NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SENATE BILL 385 (SB 385) relating to the Regulation of HMOs SECTION 1 amends Article 1.35A, Texas Insurance Code
Effective Date of Statute: 9/1/97
Requirements of Statute
This summary does not include the Patient Protection Rules which where codified into Chapter 20A by SB 385. HMO Report Card - The Office of Public Insurance Council (OPIC) shall develop and implement a system to compare and evaluate the quality of care provided by and the performance of HMOs. In developing the system, OPIC may use information/data from any person/agency organization/governmental unit that OPIC deems reliable. TDI and the health care information council shall provide information/data as requested by OPIC to accomplish these duties. OPIC is entitled to information that is confidential under any law of this state. OPIC may summarize confidential information provided as long as the summary does not directly or indirectly identify the HMO that is the subject of the information. OPIC may not release information that reveals the identity of a patient/physician; zip code of the patient's primary residence; provider discounts or differentials between payments and billed charges; or actual payments to an provider.
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Submit information as requested.
Responsibility of and/or Action Needed by TDI
Inform staff. Provide information as requested.
Applicable Date of Compliance:
9/1/97 - SECTION 29 of SB 385.
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
OPIC may not endorse/recommend a specific HMO or plan or subjectively rate/rank such entities other than through comparison and evaluation of objective criteria. OPIC shall provide a copy of the consumer report to any person on payment of a reasonable fee - Article 1.35A, Sec. 5(e).
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.
SB 385 - Continued SECTION 2 amends Article 1.35B(b), Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Assessment for OPIC - The annual assessment was increased from 3 cents for each individual policy/certificate of insurance under a group policy of life/health/accident insurance to 5.7 cents.
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Pay assessment.
Responsibility of and/or Action Needed by TDI
Inform staff.
Applicable Date of Compliance:
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued SECTION 3 amends Article 20A, Sec. 2, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Definitions - The following terms were added: adverse determination, capitation, complainant, complaint, life threatening, and prospective enrollee. The following terms were modified: basic health care services, emergency care, physician, provider - Article 20A.02.
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Monitor development and adoption of rules Revise evidence of coverage, documents given to enrollees/prospective enrollees, quality assurance plans, physician/provider manuals, provider manuals, and other internal documents, and submit to TDI in accordance with Article 20A and Article 21.58A.
Responsibility of and/or Action Needed by TDI
Inform staff. Revise and propose rules. Develop/revise checklists and other educational materials/brochures. Review filings. Take any other necessary action.
Applicable Date of Compliance:
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued SECTION 4 amends Article 20A.03, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Establishment of a HMO -Article 20A.03 was amended to include the following: (a) A person/ physician/provider may not perform any of the acts of an HMO except as provided by and in accordance with the specific authorization of Article 20A or other law; (b) A person/physician/provider who performs any of the acts that requires a certificate of authority (C/A) under Article 20A without having first obtained a C/A is subject to all enforcement processes and procedures available against an unauthorized insurer under Articles 1.14-1 and 1.19-1; (c) The previous two provisions do not apply to an activity exempt from regulation under Article 20A.26(f); (d) The commissioner may exercise subpoena authority in accordance with Article 1.19-1 in implementing Article 20A - Article 20A.03(e)(f)(g) and (h).
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.
SB 385 - Continued SECTION 5 amends Article 20A.04 Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Application for Certificate of Authority - Applications for C/A as an HMO must include a written description of health care plan terms/conditions made available to any current/prospective group contract holder or enrollees of the HMO pursuant to the requirements of Article 20A.11
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Monitor development and adoption of rules Revise evidence of coverage, documents given to enrollees/prospective enrollees, quality assurance plans, physician/provider manuals, provider manuals, and other internal documents, and submit to TDI in accordance with Article 20A and Article 21.58A.
Responsibility of and/or Action Needed by TDI
Same as above.
Applicable Date of Compliance:
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued SECTION 6 amends Article 20A.05, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Issuance of Certificate of Authority - Certain provisions for issuance of a C/A were deleted. Provisions added or changed are as follows: The commissioner shall, after notice and hearing, issue or deny a C/A to any person filing an application within 75 days of receipt of a completed application; provided that if notice and opportunity for hearing is involved in a particular issue or denial, the matter may be scheduled for a hearing within 75 days of the completed application. Issuance of a C/A shall be granted if the commissioner is satisfied that the applicant has demonstrated (a) the willingness and potential ability to assure that health care services will be provided in a manner to assure both availability and accessibility of adequate personnel/facilities, in a manner enhancing availability/accessibility/quality of care/continuity of services; (b) has arrangements for an ongoing quality of health care assurance program concerning health care processes/outcomes (in accordance with regulations promulgated by the commissioner); and (c) has a procedure to develop/compile/evaluate/ report statistics relating to the cost of operation/the pattern of utilization of its services/availability and accessibility of its services (in accordance with regulations adopted by the commissioner).
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.
SB 385 - Continued SECTION 7 amends Article 20A.05, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Evidence of Coverage - Required provisions of an evidence of coverage were expanded to include provisions that - (a) enrollees with a chronic/ disabling/life-threatening illnesses can apply to the HMO's medical director to utilize a nonprimary care physician specialist as a primary care physician (PCP). The request must include information specified by the HMO (including certification of medical need) and be signed by both the enrollee and the nonprimary care physician specialist interested in serving as the PCP. The nonprimary care physician specialist must met the HMO's requirements for PCP participation and the nonprimary care physician specialist must be willing to accept the coordination of all of the enrollee's health care needs; (b) if request for special consideration is denied, the enrollee may appeal the decision through the HMO's established complaint and appeal process; and;
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(c) the effective date of the designation of a nonprimary care physician specialist shall not be retroactive. The HMO may not reduce the amount of compensation owed to the original PCP prior to the date of the new designation - Article 20A.09(a)(3)(C)-(F). If an evidence of coverage provides benefits for rehabilitation services/therapies, the provision of those services/therapies in the opinion of a physician are medically necessary and may not be denied/ limited/terminated if they meet or exceed treatment goals for the enrollee. For a physically disabled person, treatment goals may include maintenance of functioning or prevention of or slowing of further deterioration - Article 20A.09(a)(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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
An HMO shall comply with Article 21.55 and shall make payment to a physician/provider for covered services rendered to enrollees not later than the 45th day after the date a claim for payment is received (with documentation reasonably necessary for the HMO to process the claim) or within the number of calendar days specified by written agreement between the physician/provider and the HMO - Article 20A.05(j). An HMO that offers a basic health care plan shall provide/arrange for the provision of basic health care services to its enrollees as needed (without limitations as to time and cost other than limitations adopted by rule of the commissioner) - Article 20A.05(e). Nothing in this Act shall require a HMO/physician/ provider to recommend/offer advice concerning/pay for/provide/assist in/ perform/arrange/participate in providing/performing any health care service that violates its religious convictions. A HMO that limits or denies health care services under this provision shall include such limitations in the evidence of coverage - Article 20A.05(m). The commissioner may adopt minimum standards relating to basic health care services - Article 20A.05(n).
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.
SB 385 - Continued SECTION 8 amends Article 20A.11, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Information to Prospective and Current Group Contract Holders and Enrollees - (a) The HMO shall provide to current/prospective group contract holders/enrollees, upon request, an accurate written description of the terms and conditions of the health care plan. The insurer may provide its handbook to satisfy this requirement provided the handbook's content is substantially similar to and achieve the same level of disclosure as the written description prescribed by the commissioner and the current list of physicians/providers is provided. (b) An HMO shall notify a group contract holder within 30 days of any substantive changes to the payment arrangements between the HMO health care physicians/providers. (c) No HMO (or representative) may cause/knowingly permit the use/distribution of prospective enrollee information which is untrue or misleading - Article 20A.11.
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.
SB 385 - Continued SECTION 9 adds Sec. 11A to Article 20A., Texas Insurance Code.
Effective Date of Statute:
Requirements of Statute
Access to Certain Information - Each HMO or approved nonprofit health corporation (ANHC) shall establish procedures to provide to an enrollee: (a) in the languages of the major populations of the enrolled population (1) a member handbook and (2) materials relating to the complaint and appeals process. A major population is defined as a group comprising 10 percent or more of the HMO's enrolled population. (b) who has a disability affecting the enrollee's ability to communicate or to read (1) access to a member handbook and (2) the complaint and appeals process - Article 20A.11A.
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.
SB 385 - Continued SECTION 10 adds Section 11B to Article 20A, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Information to Enrollees and Prospective Enrollees of HMO - Before a prospective enrollee is enrolled in a health care plan offered to Medicare recipients by a Medicare-contracting HMO, the HMO must provide the prospective enrollee a disclosure form promulgated by the commissioner. The commissioner shall adopt a disclosure form informing prospective enrollees in a Medicare-contracting HMO of (a) the effect enrollment in a Medicare-contracting HMO has the individual's opportunity to purchase Medicare supplement insurance; and (b) any differences in the benefits and costs between the health care plan offered to Medicare recipients and Medicare supplement insurance - Article 20A.11B.
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Monitor development and adoption of disclosure rule. Provide disclosure as required by statute and rule.
Responsibility of and/or Action Needed by TDI
Inform staff. Develop and propose rule relating to disclosure. Take any other necessary action.
Applicable Date of Compliance:
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued SECTION 11 amends Article 20A.12, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Complaint and Appeal System - (a) Every HMO shall establish/implement/maintain an internal system for the resolution of complaints, including a process for the notice and appeal of complaints. The commissioner may adopt reasonable rules as necessary to implement and administer this section. (b) If a complainant notifies the HMO orally or in writing of a complaint, the HMO not later than the 5th business day after the date of the receipt of the complaint, shall send to the complainant a letter acknowledging the date of receipt of the complaint . The letter shall include a description of the HMO's complaint procedures and time frames. If the complaint received is oral, the HMO shall also enclose a 1-page complaint form. The 1-page complaint form must prominently and clearly state that the complaint form must be returned to the HMO for prompt resolution of the complaint. (c) The HMO shall investigate each oral and written complaint received in accordance with its own policies and in compliance with Article 20A. (d) The total time for acknowledgment/ investigation/resolution of the complaint by the HMO may not exceed 30 calendar days after the date the HMO receives the written complaint or the 1-page complaint form from the complainant.
Responsibility of and/or Action Needed by Carriers
Inform staff (including agents). Monitor development and adoption of rules Revise evidence of coverage, documents given to enrollees/prospective enrollees, quality assurance plans, physician/provider manuals, and other internal documents, and submit to TDI in accordance with Article 20A and Article 21.58A..
Responsibility of and/or Action Needed by TDI
Inform staff. Revise and propose rules. Develop/revise checklists and other educational materials/brochures. Review filings. Take any other necessary action.
Applicable Date of Compliance:
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(e) Acknowledgment and time frames outlined above do not apply to complaints concerning emergencies or denials of continued stays for hospitalization. Investigation /resolution of complaints concerning emergencies or denials of continued stays for hospitalization shall be concluded in accordance with the medical or dental immediacy of the case and may not exceed 1 business day from receipt of the complaint. (f) After the HMO has investigated a complaint, the HMO shall issue a response letter to the complainant explaining the HMO's resolution of the complaint within the 30 calendar days. The letter must include a statement of the specific medical/contractual reasons for the resolution and the specialization of any physician/other provider consulted. If the resolution is to deny services based on an adverse determination of medical necessity, the clinical basis used to reach that decision must be included. The response letter must also contain a full description of the process for appeal (including the time frames for the appeals process and final decision on the appeal). (g) If the complaint is not resolved to the satisfaction of the complainant, the HMO shall provide an appeals process that includes the right of the complainant either to appear in person (where the enrollee normally receives health care services, unless another site is agreed to) before a complaint appeal panel, or to address a written appeal to the complaint appeal panel. The HMO shall complete the appeals process not later than the 30th calendar day after the date of the receipt of the request for appeal.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(h) The HMO shall send an acknowledgment letter to the complainant not later than the 5th business day after the date of receipt of the request for appeal. (i) The HMO shall appoint members to the complaint appeal panel (which shall advise the HMO on the resolution of the dispute). The complaint appeal panel shall be composed of equal numbers of HMO staff, physicians/other providers, and enrollees. A member of the complaint appeal panel may not have been previously involved in the disputed decision. The physicians/other providers must have experience in the area of care that is in dispute and must be independent of any physician/ provider who made any prior determination. If specialty care is in dispute, the appeal panel must include an additional person who is a specialist in the field of care to which the appeal relates. The enrollees may not be employees of the HMO. (j) Not later than the 5th business day before the scheduled meeting of the panel (unless the complainant agrees otherwise), the HMO shall provide to the complainant or the complainant's designated representative (1) any documentation to be presented to the panel by the HMO staff; (2) the specialization of any physicians/providers consulted during the investigation; and (3) the name and affiliation of each HMO representative on the panel.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(k) The complainant (or designated representative if the enrollee is a minor or disabled) is entitled to (1) appearance in person before the complaint appeal panel; (2) present alternative expert testimony; and (3) request the presence of and question any person responsible for making the prior determination that resulted in the appeal. (l) Investigation and resolution of appeals relating to ongoing emergencies/denials of continued stays for hospitalization shall be concluded in accordance with the medical or dental immediacy of the case (but in no event to exceed 1 business day after the complainant's request for appeal). Due to the ongoing emergency/continued hospital stay, and at the request of the complainant, the HMO shall provide (in lieu of a complaint appeal panel) a review by a physician/provider who has not previously reviewed the case and is of the same/similar specialty as typically manages the medical condition/procedure treatment under discussion for review of the appeal. The physician/provider reviewing the appeal may interview the patient (or the patient's designated representative) and shall render a decision on the appeal. Initial notice of the decision may be delivered orally if followed by written notice of the determination within 3 days. Investigation/resolution of appeals after emergency care has been provided shall be conducted in accordance with the process established including the right to a review by an appeal panel.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(m) Notice of the final decision of the HMO on the appeal must include a statement of the specific medical determination/clinical basis/contractual criteria used to reach the final decision. The notice must also include the toll-free telephone number and the address of the Texas Department of Insurance (TDI). (n) The HMO shall maintain a record of each complaint, any complaint proceeding and any actions taken on a complaint for 3 years from the date of the receipt of the complaint. A complainant is entitled to a copy of the record on the applicable complaint and any complaint proceeding. (o) Each HMO shall maintain a complaint/appeal log regarding each complaint. (p) Each HMO shall maintain documentation on each complaint received and the action taken on the complaint until the 3rd anniversary of the date of receipt of the complaint. TDI may review this documentation during any investigation of the HMO. (q) The commissioner may examine the complaint system for compliance with Article 20A and may require the HMO to make corrections - Article 20A.12.
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.
SB 385 - Continued SECTION 12 adds Sec. 12A to Article 20A, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Filing Complaints with the Texas Department of Insurance (TDI) - (a) Any person, including persons who have attempted to resolve complaints through a HMO's complaint system process, who are dissatisfied with the resolution may report an alleged violation of Article 20A to TDI. (b) The commissioner shall investigate a complaint against a HMO to determine compliance with Article 20A within 60 days after the TDI receives the complaint and all information necessary for TDI to determine compliance. The commissioner may extend the time necessary to complete an investigation in the event any of the following circumstances occur: (1) additional information is needed; (2) an on-site review is necessary; (3) the HMO/physician/provider/ complainant does not provide all documentation necessary to complete the investigation; or (4) other circumstances beyond the control of TDI occur - Article 20A.12A.
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.
SB 385 - Continued SECTION 14 amends Article 20A.14, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Prohibited Practices - (a) A HMO shall not, as a condition of a contract with a physician/provider, or in any other manner, prohibit/attempt to prohibit/discourage a physician/provider from: (1) discussing with/communicating to a current/ prospective/former patient (or a party designated by a patient) information/opinions regarding the patient's health care including, but not limited, to the patient's medical condition/treatment options; or (2) discussing with/communicating in good faith to a current/prospective/former patient (or a party designated by a patient) information /opinions regarding the provisions/terms/requirements/ services of the plan as they relate to the medical needs of the patient; (b) A HMO shall not in any way penalize/ terminate/refuse to compensate, for covered services, a physician/provider for discussing/ communicating with a current/prospective/former patient (or a party designated by a patient). (c) A HMO may not use any financial incentive/make any payment to a physician/ provider that acts directly/indirectly as an inducement to limit medically necessary services. This does not prohibit the use of capitation as a method of payment - Article 20A.14.
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.
SB 385 - Continued SECTION 17 amends Article 20A.17, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Examinations - (a) The examination provisions were expanded to include examinations concerning the quality of health care services and of the affairs of any applicant for a certificate of authority. Examination may be as often as the commissioner deems necessary; (b) A copy of any contract/agreement/other arrangement between a HMO and a physician/ provider shall be provided to the commissioner by the HMO on request of the commissioner. Such documentation provided to the commissioner shall be deemed confidential and not subject to the open records law; (c) The commissioner may examine and use the records of a HMO, (including records of a quality of care assurance program/a medical peer review committee) as necessary to carry out the purposes of Article 20A, including an enforcement action under Article 20A.20. That information is confidential and privileged and is not subject to the open records, or to subpoena (except as necessary for the commissioner to enforce Article 20A - Article 20A.17.
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.
SB 385 - Continued SECTION 19 adds Sec. 18A to Article 20A, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Physician and Provider Contracts - (a) Before terminating a contract with a physician/provider, the HMO shall provide a written explanation to the physician/provider of the reasons for termination. On request and before the effective date of the termination (but within a period not to exceed 60 days) a physician/provider shall be entitled to a review of the HMO's proposed termination by an advisory review panel (except in a case in which there is imminent harm to patient's health or an action by a state medical/dental board; other medical/dental licensing board; other licensing board or other government agency, that effectively impairs the physician's/provider's ability to practice medicine/dentistry/another profession, or in a case of fraud/malfeasance. The advisory review panel shall be composed of physicians/providers, including at least 1 representative in the physician's/provider's specialty/similar specialty, if available, appointed to serve on the standing quality assurance committee or utilization review committee of the HMO. The decision of the advisory review panel must be considered but is not binding on the HMO. The HMO shall provide to the affected physician/provider, on request, a copy of the recommendation of the advisory review panel and the HMO's determination.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(b) Each contract between an HMO and a physician/provider of health care services must provide (1) that reasonable advance notice be given to an enrollee of the impending termination from the plan of a physician/provider who is currently treating the enrollee; (2) that the termination of the physician/provider contract (except for reason of medical competence/professional behavior) does not release the HMO from the obligation to reimburse the physician/provider who is treating an enrollee of special circumstance (as defined in the bill) at no less than the contract rate for that enrollee's care in exchange for continuity of ongoing treatment of an enrollee then receiving medically necessary treatment in accordance with the dictates of medical prudence. The special circumstance shall be identified by the treating physician/provider, who must request that the enrollee be permitted to continue treatment under the physician's/provider's care and agree not to seek payment from the patient of any amounts for which the enrollee would not be responsible if the physician/provider were still on the HMO network; (3) reimbursement to a terminating physician/provider is extended beyond 90 days for the following reasons: (a) an enrollee has a terminal illness (payment is extended to 9 months); and (b) an enrollee who is past the 24th week of pregnancy (payment is extended through delivery of the child, immediate post-partum care and follow up checkup within the first 6 weeks of delivery).
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(c) A physician/provider who is terminated/ deselected shall be entitled to an expedited review process by the HMO on request by the physician/provider. If the physician/provider is deselected for reasons other than at the physician's/ provider's request, the HMO may not notify patients of the physician's/provider's deselection until the effective date of the termination or the time a review panel makes a formal recommendation. If a physician/provider is deselected for reasons related to imminent harm, the HMO may notify patients immediately.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(d) HMOs that use capitation as a method of compensation shall (1) shall begin payment of capitated amounts to the enrollee's PCP calculated from the date of enrollment, no later than the 60th day following the date an enrollee has selected or has been assigned a PCP. If selection/assignment does not occur at the time of enrollment, capitation which would otherwise have been paid to a selected PCP had a selection been made shall be reserved as a capitation payable until such time as an enrollee makes a selection or the plan assigns a PCP; (2) an HMO may assign an enrollee to a PCP, if an enrollee does not select a PCP at the time of application or enrollment. If an HMO elects to assign an enrollee to a PCP, the assignment shall be made to a PCP located within the zip code nearest the enrollee's residence/place of employment and, to the extent practicable given the zip code limitation, shall be done in a manner that results in a fair and equal distribution of enrollees among the plan's PCPs. The HMO shall inform an enrollee of the name, address, and telephone number of the PCP to whom the enrollee has been assigned and of the enrollee's right to select a different PCP. An enrollee shall have the right at any time to reject the PCP assigned and to select another physician/provider from the list of the HMO's PCPs. An election by an enrollee to reject an assigned PCP shall not be counted as a change in provider for purposes of the limitation in Article 20A.11(a); (3) notify a physician/provider of the selection of the physician/provider as a PCP by an enrollee within 30 working days of the selection or assignment of an enrollee to that physician/provider by the HMO.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(e) All contracts or other agreements between a HMO and a physician/provider shall specify that the physician/provider will hold an enrollee harmless for payment of the cost of covered services in the event the HMO fails to pay the provider for services. (f) A contract between an HMO and a physician/ provider must require the physician/provider post, in the office of the physician/provider, a notice to enrollees on the process for resolving complaints with the HMO. The notice must include TDI's toll-free telephone number for filing complaints - Article 20A.18A.
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.
SB 385 - Continued SECTION 21 amends Article 20A.20, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Suspension/Revocation of Certificate of Authority (C/A) - After notice and opportunity for hearing the commissioner may (a) suspend or revoke any C/A issued to a HMO; (b) impose sanctions under Article 1.10, Sec. 7; (c) impose administrative penalties under Article 1.10E; or (d) issue a cease and desist order under Article 1.10A, if the commissioner finds that any of the conditions outlined the statute exist. The list of conditions was expanded to include the following: the HMO has failed to carry out corrective action the commissioner considers necessary to correct a failure to comply with Article 20A; any applicable provision of the Insurance Code; or any applicable rule or order of the commissioner within 30 days after the date of notice of a deficiency or within any longer period of time that the commissioner determines to be reasonable and specifies in the notice - Article 20A.20.
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.
SB 385 - Continued SECTION 22 amends (Article 20A.22, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Rules and Regulations - The commissioner's authority to promulgate rules was expanded to include rules to (a) ensure that enrollees have adequate access to health care services; (b) establish minimum physician/patient ratios; (c) mileage requirements for primary and specialty care; (d) maximum travel time; and (e) maximum waiting times for obtaining appointments. Additionally, the commissioner may promulgate such reasonable rules and regulations as are necessary and proper to meet the requirements of federal law and regulations - Article 20A.22.
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.
SB 385 - Continued SECTION 24 amends Article 20A.26, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Except for Articles 21.07-6 and 21.58A, the insurance laws (including the group hospital service corporation law do not apply to physicians and providers; however, a physician or provider who conducts utilization review during the ordinary course of treatment of patients pursuant to a joint or delegated review agreement or agreements with a HMO on services rendered by the physician or provider shall not be required to obtain certification under Section 3, Article 21.58A, Insurance Code. Article 20A applies to a medical school and medical/dental unit as defined by Section 61.003, 61.501, or 74.601, Education Code, except when such a medical school and medical/dental unit contracts to deliver medical care within a HMO delivery network - Article 20A.26.
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.
SB 385 - Continued SECTION 26 amends Article 20A.32, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
Fees - (a) The fee for filing and review of an original application for a certificate of authority, has been increased from an amount not to exceed $15,00 to $18,000; (b) HMOs must pay for the expenses of an examination under Article 20A.17(a) incurred by the commissioner or under the commissioner's authority, provided that: (1) examination expenses are the expenses attributable directly to a specific examination including the actual salaries and expenses of the examiners directly attributable to that examination as determined under rules adopted by the commissioner; and (2) the expenses shall be assessed by the commissioner and paid in accordance with rules adopted by the commissioner.
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.
SB 385 - Continued SECTION 28 adds Section 37 and 38 to Article 20A, Texas Insurance Code
Effective Date of Statute:
Requirements of Statute
HMO Quality Assurance - (a) A HMO shall establish procedures to assure that the health care services provided to enrollees shall be rendered under reasonable standards of quality of care consistent with prevailing professionally recognized standards of medical practice. Such procedures shall include mechanisms to assure availability/ accessibility/quality/continuity of care. (b) A HMO shall have an ongoing internal quality assurance program to monitor and evaluate its health care services, including primary and specialist physician services, and ancillary and preventive health care services, in all institutional and noninstitutional contexts. The commissioner by rule may establish minimum standards and requirements for ongoing internal quality assurance programs for HMOs, including but not limited to standards for assuring availability/accessibility/ quality/continuity of care. (c) A HMO shall record formal proceedings of quality assurance program activities and maintain documentation in a confidential manner. Quality assurance program minutes shall be available to the commissioner. (d) A HMO shall establish and maintain a physician review panel to assist in reviewing medical guidelines/criteria and to assist in determining the prescription drugs to be covered by the HMO (if the HMO offers a prescription drug benefit).
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(e) A HMO shall ensure the use and maintenance of an adequate patient record system that will facilitate documentation/retrieval of clinical information for the purpose of the HMO's evaluation of continuity and coordination of patient care and assessment of the quality of health and medical care provided to enrollees. (f) Enrollees' clinical records shall be available to the commissioner for examination and review to determine compliance. Such records are confidential and privileged, and are not subject to the open records law (or to subpoena, except to the extent necessary to enable the commissioner to enforce this article). (g) A HMO shall establish a mechanism for the periodic reporting of quality assurance program activities to its governing body/providers/appropriate organization staff - Article 20A.37.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
Effect of Dental Point-of-Service Option on Health Maintenance Organization - Each dental HMO or other single service health maintenance organization that provides dental benefits is subject to Article 20A.38; except for a HMO with 10,000 or fewer enrollees in this state enrolled in dental benefit plans based on a provider panel.
Responsibility of and/or Action Needed by Carriers
Same as above.
Responsibility of and/or Action Needed by TDI
Revise and propose rules. Develop/revise checklists and other educational materials/brochures. Review filings.
Applicable Date of Compliance:
NUMBER of BILL. (SECTION/ARTICLE) Statute and Title.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(a) If an employer/association/other private group arrangement that employs or has 25 or more employees/members offers and contributes to the cost of dental benefit plan coverage to employees/ individuals only through a provider panel, the HMO with which the employer/association/other private group arrangement is contracting for the coverage shall offer, or contract with another entity to offer, a dental point-of-service option to the employer/ association/other private group arrangement. The employer may offer the dental point-of-service option to the employee or individual to accept or reject. (b) If a HMO's dental provider panel is the sole delivery system offered to employees by an employer, the HMO: (1) shall offer the employer a dental point-of-service option; (2) may not impose a minimum participation level on the dental point-of-service option; and (3) as part of the group enrollment application, shall provide to each employer disclosure statements as required by rules adopted under this code for each dental plan offered. (c) An employer may require an employee or individual who accepts the point-of-service option to be responsible for the payment of a premium over the amount of the premium for the coverage provided to employees or members under the dental benefit plan offered through a provider panel either directly or by payroll deduction in the same manner in which the other premium is paid. The premium for the point-of-service option must be based on the actuarial value of that coverage.
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
(d) Different cost-sharing provisions may be imposed for the point-of-service option. (e) An employer may charge an employee or individual who accepts the point-of-service option a reasonable administrative fee for costs associated with the employer's reasonable administration of the point-of-service option - Article 20A.38. (f) Definitions are included for (1) "Point-of-service option;" (2) "Provider panel."
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.
SB 385 - Continued
Effective Date of Statute:
Requirements of Statute
Miscellaneous - Numerous additional changes/deletions were made to Article 20A including but not limited to references to State Board of Insurance, opportunity for hearing - Article 20A.
Responsibility of and/or Action Needed by Carriers
Responsibility of and/or Action Needed by TDI
Applicable Date of Compliance:
* Summary Information is not all inclusive of all requirements of new and/or amended statutes. Summary information is primarily provided for carriers/persons/other entities/HMOs/MEWAs involved with submission of life/health/annuity/HMO/MEWA forms and/or filings for review and/or approval.