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Health Coverage for Diabetes Equipment and Supplies - S.B. 163

by Senator Zaffirini, et al.

House Sponsor: Representative Berlanga

§ Requires defined health benefit plans that provide benefits for the treatment of diabetes and associated conditions to provide coverage to qualified individuals for diabetes equipment, supplies, and self-management training programs.

§ Requires defined health benefit plans to include coverage of new or improved equipment or supplies approved by the United States Food and Drug Administration.

§ Prohibits setting deductibles, copayments, or coinsurance requirements for diabetes benefits at a higher rate than those for treatment of other analogous chronic medical conditions.

§ Requires the Commissioner of Insurance (commissioner) to adopt necessary rules for implementation of this bill.

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Regulation of Insolvent HMOs and Limited Service Plans - S.B. 382

by Senator Madla, et al.

House Sponsor: Representative Smithee, et al.

§ Requires a health maintenance organization (HMO) that provides limited health care service plans to obtain a certificate of authority from the Texas Department of Insurance (TDI). Also requires the agency to provide TDI with a description of the health care services being provided under the plan.

§ Sets the level of minimum surpluses required to be held by an HMO providing a limited health care service plan in the state.

§ Prohibits an HMO that is organized to do business in Texas from going to federal bankruptcy court upon determination that it is insolvent and provides exclusive venue of receivership and delinquency proceedings to occur in Travis County.

§ Requires the TDI commissioner to allocate enrollees of an insolvent HMO among all the remaining HMOs in that service area.

§ Establishes coverage rates for the successor HMOs.

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Quality Standards for PPOs and Consumer Protections - S.B. 383

by Senator Cain, et al.

House Sponsor: Representative Smithee, et al.

§ Authorizes insurers to offer a preferred provider benefit plan to enrollees if the plan complies with certain requirements.

§ Requires insurers offering preferred provider benefit plans to:

§ afford all health care providers with an opportunity to become preferred providers. Establishes notification requirements, an appeals process for those providers not selected, and an annual opportunity for physicians to participate in the plan;

§ contract with enough providers to assure that all medical and health care services are covered. Requires each insured patient to have the right to treatment and diagnostic techniques as prescribed by the provider;

§ establish a system for resolving complaints and terminating providers. Requires insurers to release information on provider performance if used for admitting or terminating providers including benchmark standards;

§ use at least three contracting physicians for quality assessment purposes; and

§ ensure that benefits are reasonably available to all those insured within a designated service area, or requires reimbursement to nonpreferred providers.

§ Establishes requirements to be included in preferred provider contracts, including: prohibition against "hold harmless" clauses which remove the insurer's tort liability that results from its acts or omissions; prohibition in the billing of enrollees by providers at prices different than the contractual price; insurer assuring compliance if it contracts for services with another preferred provider organization; and insurer providing prompt payment to providers.

§ Establishes procedures for continuity of treatment when a provider is terminated from the preferred provider plan, including reasonable advanced notice of termination to patients and obligation of provider to continue treatment and of the insurer to continue payments to providers. Lists special circumstances under which coverage may be continued, although in most instances continuation of coverage following provider termination is limited to 90 days.

§ Requires insurers to reimburse out-of-network providers for defined emergency care services.

§ Establishes mandatory disclosure requirements for insurers to enrollees, and provides guidelines for notification in cases of provider termination.

§ Prohibits retaliatory action against an enrollee or provider for filing a complaint against the insurer.

§ Requires the commissioner to adopt necessary rules to ensure reasonable accessibility and availability of preferred and basic level benefits to Texans.

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Utilization Review for Health Care Agencies - S.B. 384

by Senator Nelson, et al.

House Sponsor: Representative Smithee, et al.

§ Requires utilization review (UR) decisions to be made in accordance with currently accepted medical or health care practices. Requires screening criteria to meet certain guidelines, and to only be used to determine whether to approve the requested treatment. Requires denials to be referred to an appropriate provider to determine medical necessity.

§ Requires a UR agent to maintain a complaint system for oral and written complaints.

§ Authorizes a UR agent to delegate UR to qualified personnel, while retaining full responsibility for ensuring compliance.

§ Requires the UR agent to disclose the clinical basis for denying coverage and establishes a complaint and appeals process.

§ Requires UR agent to provide a written description to the commissioner on the procedures to be used when responding to post-stabilization care subsequent to emergency treatment as requested by a provider.

§ Prohibits disclosure by UR agents of any personal information about the patient without written consent, except to the commissioner, who may still collect the personal information to determine compliance. Allows individuals to access their own recorded personal information, at a reasonable charge, from UR agents.

§ Authorizes the commissioner to assess administrative penalties for violating applicable regulations.

§ Requires a UR agent who reviews specialty health care services, including but not limited to dentistry, chiropractic, or physical therapy, to comply with certain UR provisions.

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Consumer Protection and Increased Accountability of HMOs - S.B. 385

by Senator Sibley, et al.

House Sponsor: Representative Smithee, et al.

General Provisions

§ Requires the office of public insurance counsel to develop and implement a system to compare and evaluate, on an objective basis, the quality of care provided by and performance of an HMO established under the Texas Health Maintenance Organization Act.

§ Prohibits a person, physician, or provider from performing any of the acts of an HMO, except as provided by and in accordance with specific authorizations under law. Prohibits performance of any of the acts of a HMO without a certificate of authority from TDI and gives the TDI commissioner subpoena authority.

§ Requires additional information to be provided in obtaining a certificate, including health care plan terms and conditions; network configuration; types of compensation arrangements; and guarantee of coverage and payment for defined emergency care services. Requires the TDI commissioner to be satisfied that an HMO has met certain criteria before issuing a certificate of authority.

§ Requires HMOs to provide coverage to non-network providers if network providers are not available and to allow for coverage by nonprimary care physician specialists when an enrollee has a chronic, disabling, or life threatening illness.

§ Mandates prompt payment from HMOs to enrollees and payment to a physician or provider within 45 days after the claim for payment is received.

§ Requires HMOs that offer basic health care plans to provide services to enrollees as needed without limitations as to time and cost, other than those prescribed by TDI.

§ Allows enrollees in HMOs to change their primary care provider to another physician in the HMOs up to four times per year.

§ Requires HMOs to establish and maintain an internal system for resolving any written or oral complaints. Authorizes the commissioner to adopt reasonable rules for implementation and administration purposes. Authorizes any person to use TDI, if the person is dissatisfied with the resolution of an issue.

§ Establishes requirements for certain dental HMOs or other single service HMOs that provide dental benefits.

HMO Contract Provisions

§ Requires Medicare-contracting HMOs to provide prospective enrollees with a disclosure form, developed by the commissioner, which details the impact of selecting a Medicare HMO.

§ Requires HMOs to establish and maintain an internal system for resolving any written or oral complaints. Authorizes the commissioner to adopt reasonable rules for implementation and administration purposes. Authorizes any person to use TDI, if the person is dissatisfied with the resolution of an issue.

§ Prohibits HMOs from including gag rules in provider contracts and from taking retaliatory action against a provider or enrollee for filing a complaint or appealing a decision. Prohibits HMOs from using financial incentives to a physician or provider that could act as an inducement to limit necessary services.

§ Requires an HMO to provide to the commissioner a copy of any contract, agreement, or other arrangement between an HMO and a physician or provider upon request. Authorizes the commissioner to examine and use the records of a HMO as necessary, including for an enforcement action.

§ Requires an HMO to make available and disclose to providers, upon request, written application procedures and qualification requirements for contracting with the HMO.

§ Requires an HMO that terminates a contract with a provider to give written notice indicating the reasons for termination. Authorizes a review of the termination by an advisory review panel, except in certain situations.

§ Requires a contract between an HMO and a provider to provide that reasonable advance notice be given to an enrollee of the impending termination. Specifies that the termination does not release the HMO from the obligation to reimburse a provider treating an enrollee with special circumstances for 90 days beyond the effective date of termination.

§ Requires an HMO to provide an expedited review process, upon request, to a provider who is terminated or deselected.

§ Requires HMOs which utilize capitation as a method of payment to comply with specific provisions.

§ Prohibits a contract between an HMO and a provider from containing any clause purporting to indemnify the HMO for any tort liability resulting from acts or omissions of the HMO.

§ Requires contracts between HMOs and providers to specify that the provider will hold an enrollee harmless for payment of the cost of covered health care services in the event the HMO fails to pay the provider for services.

§ Requires an HMO that uses economic profiling of providers within the HMO to make this information available to a network provider, on request.

§ Requires contracts between an HMO and a provider to mandate the provider to post a notice to enrollees on the process for resolving complaints with the HMO.

Enforcement Provisions

§ Authorizes TDI to impose sanctions, administrative penalties, or to issue a cease and desist order to HMOs not in compliance with the Act.

§ Authorizes TDI to develop rules to ensure that enrollees have adequate access to health care services, and to establish a minimum physician/patient ratio, mileage requirement for primary and specialty care, maximum travel time, and maximum waiting times for appointments.

§ Requires an HMO to establish procedures to assure that the health care services provided to enrollees are rendered under reasonable standards of quality of care. Requires HMOs to develop an internal quality assurance program, patient record system, and reporting system. Authorizes TDI to access clinical records of an HMO.

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Ordinary Standard of Care for Health Insurers - S.B. 386

by Senator Sibley, et al.

House Sponsor: Representative Smithee, et al.

§ Establishes a duty of ordinary care for health insurance carriers, HMOs, and managed care entities and holds them liable for damages resulting from a failure to exercise this duty. Applies the same liability to employees, agents, ostensible agents, or representatives of these entities. Stipulates that the ordinary care duty does not create an obligation to provide non-covered treatments.

§ Authorizes a defense to prosecution for health insurance carriers, HMOs, and managed care entities in instances where they did not control, influence, or participate in the health care treatment decision and did not deny or delay payment for any treatment prescribed or recommended by a provider.

§ Provides the there is no liability created by the ordinary care duty for an employer, an employer purchasing organization, or a licensed pharmacy that purchases coverage or assumes risk on behalf of its employees.

§ Prohibits health insurance carriers, HMOs, and managed care entities from removing or refusing to renew health care providers for advocating on behalf of the enrollee to obtain appropriate and medically necessary health care.

§ Voids all "hold harmless" or "indemnification" clauses between health insurance carriers, HMOs, or managed care entities and health care providers or pharmaceutical companies.

§ Prevents health insurance carriers, HMOs, and managed care entities from using any state law prohibiting them from practicing medicine or being licensed to practice medicine as a defense in any legal action.

§ Establishes a minimum level for determining if a health care provider is an employee, agent, ostensible agent, or representative for a health insurance carrier, HMO, or managed care entity.

§ States that the law does not apply to workers' compensation insurance coverage.

§ Prohibits a person from maintaining a cause of action against a health insurance carrier, HMO, or managed care entity unless the person has exhausted the appeals and review applicable under the utilization review requirements or, before instituting the action, provides written notice of the claim and agrees to submit the claim to a review by an independent review organization. Sets forth specific guidelines for providing written notice and instances where submission to the independent review organization is not required. Allows a person to pursue other appropriate remedies in instances in which the process would place the person's health in serious jeopardy.

§ Authorizes any party, whose appeal of an adverse determination is denied by a utilization review agent, to obtain a review by an independent review organization. Requires the utilization review agent to provide certain information to the independent review organization to comply with the independent review determination, and to pay for the independent review.

§ Requires every HMO to establish and maintain a complaint system for handling oral and written complaints concerning health care services.

§ Requires the commissioner of insurance to develop standards and rules regarding independent review organizations. Sets forth time requirements for independent review organizations to render a determination. Provides that an independent review organization is not liable for damages arising from the determination unless it is done in bad faith or involves gross negligence.

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Advance Directives Act - S.B. 414

by Senator Moncrief

House Sponsor: Representative Coleman, et al.

§ Makes changes to advance directives under the Natural Death Act, out-of-hospital do-not-resuscitate (DNR) orders, and durable power of attorney for health care, and combines the changes in a new Advance Directives Act.

§ Provides a list of persons who may not be witnesses to the execution of an advance directive or issuance of a non-written advance directive. Requires the policies to include a clear and precise statement of any procedure the health care provider is unwilling or unable to withhold in accordance with an advance directive.

§ Requires a health care provider to maintain certain written policies on implementing advance directives and to provide written notice of the policies.

§ Amends the Natural Death Act.

§ Deletes the list of persons who may not be witnesses to the signature of a written advance directive.

§ Provides that a written directive for a competent adult or on behalf of a patient younger than 18 years old is effective without being notarized.

§ Allows the attending physician and the patient's legal guardian or an agent under a durable power of attorney for health care to make a treatment decision if an adult patient has not executed or issued a directive, and is comatose, incompetent, or otherwise mentally or physically incapable of communication.

§ Allows the attending physician and one person from a specified list of persons to make a treatment decision, if the patient does not have a legal guardian or an agent under a durable power of attorney for health care. Requires the treatment decision to be documented in the patient's medical record and signed by the attending physician. Deletes the requirement that the treatment decision must be made in the presence of two witnesses. Requires another physician who is not involved in the treatment of a patient to witness the treatment decision, if the patient does not have a legal guardian and a person from the list specified earlier is not available.

§ Provides that a physician or health facility that, in good faith, causes life-sustaining procedures to be withheld or withdrawn from a patient in accordance with this law, is not civilly liable for that action. Deletes the exception of negligence.

§ Provides that a health professional, acting under the direction of a physician, who participates, in good faith, in withholding or withdrawing life-sustaining procedures from a patient in accordance with this law is not civilly liable for that action. Deletes the exception of negligence.

§ Provides that a physician, or a health professional acting under the direction of a physician, who participates, in good faith, in withholding or withdrawing life-sustaining procedures from a qualified patient in accordance with this law is not criminally liable or guilty of unprofessional conduct as a result of that action. Deletes the exception of negligence.

§ Amends provisions affecting out-of-hospital DNR orders.

§ Deletes the requirements that witnesses to written out-of-hospital DNR orders, orders by nonwritten communications, and procedures when a person has not executed or issued such orders and is incompetent or incapable of communication must have the same qualifications as witnesses to a written directive by a competent adult under the Natural Death statute.

§ Provides for the attending physician and at least two qualified relatives to follow the execution of an out-of-hospital DNR order as outlined in previous changes to the Natural Death statute if a person does not have a legal guardian, proxy, or agent and is incompetent or incapable of communication.

§ Amends provisions affecting durable power of attorney for health care.

§ Authorizes an agent with the authority to make health care decisions under a durable power of attorney to make any health care decision that a person could make if the person were competent. Makes similar wording changes regarding competency throughout other provisions on durable power of attorney for health care.

§ Allows an agent to exercise authority only if the attending physician certifies in writing and files the certification in the medical record, that the person is incompetent.

§ Requires the durable power of attorney for health care to be signed by the principal in the presence of at least two witnesses meeting qualifications as provided by the new definitions adopted under the Advance Directives Act. Deletes certain restrictions on who a witness may not be, but keeps the provision that a witness may not be an agent.

§ Changes the disclosure statement and the durable power of attorney forms to incorporate changes to the list of people who may not act as witnesses.

§ Requires administrative penalties of $500 against home and community support services agencies, hospitals, nursing facilities, special care facilities, and personal care facilities that violate the section on health care providers maintaining written policies on advance directives and providing written notices of the policies.

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Statewide Rural Health Care System Act - S.B. 1246

by Senator Madla, et al.

House Sponsor: Representative Berlanga, et al.

§ Establishes the statewide rural health care system (system) to arrange for or provide health care services on a prepaid basis to enrollees who reside in rural communities.

§ Establishes requirements for the system and requires the commissioner of insurance (commissioner) to designate one organization as the system.

§ Requires the system to contract with or otherwise arrange for local health care providers to deliver health care services to enrollees. Authorizes the system to contract with health care providers who are not local health care providers, if local providers are unable to provide the type and quality of services needed.

§ Requires the state to award to the system at least one state Medicaid managed care contract, except in specific instances.

§ Requires any entity selected by the state Medicaid contracting entity to provide health care to those children to use local health care providers and hospital providers in establishing its provider network, if the system elects not to receive a subcontract or provide the state share of matching funds.

§ Requires the system to address specific qualifications for arranging to provide health care services to beneficiaries of certain governmental health care programs as a requirement for participating in any state contract.

§ Requires that the system be reimbursed at the state-defined capitation rate for each service area in which the system operates.

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Changing Regulation of HMO Agents - H.B. 219

by Representatives Brimer and Siebert

Senator Sponsor: Senator Patterson

§ Repeals the section of the HMO Act that stipulates licensing requirements for HMO agents, and makes them subject to the laws and regulations governing life, accident, and health insurance agents.

§ Prohibits an unlicensed person or legal entity from representing an HMO.

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Federal Insurance Reforms and Texas Health Insurance Risk Pool - H.B. 710

by Representative Averitt, et al.

Senate Sponsor: Senator Sibley

§ Amends the Texas Health Insurance Risk Pool (pool) to implement new federal requirements. Modifies group and individual health insurance and HMO benefits to comply with federal health reforms.

Regulating Texas' Health Insurance Risk Pool

§ Provides that a member of the board of directors of the pool (board) is not liable for an action or omission performed in good faith in the performance of powers and duties under this article.

§ Requires the plan of operation submitted by the pool's initial board to include procedures for operation of the pool and other items.

§ Requires the board to promulgate a list of medical or health conditions for which a person shall be eligible for pool coverage without applying for health insurance.

§ Requires the board to make an annual report on the activities of the pool.

§ Authorizes, rather than requires, the board, after completing a competitive bidding process to select one or more insurers or a third party administrator to administer the pool.

§ Authorizes the commissioner to establish additional powers and duties of the board and other rules as necessary.

§ Authorizes, rather than requires, the board to consider appropriate risk factors in accordance with established actuarial and underwriting practices in regard to rates and rate schedules.

§ Outlines new provisions for the pool to determine the standard risk rate and other rates.

General Standards for Coverage

§ Requires any individual person who is and continues to be a resident of Texas and a citizen of the United States to be eligible for coverage from the pool if certain evidence is provided.

§ Requires each dependent of a person who is eligible for coverage to also be eligible.

§ Requires resident family members, in the instance of a child who is the primary insured, to be eligible for coverage.

§ Revises provisions regarding who is not eligible for coverage from the pool.

§ Provides when pool coverage ceases.

§ Requires the pool to offer pool coverage consistent with major medical expense coverage to each eligible person who is not eligible for Medicare. Requires the board, with the approval of the commissioner, to establish the coverage to be provided by the pool and other provisions.

§ Requires pool coverage to exclude certain charges or expenses incurred for preexisting conditions, as defined. Prohibits a preexisting condition provision from applying to an individual who has been continuously covered for an aggregate period of 12 months by health insurance.

§ Authorizes the board to assess insurers and make advance interim assessments as reasonable and necessary for the plan's organizational and interim operating expenses. Requires the excess to be used to offset future losses or reduce future assessments.

§ Requires the board to determine and report annually to the commissioner the net loss, if any, of the pool for the previous calendar year, taking into account investment income and other appropriate gains and losses. Requires any net loss for the year to be recouped by assessments on insurers. Requires each insurer's assessment to be determined annually by the board, based on annual statements and other reports.

§ Authorizes an insurer to petition the commissioner for an abatement or deferment of all or part of an assessment. Authorizes the commissioner to abate or defer such assessment and adds other provisions regarding abating and deferring assessments. Prohibits the total of all assessments on an insurer from exceeding one-half of one percent of the insurer's collected premiums for health insurance in this state.

§ Entitles an applicant or participant covered under the pool to have complaints against the pool reviewed by a grievance committee appointed by the board. Establishes procedures for the grievance committee.

§ Requires the state auditor to conduct annually a special audit of the pool.

Group Coverage

§ Requires any insurer or group hospital service corporation, as defined, to provide a group privilege.

§ Requires policies to provide continuation of group coverage for employees or members and their eligible dependents subject to the eligibility provisions. Deletes provisions requiring insurers to first offer conversion policies and other provisions.

§ Authorizes an insurer to offer to each employee, member, or dependent a conversion policy, and outlines its issuance and other restrictions.

Individual Coverage

§ Prohibits a preexisting condition provision in an individual health insurance policy from applying to an individual who was continuously covered for an aggregate period of 18 months by creditable coverage.

§ Requires an individual health insurance policy providing benefits for medical care under a hospital, medical, or surgical policy to be renewed or continued in force at the option of the individual.

§ Authorizes an individual health insurance policy providing benefits for certain medical care to not be renewed or to be discontinued only for certain reasons.

§ Requires an HMO to provide a group continuation privilege as required, including specific provisions for the continuation of group coverage.

§ Authorizes an HMO to offer each enrollee a conversion contract.

§ Authorizes an HMO to provide an individual health care plan as required.

§ Authorizes an HMO to limit its enrollees to those who live, reside, or work within the service area for such network plan.

§ Authorizes an individual health care plan or conversion contract to be renewable at the option of the enrollee, and permits denial of renewals only for specific reasons.

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Prohibiting Restrictions on Physician Communications - H.B. 812

by Representative Janek, et al.

Senate Sponsor: Senator Sibley

§ Prohibits an HMO from restricting the ability of a physician, dentist, or provider, as a condition of a contract, to communicate with a current, prospective, or former patient regarding certain information or opinions.

§ Prohibits a HMO from penalizing, terminating, or refusing to compensate, for covered services, a physician, dentist, or provider who communicates certain information with a current, prospective, or former patient. Makes all contract provisions violating these prohibitions void.

§ Prohibits a hospital from restricting a physician's ability to communicate certain information to a patient.

§ Prohibits a hospital from restricting a physician's staff privileges based on the fact that the physician or a partner, associate, or employee of the physician is providing medical or health care services at a different hospital or hospital system. Authorizes a hospital to limit staff privileges based on its medical staff development plan or limit the ability of its medical directors to hold medical staff privileges at a different hospital. Makes all contract provisions violating the prohibition void.

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Health Insurance for Victims of Family Violence - H.B. 839

by Representative Driver, et al.

Senate Sponsor: Senator Cain

§ Prohibits certain health benefit plan insurers or life insurers (insurers) from denying coverage, refusing to renew coverage, canceling coverage, or limiting the amount, extent, or kind of coverage available to a person because of that person's status as a victim of family violence.

§ Prohibits an insurer from releasing information relating to the victim of family violence except to certain persons.

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Health Insurance Portability and Availability - H.B. 1212

by Representative Averitt, et al.

Senate Sponsor: Senator Sibley

General Provisions

§ Defines "large employer" as an employer who employed an average of at least 51 eligible employees on business days during the preceding calendar year and who employs at least two eligible employees on the first day of the plan year. Defines "small employer" as an employer who employed at least two but not more than 50 eligible employees on business days during the preceding calendar year and who employs at least two eligible employees on the first day of the plan year.

§ Sets forth types of coverage for an individual which is deemed to be creditable.

§ Authorizes an independent school district to participate in the small employer market without regard to the number of eligible employees.

§ Requires the commissioner to adopt rules as necessary to meet the minimum requirements of federal law and regulations.

§ Requires initial enrollment period to consist of an entire calendar month. Prohibits the period from which a preexisting condition provision is imposed from exceeding 18 months from the date of the initial application.

Small Employer Provisions

§ Prohibits a small employer health benefit plan from limiting or excluding initial coverage of an adopted child of an insured.

§ Adds requirements under which a small employer carrier does not have to:

§ offer or issue the small employer benefit plan that the carrier is acting uniformly without regard to claims experience of the employer or any health status related factor of employees or dependents; or

§ renew the small employer health benefits plan to include no enrollee residing in authorized service area or membership of an employer in an association terminates.

§ Authorizes a small employer carrier to:

§ discontinue a particular type of small employer coverage only if the carrier provides notice to each employer, offer option small employer coverage to each employer, and acts uniformly without regard to claims experience or health status; and

§ establish premium discounts, rebates, or a reduction to copayments or deductibles in return for complying with health promotion and disease prevention programs.

§ Requires each small employer carrier to disclose on request the benefits and premiums under all small employer coverage for which the employer is qualified, unless the information is proprietary or a trade secret.

§ Prohibits a small employer carrier from treating genetic information in absence of a diagnosis of the condition and pregnancy as a preexisting condition.

§ Authorizes an HMO to impose an affiliation period or an approved alternative method, subject to specific time limits, to address adverse selection.

Large Employer Provisions

§ Establishes oversight of health benefit plans for large employers if a portion of the premium or benefits is paid by the large employer or the plan is treated by the employer or by a covered individual as part of a federal tax deductible plan or program.

§ Requires each health carrier to certify to the commissioner whether it is offering a health large employer health benefit plan.

§ Authorizes a large employer carrier to refuse to provide coverage to a large employer in accordance with the carrier's underwriting stands and criteria. Requires, on issuance of the plan, that the carrier provide coverage to the employees who meet the participation criteria without regard to an individual's health status.

§ Requires a large employer carrier to either accept or reject the entire group of individuals who meet the participation criteria established by the employer and who choose coverage. Allows a carrier to exclude only those employees or dependents who decline coverage. Requires carrier to obtain a written waiver for each employee who declines coverage. Prohibits a carrier from offering coverage if it knows the large employer has induced or pressured an employee to decline coverage.

§ Authorizes a large employer carrier to require a large employer to meet minimum contribution or participation requirements as a condition of issuance and renewal of a health benefit plan.

§ Requires an initial enrollment period for employees and dependents meeting the participation criteria. Authorizes a large employer to establish a waiting period for new employees. Authorizes a late enrollee to be excluded from coverage until the next annual open enrollment period and subject to a 12-month preexisting condition provision.

§ Prohibits a large employer health benefit plan from using a rider or amendment applicable to a specific individual to limit or exclude coverage by type of illness, treatment, medical condition, or accident, except for a permitted preexisting condition.

§ Prohibits a large employer health benefit plan from limiting or excluding initial coverage or a newborn child of a covered employee. Requires coverage to terminate on the 32nd day after the date of birth unless the child is eligible for coverage and any additional premium is paid. Requires a plan to include an adopted child as a dependent if the dependent is eligible for coverage.

§ Establishes similar coverage requirements for a large employer carrier as is developed for a small employer carrier in regard to geographic coverage; renewal of coverage; refusal to renew; notice to covered persons; and preexisting condition provisions.

§ Prohibits a large employer carrier from charging an adjustment to premium rates for individual employees or dependents for health status related factors or duration of coverage.

§ Requires a large employer to give, on request, a summary of all health benefit plans for which the employer is eligible. Authorizes TDI to require periodic reports by large employer carriers and agents regarding the large employer health benefit plans issued by those carriers.

§ Prohibits a large employer carrier or agent from encouraging a large employer to exclude an employee who meets the participation criteria from health coverage provided in connection with employment.

§ Prohibits a large employer carrier from terminating, failing to renew, or limiting its contract with an agent because of any health status related factors of a large employer group placed by the agent with the carrier.

§ Requires a third-party administrator, if used by a large employer carrier for administrative, marketing, or other services relating to the offering of large employer health benefit plans, to be subject to regulation.

§ Establishes requirements for certification of coverage. Requires each issuer of a health benefit plan to provide a certification of coverage, in accordance with standards adopted by the commissioner, as necessary to determine the period of applicable creditable coverage of health benefit plans.

Multiple Employer Welfare Arrangement (MEWA) Provisions

§ Establishes requirements for a MEWA, which are the same as large employer in regard to coverage requirements, renewal of coverage, refusal to renew, notice to covered persons, premium rates, fair marketing, preexisting condition provisions, written statement of denial, cancellation, or refusal to renew, and third-party administrator.

§ Requires each MEWA to file any modified terms of a plan document along with a certification that any changes are in compliance with minimum standards. Authorizes the commissioner to take corrective action against a MEWA not in compliance with minimum standards.

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Health Coverage Using Telemedicine - H.B. 2033

by Representative Gray

Senate Sponsor: Senator Sibley

§ Prohibits certain health benefit plans from excluding a service from coverage solely because the service is provided through telemedicine and not provided through face-to-face consultation.

§ Authorizes a deductible, copayment, or coinsurance to be required for telemedicine services, but these cannot exceed amounts required for the same services provided through a face-to-face consultation.

§ Requires a treating physician or other health care provider who provides or facilitates the use of telemedicine to ensure that informed consent of the patient is obtained and the patient's medical information is kept confidential.

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Insurance Coverage of Services Provided by Advanced Practice Nurses and Physician Assistants - H.B. 2846

by Representatives Berlanga and Maxey

Senate Sponsor: Senator Madla

§ Requires an HMO to cover health care services provided by an advanced practice nurse (APN) or a physician assistant (PA).

§ Expands the definition of "primary practice site" to include a clinic operated by or for the benefit of a public school district for the purpose of providing care to the students of that district and the siblings of those students, if consent to treatment at that clinic is obtained.

§ Establishes time requirements once every 10 business days, for on-site physician supervision of an APN or PA.

§ Prohibits an HMO from refusing to identify an APN or PA as a provider in the provider network unless the PA or APN fails to meet certain quality standards.

§ Prohibits an HMO from refusing to contract with refusing to reimburse for covered services, or otherwise discriminating against an APN or PA.

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HMO Coverage for Non-Network and Nonprimary Care Providers - H.B. 3269

by Representative Berlanga

Senate Sponsor: Senator Sibley

§ Requires an HMO to allow referral to a non-network physician or provider if medically necessary covered services are not available through network physicians or providers. Requires reimbursement of the non-network physician or provider at the usual and customary or an agreed rate.

§ Authorizes an enrollee with a chronic, disabling, or life-threatening illness to apply to the HMO's medical director to use a nonprimary care physician specialist as the enrollee's primary care physician.