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Summary of Health Care Coverage/Life Related Legislation Enacted - 75th Legislative Session (Senate Bills Continued)

   

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

SENATE BILL 217 (SB 217) relating to Reconstructive Surgery Incident to a Mastectomy SECTION 1 adds Article 21.53D to the Texas Insurance Code

Effective Date of Statute: 9/1/97

Requirements of Statute

Scope of Article - This article applies to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy/agreement, a group hospital service contract or 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 or another analogous benefit arrangement - Article 21.53D, Sec. 2(a).

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance:


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

SB 217- Continued

Effective Date of Statute:

Requirements of Statute

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

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance:


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

SB 217- Continued

Effective Date of Statute:

Requirements of Statute

Coverage Required - A health benefit plan that provides coverage for mastectomy must provide coverage for breast reconstruction. The coverage may be subject to the same deductible or copayment applicable to mastectomy - Article 21.53D, Sec. 3.

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

Applicable Date of Compliance:

Applies to any policy, contract, evidence of coverage issued, delivered or renewed on or after 1/1/98 - SECTION 2 of SB 217.

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

SB 217 - Continued

Effective Date of Statute:

Requirements of Statute

Prohibition - A health benefit plan may not offer a financial incentive for a patient to forgo breast reconstruction or to waive the coverage required by this Article - Article 21.53D, 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:

Same as above.

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

SB 217 - Continued

Effective Date of Statute:

Requirements of Statute

Rules - The commissioner may adopt rules as necessary to administer this article - Article 21.53D, Sec. 5.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules.

Responsibility of and/or Action Needed by TDI

Develop and propose rules.

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.


   

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

SENATE BILL 258 (SB 258) relating to Tests for Detection of Prostate Cancer SECTION 1 adds Article 21.53F to the Texas Insurance Code

Effective Date of Statute: 9/1/97

Requirements of Statute

Scope of Article - This article applies to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including an individual, group, blanket, or franchise insurance policy/agreement, a group hospital service contract or 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), to the extent permitted by the Employee Retirement Income Security Act, a multiple employer welfare arrangement or another analogous benefit arrangement, any other entity that contracts directly for health care services or health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code - Article 21.53F, Sec. 2(a).

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance:


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

SB 258 - Continued

Effective Date of Statute:

Requirements of Statute

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

Responsibility of and/or Action Needed by Carriers

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance:


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

SB 258 - Continued

Effective Date of Statute:

Requirements of Statute

Required Coverage for Certain Tests for the Detection of Prostate Cancer - A health benefit plan that provides benefits for diagnostic medical procedures must provide coverage for each male enrolled in the plan for expenses incurred in conducting an annual medically recognized diagnostic examination for the detection of prostate cancer. Minimum benefits must include: (1) a physical examination for the detection of prostate cancer; and (2) a prostate specific antigen test used for the detection of prostate cancer for each male enrolled in the plan who is: (A) at least 50 years of age and asymptomatic; or (B) at least 40 years of age with a family history of prostate cancer or another prostate cancer risk factor - Article 21.53F, Sec. 3.

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

Applicable Date of Compliance:

Applies to any policy, contract, evidence of coverage issued, delivered or renewed on or after 1/1/98 - SECTION 2 of SB 258.

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

SB 258 - Continued

Effective Date of Statute:

Requirements of Statute

Notice - Each health benefit plan shall provide written notice to each person enrolled in the plan regarding the coverage required by this article. The notice must be provided in accordance with rules adopted by the commissioner - Article 21.53F, Sec. 4.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules. Provide notice as required.

Responsibility of and/or Action Needed by TDI

Develop and propose rules.

Applicable Date of Compliance:


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

SB 258 - Continued

Effective Date of Statute:

Requirements of Statute

Rules - The commissioner shall adopt rules as necessary to administer this article - Article 21.53F, Sec. 5.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules.

Responsibility of and/or Action Needed by TDI

Same as above.

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.


   

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

SENATE BILL 333 (SB 333) relating to Payment of Insurance Benefits for a Child to a Possessory Conservator of the Child SECTION 1 amends Article 3.51-13, Texas Insurance Code

Effective Date of Statute: 9/1/97

Requirements of Statute

Payment of A&H Benefits to a Possessory Conservator - The law addressing payment on behalf of a child under a group accident and sickness policy to a managing conservator has been expanded to include payment to a possessory conservator - Article 3.51-13, Secs. 1, 2, and 3.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). If proposed, 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) 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:

Applies to policies delivered, issued for delivery or renewed on or after 1/1/98 - SECTION 2 of SB 333.
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* 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.


   

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

SENATE BILL 382 (SB 382) relating to the Regulation of HMOs SECTION 1 amends Article 20A.02, Texas Insurance Code

Effective Date of Statute: 9/1/97

Requirements of Statute

Definitions - Definitions added include limited health care services and limited health care service plan. Definitions amended include health care services, health maintenance organization and person - Article 20A.02.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Review physician and provider contracts to determine compliance concerning coverage for mental health; chemical dependency; mental retardation; or long-term care and submit to TDI in accordance with Article 20A.

Responsibility of and/or Action Needed by TDI

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

Applicable Date of Compliance:

9/1/97 - SECTION 12 of SB 382.

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

SB 382 - Continued SECTION 2 amends Article 20A.04, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Certificate of Authority - A limited health care service plan must submit as part of the application for certificate of authority (C/A) a specific description of the health care services to be provided - Article 20A.04(a)(13).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Develop as applicable evidence of coverage and other applicable documents given to enrollees, quality assurance plans, physician/ provider contracts, other necessary documents and submit to TDI in accordance with Articles 20A and 21.58A.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 382- Continued SECTION 3 amends Article 20A.05, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Bankruptcy - By applying for and receiving a C/A, an HMO agrees and admits that it is not subject to the U.S. Bankruptcy Code and is not eligible to proceed under that code - Article 20A.05(e).

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:


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

SB 382- Continued SECTION 5 amends Article 20A.13, Texas Insurance

Effective Date of Statute:

Requirements of Statute

Initial Deposit - The amount of the initial deposit or other guarantee is $75,000 for an organization offering limited health care services - Article 20A.13(b)(1).

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:


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

SB 382- Continued

Effective Date of Statute:

Requirements of Statute

Surplus requirements - Subject to the phase-in provisions, an HMO shall maintain the following surplus (net of accrued uncovered liabilities: (a) $1,500,000 for an HMO offering for basic health care services and (b) $1,000,000 for an HMO offering limited health care services - Article 20A.13(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:


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

SB 382- Continued

Effective Date of Statute:

Requirements of Statute

Phase-in provisions for surplus requirements - Minimum surplus requirements for HMOs offering basic health care services, limited health care services and single health care services are phased in beginning 1998 and ending 2002 - Article 20A.13(j).

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:


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

SB 382- Continued

Effective Date of Statute:

Requirements of Statute

Insolvency - In the event of the insolvency of an HMO, the commissioner shall allocate equitably the insolvent HMO's group contracts or nongroup enrollees among all HMOs that operate within a portion of the insolvent HMO's service area (taking into consideration the resources of each HMO). Each HMO to which allocation has been made shall offer (a) to a group the HMO's group coverage; (b) to nongroup enrollees the HMO's existing coverage for individuals or conversion coverage. Rates for the coverage offered shall be determined in accordance with the successor HMO's existing methodology or as adjusted by the commissioner. Successor HMOs that do not offer nongroup enrollment shall provide coverage at rates that reflect the average group rate of the successor HMO - Article 20A.13(m).

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:


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

SB 382- Continued SECTION 9 amends Article 20A.31, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Jurisdiction for Injunctions and Receivership and Delinquency Proceedings - In addition to all other remedies available by law, when it appears to the commissioner that a HMO or other person is insolvent or does not possess the surplus required, the commissioner may bring suit in a district court of Travis County to be named receiver in accordance Article 20A.21 and Article 21.28. A court of competent jurisdiction may find that a receiver should take charge of the assets of a HMO and name the commissioner as the receiver of the HMO. The operations and business of an HMO represent the business of insurance for purposes of Article 20A.21 and Articles 21.28 and 21.28-A, Texas Insurance Code. Exclusive venue of receivership and delinquency proceedings for a HMO shall be in Travis County - Article 20A.31(b)-(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:

9/1/97

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

SB 382- Continued

Effective Date of Statute:

Requirements of Statute

Miscellaneous - Throughout the bill numerous editorial changes were made including, but not limited to, additions of terms such as limited health care services and commissioner and deletions of State Board of Insurance.

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.


   

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

SENATE BILL 383 (SB 383) relating to Preferred Provider Benefit Plans (PPO) SECTION 1 adds Article 3.70-3C to the Texas Insurance Code

Effective Date of Statute: 6/19/97

Requirements of Statute

The majority of SB383 codifies the Preferred Provider (PPO) Rules contained in 28 TAC 3.3701-3.3705. This summary only outlines the changes/additions made to the language of the rules. Definitions - The following definitions are either different than those contained in the rules or are new: (a) emergency care; (b) life threatening; (c) practitioner (includes occupational therapist, physical therapist and advance practice nurse (refer also to HB 2846); and (d) quality assessment - Article 3.70-3C, Sec. 1.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) claim payment procedures; (b) contracts with providers; (c) disclosures notices; (d) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42; and (e) any other internal documents.

Responsibility of and/or Action Needed by TDI

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

Applicable Date of Compliance:

Applies to any insurance policy or contract issued, delivered or renewed on or after 6/19/97.

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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Review Mechanism/Resolution of Complaints - (a) The review mechanism and the requirement for resolution of complaints is available to both physicians and practitioners - Article 3.70-3C, Sec. 3. (b) Prior to termination of a physician/ practitioner, an insurer must give the physician/ practitioner a time period (not to exceed 60 days) to request and receive a review by a panel - Article 3.70-3C, Sec. 3(g). (c) On request, an expedited review process shall be made available to a physician/practitioner being terminated. The expedited review process shall comply with rules established by the commissioner - Article 3.70-3C, Sec. 3(g).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) review mechanism/procedures; (b) contracts with providers; and (c) 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. Take any other necessary action.

Applicable Date of Compliance:


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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Payment to Insureds and Physicians/Providers - (a) An insurer shall comply with Article 21.55 with respect to prompt payment to insureds. (b) A PPO contract must include a provision for payment to the physician/provider for covered services that are rendered not later than 45 days after the date on which a claim for payment is received or within the number of calendar days specified by written agreement between the physician/provider and the insurer - Article 3.70-3C, Sec. 3(m).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) claim payment; (b) contracts with providers; and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Continuity of Care - Reimbursement to a terminating physician/provider or insured at preferred provider rate 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) - Article 3.70-3C, Sec. 4(e).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) claim payment procedures; (b) contracts with providers; (c) disclosure notices; (d) A&H forms or amendments to bring previously submitted forms into compliance and submit in accordance with Article 3.42 and (e) 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:


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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Mandatory Disclosure - The insurer shall provide to current or prospective group contract holders or insureds, upon request, an accurate written description of the terms and conditions of the policy. 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 - Article 3.70-3C, Sec. 6(b).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) procedures/ disclosures notices; (b) submit disclosure notices as required and (c) any other internal documents.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Current list of preferred providers - A current list of providers shall be provided to all insureds no less than annually - Article 3.70-3C, Sec. 6(c).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable procedures relating to distribution of preferred provider list.

Responsibility of and/or Action Needed by TDI

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

Applicable Date of Compliance:


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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Prohibited Practices - An insurer shall not, as a condition of contract with a physician/provider (a) attempt to prohibit/discourage a physician/provider from discussing/communicating with patients (or designee of the patient) information/opinions regarding the patient's health care or information/opinions regarding provisions, terms, requirements or services of the health care plan as they relate to the medical needs of the patient and (b) penalize/terminate/refuse to compensate for covered services a physician/provider for discussing/communicating with a patient (or designee of the patient) - Article 3.70-3C, Sec. 7(c).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop as applicable (a) contracts with providers and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 383 - Continued

Effective Date of Statute:

Requirements of Statute

Rules - The commissioner shall adopt rules as necessary to implement this article and ensure reasonable accessibility and availability of preferred provider and basic level benefits - Article 3.70-3C, Sec. 9.

Responsibility of and/or Action Needed by Carriers

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

Responsibility of and/or Action Needed by TDI

Same as above.

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.


   

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

SENATE BILL 384 (SB 384) - Relating to Utilization Review (UR) under Health Benefit Plans and Health Insurance Policies SECTION 1 amends Article 21.58A, Sec. 2, Texas Insurance Code

Effective Date of Statute: 9/1/97

Requirements of Statute

Definitions - The following outlines the major changes to definitions in Article 21.58A: (a) The definition for adverse determination is modified; (b) emergency care is re-defined; and (c) a new definition for life threatening is added - Article 21.58A. Sec. 2.

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise or develop (a) application documents previously filed in connection with certificates of registration in accordance with Article 21.58A and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Inform staff. Proposed rules relating to UR published in Texas Register on 9/5/97. Develop/revise checklists and other educational materials/brochures. Review filings. Take any other necessary action.

Applicable Date of Compliance:

9/1/97 - SECTION 11 of SB 384.

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

SB 384 - Continued SECTION 2 amends Article 21.58A, Sec. 3 Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Complaints - Procedures for handling complaints must include oral complaints as well as written -Article 21.58A, Sec. 3(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:


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

SB 384 - Continued SECTION 3 amends Article 21.58A, Sec. 4, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Standards for Utilization Review - Personnel receiving clinical information regarding a patient's specific medical condition/diagnosis/ treatment/ treatment options/protocols must be either a physician/nurse/physician assistant/health care provider who is qualified to provide the service requested by the provider. Language was deleted allowing registered records technicians/individuals who receive formal orientation/training from receiving clinical information - Article 21.58A, Sec. (4)(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:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

Dentists were added to the list of those who periodically evaluate and update UR procedures. Criteria must be used only to determine whether to approve the requested treatment. Denials must be referred to a physician/dentist/ other health care provider to determine if there is medical necessity - Article 21.58A, Sec. (4)(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:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

The reference to dentist is deleted (Note: SECTION 10 adds requirements for specialty UR agents) - Article 21.58A, Sec. 4(k).

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:


SB Index HB Index Previous Bill Next Bill

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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

Oral as well as written complaints must be covered by a UR agent's complaint handling system. Records of oral and written complaints are to be kept for 3 years (formerly 2). The UR agent shall respond to the complaint within 30 days (formerly 60 days) - Article 21.58A, Sec. 4(m).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Revise complaint forms. Update certificate of registration, documents previously filed in connection with certificates of registration and new applications in accordance with Article 21.58A. Amend internal documents/procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

If a UR agent delegates review, delegation shall not relieve the UR agent of full responsibility for compliance with Article 21.58A (including the conduct of those to whom UR has been delegated) - Article 21.58A, Sec. 4(n).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Update application documents previously filed in connection with certificates of registration in accordance with Article 21.58A. Amend internal documents/procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued SECTION 4 amends Article 21.58A, Sec. 5, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Notice of Determination - The notification of adverse determination by the UR agent must include the clinical basis for the adverse determination as well as a description of the procedure for the complaint and appeal process - Article 21.58A, Sec. 5(c). For a patient who is hospitalized at the time of an adverse determination, the notice shall be provided within 1 working day by telephone or electronic transmission. The notice shall be followed by a letter within 3 working days - Article 21.58A, Sec. 5(d)(1). The notice of the adverse determination shall occur within the time appropriate to the circumstances relating to the delivery of the services and the condition of the patient (but in no case should the delivery of the UR agent's determination take longer than 1 hour in the case of denying post-stabilization care after emergency treatment) - Article 21.58A, Sec. 5(d)(3).

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:


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

SB 384 - Continued SECTION 5 amends Article 21.58A, Sec. 6, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Appeals of an Adverse Determination - Procedures for appeals must include procedures for oral and written appeals. If the appeal is oral, the UR agent shall send a 1-page appeal form to the appealing party. The UR agent must respond to an appeal within 5 working days by sending a letter acknowledging receipt of the date of the appeal and include a list of documents needed to be submitted by the appealing party - Article 21.58A, Sec. 6(b)(1)&(2).

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:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

If an appeal is denied, the health care provider may request a particular type of specialty provider review the case. Such health care provider shall be the same or similar specialty as typically manages the medical/dental/ specialty condition/procedure/ treatment under discussion. Such review shall be completed within 15 working days of receipt of the request - Article 21.58A, Sec. 6(b)(3).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Update certificate of registration, documents previously filed in connection with certificates of registration and new applications in accordance with Article 21.58A. Amend internal documents/procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

The expedited appeal procedure was expanded to include denials of care for life-threatening conditions. The expedited appeal procedure shall include a review by a health care provider in the same or a similar specialty that typically manages the medical/procedure/treatment being reviewed. Such appeal shall be completed based on the medical/dental immediacy of the condition/ procedure, but not to exceed 1 working day from the date all of the information necessary for the appeal is received - Article 21.58A, Sec. 6(b)(4).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Update application documents previously filed in connection with certificates of registration in accordance with Article 21.58A. Amend internal documents/procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

The response letter explaining the resolution of the appeal shall include a statement of the specific medical/dental/contractual reasons for the resolution, the clinical basis for such decision and the specialization of any physician/provider consulted - Article 21.58A, Sec. 6(b)(5).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Update application documents previously filed in connection with certificates of registration in accordance with Article 21.58A. Revise evidence of coverage, applicable documents given to enrollees, quality assurance plans, any other internal documents, and submit to TDI in accordance with Articles 20A and 21.58A.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

A UR agent must provide written notification of the determination of the appeal to the appealing party as soon as practical (but no later than 30 days after the date of receipt of the appeal) - Article 21.58A, Sec. 6(b)(6).

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:


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

SB 384 - Continued SECTION 6 amends Article 21.58A, Sec. 7, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Poststabilization Care Subsequent to Emergency Treatment - A UR agent must provide to the commissioner a written description of procedures that shall be used when responding to requests by a treating physician/health care provider for poststabilization care after emergency treatment - Article 21.58A, Sec. 7(c).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Update application documents previously filed in connection with certificates of registration in accordance with Article 21.58A. Amend internal documents/procedures.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued SECTION 7 amends Article 21.58A, Sec. 8, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Confidentiality - The list of items considered confidential was amended to include personal information. UR agents may not disclose confidential information unless prior written consent of the patient is obtained (or other authorization as required by law is supplied). Other requirements were added regarding the release of personal or confidential information to someone other than the patient - Article 21.58A, Sec. 8(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:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

Requirements and timelines for responding to requests for personal information to an individual are included in Article 21.58A, Sec. 8(d).

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:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

A UR agent may charge for providing copies of personal information; however, such changes must be reasonable, as determined by the commissioner, and may not include any costs that are otherwise recouped as part of the charge for UR - Article 21.58A, Sec. 8(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:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

The commissioner may request individual medical records or other information from UR agents. Information provided to the commissioner is confidential and privileged, and is not subject to the Open Records Law. The information is also not subject to subpoena (except to the extent necessary for the commissioner to enforce Article 21.58A) - Article 21.58A, Sec. 8(i).

Responsibility of and/or Action Needed by Carriers

Submit information requested by commissioner.

Responsibility of and/or Action Needed by TDI

Same as above.

Applicable Date of Compliance:


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

SB 384 - Continued SECTION 8 amends Article 21.58A, Sec. 9, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Violations - The enforcement authority of the commissioner for violations involving UR has been expanded to provide authority over any person/entity involved in UR. Time lines in which the commissioner may initiate proceedings have been deleted. Additionally, the commissioner may assess administrative penalties under Article 1.10E for violations of Article 21.58A - Article 21.58A, Sec. 9(a)(b), and (d).

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:


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

SB 384 - Continued SECTION 9 amends Article 21.58A, Sec. 13, Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Advisory Committee - The composition of the advisory committee is to include a representative from consumer organizations - Article 21.58A, Sec. 13.

Responsibility of and/or Action Needed by Carriers

Monitor appointment to committee.

Responsibility of and/or Action Needed by TDI

Appoint representative to committee.

Applicable Date of Compliance:


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

SB 384 - Continued SECTION 10 amends Article 21.58A, Sec. 14 Texas Insurance Code

Effective Date of Statute:

Requirements of Statute

Application - Changes to Article 21.58A, Sec. 14(b)(2) state that except as provided by Subsection (g), this article shall not apply to the Texas Medicaid Program, the chronically ill and disabled children's services program created pursuant to Chapter 35, Health and Safety Code, any program administered under Title 2, Human Resources Code, any program of the Texas Department of Mental Health and Mental Retardation, or any program of the Texas Department of Criminal Justice.

Responsibility of and/or Action Needed by Carriers

Monitor development and adoption of rules. Revise or develop (a) application documents previously filed in connection with certificates of registration in accordance with Article 21.58A and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Proposed rules relating to UR published in Texas Register on 9/5/97.

Applicable Date of Compliance:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

HMOs that are covered by Article 21.58A are more precisely defined (including those HMOs that contract with the Health and Human Services Commission, or an agency operating part of the state Medicaid managed care program which provides assistance to enrollees pursuant to Chapter 32 of the Human Resources Code). HMOs and insurers performing UR shall comply with all sections of Article 21.58A, except Secs. 3 and 10 - Article 21.58A, Sec. 14 (b),(e),(g), and (h).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development of rules. Update certificate of registration, documents previously filed in connection with certificates of registration and new applications in accordance with Article 21.58A. Revise or develop as applicable (a) evidence of coverage and other applicable documents given to enrollees, quality assurance plans and submit in accordance with Articles 20A and 21.58A, and (b) any other internal documents.

Responsibility of and/or Action Needed by TDI

Applicable Date of Compliance:


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

SB 384 - Continued

Effective Date of Statute:

Requirements of Statute

Provisions specific to specialty utilization review have been added. A specialty UR agent is one who conducts UR for specialty health care services including, but not limited to, dentistry/chiropractic/ physical therapy - Article 21.58A, Sec. 14(j).

Responsibility of and/or Action Needed by Carriers

Inform staff (including agents). Monitor development and adoption of rules. Apply for certificates of registration and file UR plan documents for certification in accordance with Article 21.58A.

Responsibility of and/or Action Needed by TDI

Same as above.

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.

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Last updated: 04/08/2014



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