State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1453-disclosure-of-reimbursement-guidelines-under-managed-care-plan
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.
State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1453-disclosure-of-reimbursement-guidelines-under-managed-care-plan
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.
State Codes and Statutes
Statutes >
Texas >
Insurance-code >
Title-8-health-insurance-and-other-health-coverages >
Chapter-1453-disclosure-of-reimbursement-guidelines-under-managed-care-plan 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.
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