By:  Hunter, Todd                                     H.B. No. 1472
       73R4598 E
                                 A BILL TO BE ENTITLED
    1-1                                AN ACT
    1-2  relating to the selection of health care providers.
    1-3        BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
    1-4        SECTION 1.  Section 2, Article 21.53, Insurance Code, is
    1-5  amended to read as follows:
    1-6        Sec. 2.  PROHIBITED PROVISIONS.  No health insurance policy
    1-7  or employee benefit plan which is delivered, renewed, issued for
    1-8  delivery, or otherwise contracted for in this state shall:
    1-9              (a)  prevent any person who is a party to or
   1-10  beneficiary of any such health insurance policy or employee benefit
   1-11  plan from selecting the dentist of his choice to furnish the dental
   1-12  care services offered by said policy or plan or interfere with said
   1-13  selection provided the dentist is licensed to furnish such dental
   1-14  care services in this state;
   1-15              (b)  deny any dentist the right to participate as a
   1-16  contracting provider for such policy or plan provided the dentist
   1-17  is licensed to furnish the dental care services offered by said
   1-18  policy or plan;
   1-19              (c)  authorize any person to regulate, interfere, or
   1-20  intervene in any manner in the diagnosis or treatment rendered by a
   1-21  dentist to his patient for the purpose of preventing, alleviating,
   1-22  curing, or healing dental illness or injury provided said dentist
   1-23  practices within the scope of his license; <or>
   1-24              (d)  require that any dentist furnishing dental care
    2-1  services must make or obtain dental x-rays or any other diagnostic
    2-2  aids for the purpose of preventing, alleviating, curing, or healing
    2-3  dental illness or injury; provided, however, that nothing herein
    2-4  shall prohibit requests for existing dental x-rays or any other
    2-5  existing diagnostic aids for the purpose of determining benefits
    2-6  payable under a health insurance policy or employee benefit plan;
    2-7  or
    2-8              (e)  deny any person who is a party to or beneficiary
    2-9  of any such health insurance policy or employee benefit plan the
   2-10  right to receive the maximum benefit payable under said policy or
   2-11  plan on the basis that the beneficiary received dental care
   2-12  services from his or her "dentist of choice" rather than a
   2-13  participating contract provider or "preferred provider".
   2-14        Nothing herein shall prohibit the predetermination of
   2-15  benefits for dental care expenses prior to treatment by the
   2-16  attending dentist.
   2-17        SECTION 2.  Section 14, Texas Health Maintenance Organization
   2-18  Act (Article 20A.14, Vernon's Texas Insurance Code), is amended to
   2-19  read as follows:
   2-20        Sec. 14.  Prohibited Practices.  (a)  No health maintenance
   2-21  organization, or representatives thereof, may cause or knowingly
   2-22  permit the use of advertising which is untrue or misleading,
   2-23  solicitation which is untrue or misleading, or any form of evidence
   2-24  of coverage which is deceptive.  For the purposes of this Act:
   2-25              (1)  a statement or item of information shall be deemed
   2-26  to be untrue if it does not conform to fact in any respect which is
   2-27  or may be significant to an enrollee of, or person considering
    3-1  enrollment in, a health care plan;
    3-2              (2)  a statement or item of information shall be deemed
    3-3  to be misleading, whether or not it may be literally untrue, if, in
    3-4  the total context in which said statement is made or such item of
    3-5  information is communicated, such statement or items of information
    3-6  may be reasonably understood by a reasonable person, not possessing
    3-7  special knowledge, regarding health care coverage, as indicating
    3-8  any benefit or advantage or absence of any exclusion, limitation,
    3-9  or disadvantage of possible significance to an enrollee of or
   3-10  person considering enrollment in, a health care plan, if such
   3-11  benefit or advantage or absence of limitation, exclusion, or
   3-12  disadvantage does not in fact exist;
   3-13              (3)  an evidence of coverage shall be deemed to be
   3-14  deceptive if the evidence of coverage, taken as a whole, and with
   3-15  consideration given to typography and format, as well as language,
   3-16  shall be such as to cause a reasonable person, not possessing
   3-17  special knowledge regarding health care plans, and evidence of
   3-18  coverage therefor, to expect benefits, services, charges, or other
   3-19  advantages which the evidence of coverage does not provide or which
   3-20  the health care plan issuing such evidence of coverage does not
   3-21  regularly make available for enrollees covered under such evidence
   3-22  of coverage.
   3-23        (b)  Articles 21.21, 21.21A, 21.21-2, and 21.21-3, Insurance
   3-24  Code, and Chapter 122, Acts of the 57th Legislature, Regular
   3-25  Session, 1961 (Article 21.21-1, Vernon's Texas Insurance Code),
   3-26  apply to health maintenance organizations that offer both basic and
   3-27  single health care coverages and to basic and single health care
    4-1  plans and the evidence of coverage under those plans, except to the
    4-2  extent that the commissioner determines that the nature of health
    4-3  maintenance organizations and health care plans and evidence of
    4-4  coverage renders any provision of those articles clearly
    4-5  inappropriate.
    4-6        (c)  An enrollee may not be cancelled or not renewed except
    4-7  for the failure to pay the charges for such coverage, or for such
    4-8  other reason as may be promulgated by rule of the commissioner.
    4-9        (d)  No health maintenance organization, unless licensed as
   4-10  an insurer, may use in its name, contracts, or literature, any of
   4-11  the words "insurance," "casualty," "surety," "mutual," or any other
   4-12  words descriptive of the insurance, casualty, or surety business or
   4-13  deceptively similar to the name or description of any insurance or
   4-14  surety corporation doing business in this state.
   4-15        (e)  No physician or health care provider or group of
   4-16  physicians or providers or health care facility or institution may
   4-17  exclude any other physician or provider from staff privileges,
   4-18  facilities, or institutions solely on the ground that such
   4-19  physician or provider is associated with a health maintenance
   4-20  organization issued a certificate of authority under this Act.
   4-21        (f)  Only those persons who comply with the provisions of
   4-22  this Act and are issued a certificate of authority by the
   4-23  commissioner may use the phrase "health maintenance organization"
   4-24  or "HMO" in the course of operation.
   4-25        (g)  No type of provider licensed or otherwise authorized to
   4-26  practice in this state may be denied participation to provide
   4-27  health care services which are delivered by the health maintenance
    5-1  organization and which are within the scope of licensure or
    5-2  authorization of the type of provider on the sole basis of type of
    5-3  license or authorization.  This section may not be construed to (1)
    5-4  require a health maintenance organization to utilize a particular
    5-5  type of provider in its operation; (2) require that a health
    5-6  maintenance organization accept each provider of a category or
    5-7  type; or (3) require that health maintenance organizations contract
    5-8  directly with such providers.  Notwithstanding any other provision
    5-9  nothing herein shall be construed to limit the health maintenance
   5-10  organization's authority to set the terms and conditions under
   5-11  which health care services will be rendered by providers.  All
   5-12  providers must comply with the terms and conditions established by
   5-13  the health maintenance organization for the provision of health
   5-14  services and for designation as a provider.
   5-15        (h)  A health maintenance organization that provides coverage
   5-16  for health care services or medical care through one or more
   5-17  providers or physicians who are not partners or employees of the
   5-18  health maintenance organization or one or more providers or
   5-19  physicians that are not owned or operated by the health maintenance
   5-20  organization shall provide a (20) twenty calendar day period each
   5-21  calendar year during which any provider or physician in the
   5-22  geographic service area may apply to participate in providing
   5-23  health care services or medical care under the terms and conditions
   5-24  established by the health maintenance organization for the
   5-25  provision of such services and the designation of such providers
   5-26  and physicians.  A health maintenance organization will notify, in
   5-27  writing, such provider or physician of the reason for nonacceptance
    6-1  to participate in providing health care services or medical care.
    6-2  This section may not be construed to (1) require that a health
    6-3  maintenance organization utilize a particular type of provider or
    6-4  physician in its operation; (2) require that a health maintenance
    6-5  organization accept a provider or physician of a category or type
    6-6  that does not meet the practice standards and qualifications
    6-7  established by the health maintenance organizations; or (3) require
    6-8  that a health maintenance organization contract directly with such
    6-9  providers or physicians.
   6-10        (i)  A health maintenance organization that provides coverage
   6-11  for the purpose of preventing, alleviating, curing, or healing
   6-12  dental illness or injury through one or more dentists or other
   6-13  health care providers shall not deny any other qualified dentist
   6-14  the right to participate as a contracting provider.
   6-15        (j)  A health maintenance organization that provides coverage
   6-16  for the purpose of preventing, alleviating, curing, or healing
   6-17  dental illness or injury through one or more dentists or other
   6-18  health care providers shall not deny any enrollee the right to
   6-19  receive the maximum benefit payable under the health care plan on
   6-20  the basis that the enrollee received dental care services from his
   6-21  or her "dentist of choice" rather than a "contracting provider."
   6-22        SECTION 3.  Title 1, Revised Statutes, is amended by adding
   6-23  Article 2 to read as follows:
   6-24        Art. 2.  Notwithstanding the provisions of any other law, a
   6-25  health care plan whereby a state, county, local, or other
   6-26  governmental entity, including the state, a county, a municipality,
   6-27  school district, hospital district, or any other political
    7-1  subdivision of a county or the state, provides dental care benefits
    7-2  in the event of accident or sickness to its employees or their
    7-3  beneficiaries, through the purchase of insurance or otherwise,
    7-4  shall not:
    7-5              (1)  prevent the employee or beneficiary from selecting
    7-6  the dentist of his or her choice to furnish the dental care
    7-7  services covered by said plan or interfere with said selection
    7-8  provided the dentist is licensed to furnish such dental care
    7-9  services in this state;
   7-10              (2)  deny any dentist the right to participate as a
   7-11  contracting provider for such plan provided the dentist is licensed
   7-12  to furnish the dental care services covered by said plan; or
   7-13              (3)  deny any employee or beneficiary of such plan the
   7-14  right to receive the maximum benefit payable under said plan on the
   7-15  basis that the employee or beneficiary received the dental care
   7-16  services from his or her "dentist of choice" rather than a
   7-17  "contracting provider."
   7-18        SECTION 4.  The importance of this legislation and the
   7-19  crowded condition of the calendars in both houses create an
   7-20  emergency and an imperative public necessity that the
   7-21  constitutional rule requiring bills to be read on three several
   7-22  days in each house be suspended, and this rule is hereby suspended,
   7-23  and that this Act take effect and be in force from and after its
   7-24  passage, and it is so enacted.