SRC-HRD C.S.S.B. 54 75(R)BILL ANALYSIS Senate Research CenterC.S.S.B. 54 By: Shapiro Economic Development 2-27-97 Committee Report (Substituted) DIGEST 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. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. Requires each health benefit plan subject to this article to permit a woman who is entitled to coverage to select, in addition to a primary care physician, an obstetrician or gynecologist to provide health care services within the scope of the professional specialty practice of a properly credentialed obstetrician or gynecologist. Requires the plan to include a number of properly credentialed obstetricians and gynecologists sufficient to ensure access to the services that fall within the scope of that credential. Provides that this section does not affect the authority of a health benefit plan to establish selection criteria regarding other physicians who provide services through the plan. Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR GYNECOLOGIST. Requires each health benefit plan, in addition to other benefits authorized by the plan, to permit a woman who designates an obstetrician or gynecologist as provided under Section 3 of this article direct access to the health care services of the designated obstetrician or gynecologist without a referral by the woman's primary care physician or prior authorization or precertification from a health benefit plan. Sets forth the health care services that this article includes. Sets forth prohibitions regarding copayments or deductibles for direct access to the health care services of an obstetrician or gynecologist under this section. Provides that this section does not affect the authority of a health benefit plan to require the designated obstetrician or gynecologist to forward information concerning the medical care of the patient to the primary care of the physician. Prohibits, nonetheless, the failure on the part of the obstetrician or gynecologist to provide such information from resulting in any penalty imposed upon the obstetrician or gynecologist or the patient by the health plan. Authorizes a health benefit plan, in implementing the access required under Section 3 of this article, to limit a woman enrolled in the plan to self-referral to one participating obstetrician and gynecologist for both gynecological care and obstetrical care. Provides that this subsection does not affect the right of the woman to select the physician who provides that care. Prohibits a health benefit plan from sanctioning or terminating primary care physicians as a result of female enrollees' access to participating obstetricians and gynecologists under this section. Sec. 5. NOTICE. Requires each benefit plan to provide to persons covered by the plan a timely written notice in clear and accurate language of the direct access to health care services required by this article. Sec. 6. RULES. Requires the commissioner of insurance to adopt rules as necessary to implement this article. 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 an administrative penalty as provided by Article 1.10E of this code. SECTION 2. Makes application of this Act prospective to January 1, 1998. SECTION 3. Effective date: September 1, 1997. SECTION 4. Emergency clause. SUMMARY OF COMMITTEE CHANGES Amends SECTION 1 as follows: Amends Section 1 to provide that "health benefit plan" means a plan described in Section 2 of this article. Amends Section 2 to change the title of the section and to provide that this article applies to certain health benefit plans. Amends Section 3 to change the title of the section and to provide that this section does not affect the authority of a health benefit plan to establish selection criteria regarding other physicians who provide services through the plan. Amends Section 4 to revise the title of the section and set forth certain requirements for a health benefit plan. Amends Section 5 to require a health benefit plan to provide to persons covered by the plan a timely written notice in clear and accurate language of the direct access to health care services required by this article. Adds Section 7 to provide that an insurance company, health maintenance organization, or other entity that operates a health benefit plan in violation of this article is subject to an administrative penalty as provided by Article 1.10E of this code.