By: Lucio S.B. No. 913
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.