RS C.S.S.B. 54 75(R) BILL ANALYSIS INSURANCE C.S.S.B. 54 By: Shapiro (Gray) 4-21-97 Committee Report (Substituted) BACKGROUND Currently, Texas law does not require a health benefit plan to allow a woman to select an obstetrician or gynecologist in addition to a primary care physician. Furthermore, most plans allow a woman only one well-woman examination per year and require a woman to obtain a referral from her primary care physician before seeing her obstetrician or gynecologist for female-related care needs. This bill would require a health benefit plan to allow a woman to designate, in addition to a primary care physician, an obstetrician or gynecologist to provide health care services within his or her speciality. In addition, a woman would be allowed to have direct access to her obstetrician or gynecologist without having to first obtain a referral from a primary care physician. PURPOSE As proposed, C.S.S.B. 54 requires a health benefit plan to allow a woman who is covered under the plan to select, in addition to a primary care physician, an obstetrician or gynecologist without a referral from her primary care physician. RULEMAKING AUTHORITY Rulemaking authority is granted to the commissioner of insurance under SECTION 1 (Section 6, Article 21.53D, Insurance Code), of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Chapter 21E, Insurance Code, by adding Article 21.53D, as follows: Art. 21.53D. ACCESS TO CERTAIN OBSTETRIC OR GYNECOLOGICAL CARE Sec. 1. DEFINITIONS. Defines "enrollee," "health benefit plan," and "physician.," Sec 2. SCOPE OF ARTICLE. Provides that this article applies to certain health benefit plans. Sec. 3(a). ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. Authorizes each health benefit plan to permit a female enrollee to select in addition to her primary care physician an obstetrician and gynecologist for obstetrical and gynecological care. Sec. 3(b). Requires that the health benefit plan provide sufficient number of OB/GYNs to ensure access to those types of services. Sec. 3(c). Provides that the health benefit plan may continue to establish selection criteria regarding other physicians who provide services through the plan. Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR GYNECOLOGIST. (a) Requires each health benefit plan to permit a woman direct access to the health care services of the designated obstetrician or gynecologist without a referral by the woman's primary care physician. Sec. 4(b). Establishes the types of health care services to be provided. Sec. 4(c). Sets forth prohibitions regarding copayments or deductibles for direct access to the health care services of an obstetrician or gynecologist. Sec. 4(d). Provides for the authority of a health benefit plan to require the designated OB/GYN to forward information concerning the medical care of the patient to the primary care of the physician. However, failure to provide this information may not cause a penalty to be imposed upon the OB/GYN or patient. Sec. 4(e). Establishes that the health benefit plan may limit the enrollee to selfreferral to one participating OB/GYN for both obstetrical and gynecological care. Sec. 4(f). Prohibits the health benefit plan from sanctioning or terminating a primary care physician from the plan because female enrollees select an OB/GYN for care. Sec. 5. NOTICE. Provides that the health benefit plan should provide adequate, timely written notice to the enrollees. Sec. 6. RULES. Authorizes the Commissioner of Insurance to adopt necessary rules to implement the provision of this act. Sec. 7. ADMINISTRATIVE PENALTY. Provides that an insurance company, health maintenance organization, or other entity that operates a health benefit plan in violation of this article is subject to the administrative penalty provisions set forth in Article 1.10E of the Insurance Code. Provides that a health benefit plan may be penalized for violating this act. SECTION 2. Makes application of this Act prospective to January 1, 1998. SECTION 3. Effective date: September 1, 1997. SECTION 4. Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE The substitute incorporates the following major changes from the original bill: 1) Incorporates a woman permitted access for obstetrical and gynecological care is not precluded from selecting a family physician, internal medicine physician, or other qualified physician from providing similar care. 2) Establishes a penalty may not be incurred by the obstetrician and gynecologist for failure to provide information to the primary care physician if a reasonable good faith effort was made on behalf of the obstetrician and gynecologist. 3) Requires the notice provided by the health benefit plan to the enrolled of benefits of coverage shall include the choices of the types of physician providers for the direct access to obstetrical and gynecological care.