By Janek H.B. No. 1057
74R4948 MWV-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to freedom of choice of a health care provider by insured
1-3 individuals.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53C to read as follows:
1-7 Art. 21.53C. CHOICE OF HEALTH CARE PROVIDER
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Health insurance policy" means an individual,
1-10 group, blanket, or franchise insurance policy, insurance agreement,
1-11 group hospital service contract, or evidence of coverage issued by
1-12 a health maintenance organization that provides benefits for health
1-13 care expenses incurred as a result of an accident or sickness.
1-14 (2) "Health care services" means services furnished to
1-15 a person to prevent, alleviate, or cure illness or injury.
1-16 (3) "Health care provider" means a person licensed by
1-17 the Texas State Board of Medical Examiners under the Medical
1-18 Practice Act (Article 4495b, Vernon's Texas Civil Statutes) to
1-19 practice medicine in this state.
1-20 Sec. 2. PROHIBITED PROVISIONS. (a) A health insurance
1-21 policy that is delivered, renewed, or issued for delivery in this
1-22 state may not:
1-23 (1) prevent a person who is a party to or beneficiary
1-24 of the health insurance policy from selecting a health care
2-1 provider to furnish the health care services offered by the policy
2-2 or interfere with selection, provided the health care provider is
2-3 licensed to furnish the health care services in this state;
2-4 (2) deny a health care provider the right to
2-5 participate as a contracting provider for the policy, provided the
2-6 health care provider is licensed to furnish the health care
2-7 services offered by the policy;
2-8 (3) authorize a person to interfere in the diagnosis
2-9 or treatment rendered by a health care provider to the patient to
2-10 prevent, alleviate, or cure illness or injury within the scope of
2-11 the provider's license; or
2-12 (4) require that a health care provider furnishing
2-13 health care services make or obtain X-rays or any other diagnostic
2-14 aids to prevent, alleviate, or cure illness or injury.
2-15 (b) Subsection (a)(4) of this section does not prohibit
2-16 requests for existing X-rays or other existing diagnostic aids to
2-17 determine benefits payable under a health insurance policy.
2-18 (c) This section does not prohibit the predetermination of
2-19 benefits for health care expenses before treatment by the health
2-20 care provider.
2-21 Sec. 3. MANDATORY PROVISIONS. (a) A health insurance
2-22 policy that is delivered, renewed, or issued for delivery in this
2-23 state must:
2-24 (1) disclose, if applicable, that the benefit offered
2-25 is limited to the least costly treatment; and
2-26 (2) define and explain the standard on which the
2-27 payment of benefits or reimbursement for the cost of health care
3-1 services is based or state the amount of the payment or
3-2 reimbursement for health care services to be provided.
3-3 (b) The payment or reimbursement for a noncontracting health
3-4 care provider must be the same as the payment or reimbursement for
3-5 a contracting health care provider. A health insurance policy is
3-6 not required to pay or reimburse an amount greater than the amount
3-7 specified under Subsection (a)(2) of this section or greater than
3-8 the fee charged by the health care provider for the health care
3-9 services rendered.
3-10 Sec. 4. PROVISIONS IN CONFLICT WITH ARTICLE. A provision in
3-11 a health insurance policy that is delivered, renewed, or issued for
3-12 delivery in this state that is contrary to this article is void to
3-13 the extent of the conflict.
3-14 Sec. 5. CERTAIN EXEMPTIONS AND EXCEPTIONS NOT APPLICABLE.
3-15 The exemptions and exceptions in Articles 13.09 and 21.41 of this
3-16 code do not apply to this article.
3-17 Sec. 6. TYPE OF BENEFITS NOT MANDATED. This article does
3-18 not mandate that any type of benefits for health care expenses be
3-19 provided by a health insurance policy.
3-20 Sec. 7. CERTAIN CONDUCT PERMITTED. (a) A health care
3-21 provider may contract directly with a patient to furnish health
3-22 care services to the patient.
3-23 (b) A person providing a health insurance policy may:
3-24 (1) make available to its insureds information
3-25 relating to health care services by the distribution of factually
3-26 accurate information regarding health care services, rates, fees,
3-27 location, and hours of service only if the distribution is made on
4-1 the request of a health care provider licensed by this state;
4-2 (2) establish an administrative mechanism that
4-3 facilitates payment for health care services by insureds to the
4-4 health care provider of their choice; or
4-5 (3) pay or reimburse, on a nondiscriminatory basis,
4-6 its insureds for the cost of health care services rendered by the
4-7 health care provider of their choice.
4-8 SECTION 2. This Act takes effect September 1, 1995, and
4-9 applies only to a health insurance policy that is delivered,
4-10 renewed, or issued for delivery in this state on or after January
4-11 1, 1996. A policy delivered, renewed, or issued for delivery in
4-12 this state before January 1, 1996, is governed by the law as it
4-13 existed immediately before the effective date of this Act, and that
4-14 law is continued in effect for that purpose.
4-15 SECTION 3. The importance of this legislation and the
4-16 crowded condition of the calendars in both houses create an
4-17 emergency and an imperative public necessity that the
4-18 constitutional rule requiring bills to be read on three several
4-19 days in each house be suspended, and this rule is hereby suspended.