CHAPTER 1453. DISCLOSURE OF REIMBURSEMENT GUIDELINES UNDER MANAGED CARE PLAN - Texas Statutes

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1453. DISCLOSURE OF REIMBURSEMENT GUIDELINES UNDER

MANAGED CARE PLAN

Sec. 1453.001. DEFINITIONS. In this chapter:

(1) "Health care provider" means:

(A) a hospital, emergency clinic, outpatient clinic, or other

facility providing health care services; or

(B) an individual who is licensed in this state to provide

health care services.

(2) "Managed care entity" means:

(A) a health maintenance organization;

(B) a preferred provider benefit plan issuer;

(C) an approved nonprofit health corporation that holds a

certificate of authority under Chapter 844; or

(D) another entity that offers a managed care plan, including:

(i) an insurance company;

(ii) a group hospital service corporation operating under

Chapter 842;

(iii) a fraternal benefit society operating under Chapter 885;

(iv) a stipulated premium company operating under Chapter 884;

(v) a multiple employer welfare arrangement that holds a

certificate of authority under Chapter 846; and

(vi) an entity not authorized under this code or another

insurance law of this state that contracts directly for health

care services on a risk-sharing basis, including a capitation

basis.

(3) "Managed care plan" means a health benefit plan:

(A) under which health care services are provided through

contracts with health care providers to individuals enrolled in

or insured under the plan; and

(B) that provides financial incentives to individuals enrolled

in or insured under the plan to use health care providers

participating in the plan and procedures covered by the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1453.002. PROVISION OF INFORMATION REGARDING REIMBURSEMENT

GUIDELINES. (a) On the written request of an out-of-network

health care provider, a managed care entity shall furnish to the

provider a written description of the factors considered by the

entity in determining the amount of reimbursement the provider

may receive for goods or services provided to an individual

enrolled in or insured under the entity's managed care plan.

(b) This section does not require a managed care entity to

disclose proprietary information that is prohibited from

disclosure by a contract between the entity and a vendor that

supplies payment or statistical data to the entity.

(c) A contract between a managed care entity and a vendor that

supplies payment or statistical data to the entity may not

prohibit the entity from disclosing under this section:

(1) the name of the vendor; or

(2) the methodology and origin of information used to determine

the amount of reimbursement.

(d) A managed care entity that denies a request for information

described by Subsection (b) shall send a copy of the request and

the information requested to the department for review.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.

Sec. 1453.003. RULES. The commissioner shall adopt rules as

necessary to implement this chapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,

2005.