conducted on or after 1/1/98 - SECTION 2 of HB 3197.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HOUSE BILL 3269 (HB 3269) relating to Requirements for Evidence of Coverages issued by HMOs SECTION 1 amends Article 20A.09, Texas Insurance Code

Effective Date of Statute 9/1/97

Requirements of Statute

Contents of Evidence of Coverage - Each evidence of coverage must contain a provision that: (a) medically necessary covered services are not available through network physicians/providers, the HMO, on the request of a network physician/provider, within a reasonable period, shall allow referral to a non-network physician/provider and shall fully reimburse the non-network physician/ provider at the usual and customary or an agreed rate. Additionally, the evidence of coverage must provide for a review by a specialist of the same specialty or a similar specialty as the type of physician/provider to whom a referral is requested before the HMO may deny a referral - Article 20A, Sec. 9(f); (b) an enrollee with a chronic/disabling/life-threatening illness may apply to the HMO s medical director to use a nonprimary care physician specialist as the enrollee's primary care physician (PCP). An application made by an enrollee under this subsection must include information specified by the HMO, including certification of the medical need, and must be signed by the enrollee and the nonprimary care physician specialist interested in serving as the enrollee's PCP. To be eligible to serve as the enrollee's PCP, the specialist must meet the HMO s requirements for PCP participation and be willing to accept the coordination of all of the enrollee's health care needs - Article 20A, Sec. 9(g).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise (a) evidence of coverage, applicable documents given to enrollees, quality assurance plans, physician and provider contracts & manuals and submit to TDI in accordance with Articles 20A and 21.58A, and (b) any other internal documents/ procedures.

Responsibility of and/or Action Needed by TDI

Inform staff. Develop and propose rules. Develop/revise checklists and other educational materials/brochures. Review filings. Take any other necessary action.

Applicable Date of Compliance

Applies to evidence of coverage delivered, issued for delivery, or renewed on or after 1/1/98 - SECTION 2 of HB 3269.

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 3269 - Continued

Effective Date of Statute

Requirements of Statute

(c) if the request for special consideration is denied, an enrollee may appeal the decision through the HMO s established complaint and appeals process - Article 20A, Sec. 9(h). (d) the effective date of the designation of a nonprimary care physician specialist as an enrollee's PCP may not be applied retroactively. The HMO may not reduce the amount of compensation owed to the original PCP for services provided before the date of the new designation - Article 20A, Sec. 9(i).

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance

NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.

HB 3269 - Continued

Effective Date of Statute

Requirements of Statute

Miscellaneous - Numerous editorial, grammatical and placement changes were also made to Article 20A, Sec. 9.

Responsibility of and/or Action Needed by Carriers

Same as above.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance