RS C.S.H.B. 3269 75(R) BILL ANALYSIS INSURANCE C.S.H.B. 3269 By: Berlanga 4-16-97 Committee Report (Substituted) BACKGROUND Under current HMO rules, enrollee patients are only covered when receiving services provided by physicians included in the HMO's provider network. Often, this reduces access to important medically necessary care or requires patients to pay for these services themselves. PURPOSE To allow patients who need necessary services covered by the HMO, but not available through the HMO's network of physicians, access to care from a non-network provider. This bill would codify language taken verbatim from existing Texas Department of Insurance rules. RULEMAKING AUTHORITY It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency or institution. SECTION BY SECTION ANALYSIS SECTION 1. Amends Section 9 of Article 20A.09 as amended by Chapters 1091 and 1096 Acts of the 70th Legislature, Regular Session, 1987 of the Texas Insurance Code. Sec. 9. EVIDENCE OF COVERAGE AND CHARGES. (a) Renumbered from the previous (1). (b) Renumbered from the previous (2). (c) Clarifies language requirements for evidence of coverage provisions and what they "may not" contain. Those requirements are current statute. Makes technical changes to clarify this section in conjunction with the new language. (d) Requires that the evidence of coverage for the managed care organizations must include the requirements adopted by this statute. (e) Renumbers the existing language to conform with the new language as well as clarifying that the requirements within apply to evidence of coverage material. (f) Requires HMO referral to a non-network physician for medically necessary covered services not available through the HMO's network of providers. Referral must be made by a network physician or provider. The non-network physician is fully reimbursed by the HMO at the usual or agreed rate. A specialist must review the referral request before it may be denied. (g) Enrollees with chronic, disabling, or life-threatening illnesses may also apply to the HMO to use a specialist as their primary care physician but the non-primary care physician must agree to meet the requirements of the managed care organization for primary care physician and must be willing to accept the coordination of all the enrollee's health care needs. (h) Denial of this request may be appealed through the normal HMO appeal process. (i) Designation of a specialist as the primary care physician may not be done retroactively. (j) through (m) Sections are renumbered and changes are made accordingly in the article to reflect the new numbering system as well as corrective references to the commissioner to replace the Board of Insurance. (n) Applies to health maintenance organizations except single health care health maintenance plans Articles 3.51-9 and 3.74 of the Insurance Code and Section 1 (F)(5), Chapter 397, Acts of the 54th Legislature, Regular Session, 1955 (Article 3.70-1(F)(5) Vernon's Texas Insurance Code). (o) Evidence of coverage does not constitute a health insurance policy as that term is defined by the Insurance Code. (p) Strikes old language referring to former language existing in statute. (q) and (r) are renumbered to conform with the statute. SECTION 2. Effective date - January 1, 1998, this Article applies to evidence of coverage issued prior to the effective date. SECTION 3. Emergency clause. COMPARISON OF ORIGINAL TO THE SUBSTITUTE Original version was not a Legislative Council draft, the substitute was filed to conform with Legislative Council format and numbering.