By Hunter of Nueces H.B. No. 1010
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 beneficiary of
1-10 any such health insurance policy or employee benefit plan from
1-11 selecting the dentist of his choice to furnish the dental care
1-12 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>
2-1 (d) require that any dentist furnishing dental care services
2-2 must make or obtain dental x-rays or any other diagnostic aids for
2-3 the purpose of preventing, alleviating, curing, or healing dental
2-4 illness or injury; provided, however, that nothing herein shall
2-5 prohibit requests for existing dental x-rays or any other existing
2-6 diagnostic aids for the purpose of determining benefits payable
2-7 under a health insurance policy or employee benefit plan; or
2-8 (e) deny any person who is a party to or beneficiary of any
2-9 such health insurance policy or employee benefit plan the right to
2-10 receive the maximum benefit payable under said policy or plan on
2-11 the basis that the beneficiary received dental care services from
2-12 his or her "dentist of choice" rather than a participating contract
2-13 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
3-1 to be untrue if it does not conform to fact in any respect which is
3-2 or may be significant to an enrollee of, or person considering
3-3 enrollment in, a health care plan;
3-4 (2) a statement or item of information shall be deemed
3-5 to be misleading, whether or not it may be literally untrue, if, in
3-6 the total context in which said statement is made or such item of
3-7 information is communicated, such statement or items of information
3-8 may be reasonably understood by a reasonable person, not possessing
3-9 special knowledge, regarding health care coverage, as indicating
3-10 any benefit or advantage or absence of any exclusion, limitation,
3-11 or disadvantage of possible significance to an enrollee of or
3-12 person considering enrollment in, a health care plan, if such
3-13 benefit or advantage or absence of limitation, exclusion, or
3-14 disadvantage does not in fact exist;
3-15 (3) an evidence of coverage shall be deemed to be
3-16 deceptive if the evidence of coverage, taken as a whole, and with
3-17 consideration given to typography and format, as well as language,
3-18 shall be such as to cause a reasonable person, not possessing
3-19 special knowledge regarding health care plans, and evidence of
3-20 coverage therefor, to expect benefits, services, charges, or other
3-21 advantages which the evidence of coverage does not provide or which
3-22 the health care plan issuing such evidence of coverage does not
3-23 regularly make available for enrollees covered under such evidence
3-24 of coverage.
3-25 (b) Articles 21.21, 21.21A, 21.21-2, and 21.21-3, Insurance
4-1 Code, and Chapter 122, Acts of the 57th Legislature, Regular
4-2 Session, 1961 (Article 21.21-1, Vernon's Texas Insurance Code),
4-3 apply to health maintenance organizations that offer both basic and
4-4 single health care coverages and to basic and single health care
4-5 plans and the evidence of coverage under those plans, except to the
4-6 extent that the commissioner determines that the nature of health
4-7 maintenance organizations and health care plans and evidence of
4-8 coverage renders any provision of those articles clearly
4-9 inappropriate.
4-10 (c) An enrollee may not be cancelled or not renewed except
4-11 for the failure to pay the charges for such coverage, or for such
4-12 other reason as may be promulgated by rule of the commissioner.
4-13 (d) No health maintenance organization, unless licensed as
4-14 an insurer, may use in its name, contracts, or literature, any of
4-15 the words "insurance," "casualty," "surety," "mutual," or any other
4-16 words descriptive of the insurance, casualty, or surety business or
4-17 deceptively similar to the name or description of any insurance or
4-18 surety corporation doing business in this state.
4-19 (e) No physician or health care provider or group of
4-20 physicians or providers or health care facility or institute on may
4-21 exclude any other physician or provider from staff privileges,
4-22 facilities, or institutions solely on the ground that such
4-23 physician or provider is associated with a health maintenance
4-24 organization issued a certificate of authority under this Act.
4-25 (f) Only those persons who comply with the provisions of
5-1 this Act and are issued a certificate of authority by the
5-2 commissioner may use the phrase "health maintenance organization"
5-3 or "HMO" in the course of operation.
5-4 (g) No type of provider licensed or otherwise authorized to
5-5 practice in this state may be denied participation to provide
5-6 health care services which are delivered by the health maintenance
5-7 organization and which are within the scope of licensure or
5-8 authorization of the type of provider on the sole basis of type of
5-9 license or authorization. This section may not be construed to (1)
5-10 require a health maintenance organization to utilize a particular
5-11 type of provider in its operation; (2) require that a health
5-12 maintenance organization accept each provider of a category or
5-13 type; or (3) require that health maintenance organizations contract
5-14 directly with such providers. Notwithstanding any other provision
5-15 nothing herein shall be construed to limit the health maintenance
5-16 organization's authority to set the terms and conditions under
5-17 which health care services will be rendered by providers. All
5-18 providers must comply with the terms and conditions established by
5-19 the health maintenance organization for the provision of health
5-20 services and for designation as a provider.
5-21 (h) A health maintenance organization that provides coverage
5-22 for health care services or medical care through one or more
5-23 providers or physicians who are not partners or employees of the
5-24 health maintenance organization or one or more providers or
5-25 physicians that are not owned or operated by the health maintenance
6-1 organization shall provide a (20) twenty calendar day period each
6-2 calendar year during which any provider or physician in the
6-3 geographic service area may apply to participate in providing
6-4 health care services or medical care under the terms and conditions
6-5 established by the health maintenance organization for the
6-6 provision of such services and the designation of such providers
6-7 and physicians. A health maintenance organization will notify, in
6-8 writing, such provider or physician of the reason for nonacceptance
6-9 to participate in providing health care services or medical care.
6-10 This section may not be construed to (1) require that a health
6-11 maintenance organization utilize a particular type of provider or
6-12 physician in its operation; (2) require that a health maintenance
6-13 organization accept a provider or physician of a category or type
6-14 that does not meet the practice standards and qualifications
6-15 established by the health maintenance organizations; or (3) require
6-16 that a health maintenance organization contract directly with such
6-17 providers or physicians.
6-18 (i) A health maintenance organization that provides coverage
6-19 for the purpose of preventing, alleviating, curing, or dental
6-20 illness or injury through one or more dentists or other health care
6-21 providers shall not deny any other qualified dentist the right to
6-22 participate as a contracting provider.
6-23 (j) A health maintenance organization that provides coverage
6-24 for the purpose of preventing, alleviating, curing, or healing
6-25 dental illness or injury through one or more dentists or other
7-1 health care providers shall not deny any enrollee the right to
7-2 receive the maximum benefit payable under the health care plan on
7-3 the basis that the enrollee received dental care services from his
7-4 or her "dentist of choice" rather than a "contracting provider."
7-5 SECTION 3. Title 1, Revised Statutes, is amended by adding
7-6 Article 2 to read as follows:
7-7 Art. 2. Notwithstanding the provisions of any other law, a
7-8 health care plan whereby a state, county, local, or other
7-9 governmental entity, including the state, a county, a municipality,
7-10 school district, hospital district, or any other political
7-11 subdivision of a county or the state, provides dental care benefits
7-12 in the event of accident or sickness to its employees or their
7-13 beneficiaries, through the purchase of insurance or otherwise,
7-14 shall not:
7-15 (1) prevent the employee or beneficiary from selecting
7-16 the dentist of his or her choice to furnish the dental care
7-17 services covered by said plan or interfere with said selection
7-18 provided the dentist is licensed to furnish such dental care
7-19 services in this state;
7-20 (2) deny any dentist the right to participate as a
7-21 contracting provider for such plan provided the dentist is licensed
7-22 to furnish the dental care services covered by said plan; or
7-23 (3) deny any employee or beneficiary of such plan the
7-24 right to receive the maximum benefit payable under said plan on the
7-25 basis that the employee or beneficiary received the dental care
8-1 services from his or her "dentist of choice" rather than a
8-2 "contracting provider."
8-3 SECTION 4. The importance of this legislation and the
8-4 crowded condition of the calendars in both houses create an
8-5 emergency and an imperative public necessity that the
8-6 constitutional rule requiring bills to be read on three several
8-7 days in each house be suspended, and this rule is hereby suspended,
8-8 and that this Act take effect and be in force from and after its
8-9 passage, and it is so enacted.