By: Harris S.B. No. 430
A BILL TO BE ENTITLED
AN ACT
1-1 relating to the selection of health care providers.
1-2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-3 SECTION 1. Section 2, Article 21.53, Insurance Code, is
1-4 amended to read as follows:
1-5 Sec. 2. Prohibited Provisions. No health insurance policy
1-6 or employee benefit plan which is delivered, renewed, issued for
1-7 delivery, or otherwise contracted for in this state shall:
1-8 (a) prevent any person who is a party to or beneficiary of
1-9 any such health insurance policy or employee benefit plan from
1-10 selecting the dentist of his choice to furnish the dental care
1-11 services offered by said policy or plan or interfere with said
1-12 selection provided the dentist is licensed to furnish such dental
1-13 care services in this state;
1-14 (b) deny any dentist the right to participate as a
1-15 contracting provider for such policy or plan provided the dentist
1-16 is licensed to furnish the dental care services offered by said
1-17 policy or plan;
1-18 (c) authorize any person to regulate, interfere, or
1-19 intervene in any manner in the diagnosis or treatment rendered by a
1-20 dentist to his patient for the purpose of preventing, alleviating,
1-21 curing, or healing dental illness or injury provided said dentist
1-22 practices within the scope of his license; <or>
1-23 (d) require that any dentist furnishing dental care services
2-1 must make or obtain dental x-rays or any other diagnostic aids for
2-2 the purpose of preventing, alleviating, curing, or healing dental
2-3 illness or injury; provided, however, that nothing herein shall
2-4 prohibit requests for existing dental x-rays or any other existing
2-5 diagnostic aids for the purpose of determining benefits payable
2-6 under a health insurance policy or employee benefit plan; or
2-7 (e) deny any person who is a party to or beneficiary of any
2-8 such health insurance policy or employee benefit plan the right to
2-9 receive the maximum benefit payable under said policy or plan on
2-10 the basis that the beneficiary received dental care services from
2-11 his or her "dentist of choice" rather than a participating contract
2-12 provider or "preferred provider".
2-13 Nothing herein shall prohibit the predetermination of
2-14 benefits for dental care expenses prior to treatment by the
2-15 attending dentist.
2-16 SECTION 2. Section 14, Texas Health Maintenance Organization
2-17 Act (Article 20A.14, Vernon's Texas Insurance Code), is amended to
2-18 read as follows:
2-19 Sec. 14. Prohibited Practices. (a) No health maintenance
2-20 organization, or representatives thereof, may cause or knowingly
2-21 permit the use of advertising which is untrue or misleading,
2-22 solicitation which is untrue or misleading, or any form of evidence
2-23 of coverage which is deceptive. For the purposes of this Act:
2-24 (1) a statement or item of information shall be deemed
2-25 to be untrue if it does not conform to fact in any respect which is
3-1 or may be significant to an enrollee of, or person considering
3-2 enrollment in, a health care plan;
3-3 (2) a statement or item of information shall be deemed
3-4 to be misleading, whether or not it may be literally untrue, if, in
3-5 the total context in which said statement is made or such item of
3-6 information is communicated, such statement or items of information
3-7 may be reasonably understood by a reasonable person, not possessing
3-8 special knowledge, regarding health care coverage, as indicating
3-9 any benefit or advantage or absence of any exclusion, limitation,
3-10 or disadvantage of possible significance to an enrollee of or
3-11 person considering enrollment in, a health care plan, if such
3-12 benefit or advantage or absence of limitation, exclusion, or
3-13 disadvantage does not in fact exist;
3-14 (3) an evidence of coverage shall be deemed to be
3-15 deceptive if the evidence of coverage, taken as a whole, and with
3-16 consideration given to typography and format, as well as language,
3-17 shall be such as to cause a reasonable person, not possessing
3-18 special knowledge regarding health care plans, and evidence of
3-19 coverage therefor, to expect benefits, services, charges, or other
3-20 advantages which the evidence of coverage does not provide or which
3-21 the health care plan issuing such evidence of coverage does not
3-22 regularly make available for enrollees covered under such evidence
3-23 of coverage.
3-24 (b) Articles 21.21, 21.21A, 21.21-2, and 21.21-3, Insurance
3-25 Code, and Chapter 122, Acts of the 57th Legislature, Regular
4-1 Session, 1961 (Article 21.21-1, Vernon's Texas Insurance Code),
4-2 apply to health maintenance organizations that offer both basic and
4-3 single health care coverages and to basic and single health care
4-4 plans and the evidence of coverage under those plans, except to the
4-5 extent that the commissioner determines that the nature of health
4-6 maintenance organizations and health care plans and evidence of
4-7 coverage renders any provision of those articles clearly
4-8 inappropriate.
4-9 (c) An enrollee may not be cancelled or not renewed except
4-10 for the failure to pay the charges for such coverage, or for such
4-11 other reason as may be promulgated by rule of the commissioner.
4-12 (d) No health maintenance organization, unless licensed as
4-13 an insurer, may use in its name, contracts, or literature, any of
4-14 the words "insurance," "casualty," "surety," "mutual," or any other
4-15 words descriptive of the insurance, casualty, or surety business or
4-16 deceptively similar to the name or description of any insurance or
4-17 surety corporation doing business in this state.
4-18 (e) No physician or health care provider or group of
4-19 physicians or providers or health care facility or institution may
4-20 exclude any other physician or provider from staff privileges,
4-21 facilities, or institutions solely on the ground that such
4-22 physician or provider is associated with a health maintenance
4-23 organization issued a certificate of authority under this Act.
4-24 (f) Only those persons who comply with the provisions of
4-25 this Act and are issued a certificate of authority by the
5-1 commissioner may use the phrase "health maintenance organization"
5-2 or "HMO" in the course of operation.
5-3 (g) No type of provider licensed or otherwise authorized to
5-4 practice in this state may be denied participation to provide
5-5 health care services which are delivered by the health maintenance
5-6 organization and which are within the scope of licensure or
5-7 authorization of the type of provider on the sole basis of type of
5-8 license or authorization. This section may not be construed to (1)
5-9 require a health maintenance organization to utilize a particular
5-10 type of provider in its operation; (2) require that a health
5-11 maintenance organization accept each provider of a category or
5-12 type; or (3) require that health maintenance organizations contract
5-13 directly with such providers. Notwithstanding any other provision
5-14 nothing herein shall be construed to limit the health maintenance
5-15 organization's authority to set the terms and conditions under
5-16 which health care services will be rendered by providers. All
5-17 providers must comply with the terms and conditions established by
5-18 the health maintenance organization for the provision of health
5-19 services and for designation as a provider.
5-20 (h) A health maintenance organization that provides coverage
5-21 for health care services or medical care through one or more
5-22 providers or physicians who are not partners or employees of the
5-23 health maintenance organization or one or more providers or
5-24 physicians that are not owned or operated by the health maintenance
5-25 organization shall provide a (20) twenty calendar day period each
6-1 calendar year during which any provider or physician in the
6-2 geographic service area may apply to participate in providing
6-3 health care services or medical care under the terms and conditions
6-4 established by the health maintenance organization for the
6-5 provision of such services and the designation of such providers
6-6 and physicians. A health maintenance organization will notify, in
6-7 writing, such provider or physician of the reason for nonacceptance
6-8 to participate in providing health care services or medical care.
6-9 This section may not be construed to (1) require that a health
6-10 maintenance organization utilize a particular type of provider or
6-11 physician in its operation; (2) require that a health maintenance
6-12 organization accept a provider or physician of a category or type
6-13 that does not meet the practice standards and qualifications
6-14 established by the health maintenance organizations; or (3) require
6-15 that a health maintenance organization contract directly with such
6-16 providers or physicians.
6-17 (i) A health maintenance organization that provides coverage
6-18 for the purpose of preventing, alleviating, curing, or dental
6-19 illness or injury through one or more dentists or other health care
6-20 providers shall not deny any other qualified dentist the right to
6-21 participate as a contracting provider.
6-22 (j) A health maintenance organization that provides coverage
6-23 for the purpose of preventing, alleviating, curing, or healing
6-24 dental illness or injury through one or more dentists or other
6-25 health care providers shall not deny any enrollee the right to
7-1 receive the maximum benefit payable under the health care plan on
7-2 the basis that the enrollee received dental care services from his
7-3 or her "dentist of choice" rather than a "contracting provider."
7-4 SECTION 3. Title 1, Revised Statutes, is amended by adding
7-5 Article 2 to read as follows:
7-6 Art. 2. Notwithstanding the provisions of any other law, a
7-7 health care plan whereby a state, county, local, or other
7-8 governmental entity, including the state, a county, a municipality,
7-9 school district, hospital district, or any other political
7-10 subdivision of a county or the state, provides dental care benefits
7-11 in the event of accident or sickness to its employees or their
7-12 beneficiaries, through the purchase of insurance or otherwise,
7-13 shall not:
7-14 (1) prevent the employee or beneficiary from selecting
7-15 the dentist of his or her choice to furnish the dental care
7-16 services covered by said plan or interfere with said selection
7-17 provided the dentist is licensed to furnish such dental care
7-18 services in this state;
7-19 (2) deny any dentist the right to participate as a
7-20 contracting provider for such plan provided the dentist is licensed
7-21 to furnish the dental care services covered by said plan; or
7-22 (3) deny any employee or beneficiary of such plan the
7-23 right to receive the maximum benefit payable under said plan on the
7-24 basis that the employee or beneficiary received the dental care
7-25 services from his or her "dentist of choice" rather than a
8-1 "contracting provider."
8-2 SECTION 4. The importance of this legislation and the
8-3 crowded condition of the calendars in both houses create an
8-4 emergency and an imperative public necessity that the
8-5 constitutional rule requiring bills to be read on three several
8-6 days in each house be suspended, and this rule is hereby suspended,
8-7 and that this Act take effect and be in force from and after its
8-8 passage, and it is so enacted.