By Longoria H.B. No. 82
75R1070 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to a prohibition on certain restrictions imposed by
1-3 insurers on the performance of professional health care services by
1-4 health care practitioners.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.52G to read as follows:
1-8 Art. 21.52G. RESTRICTIONS BY INSURERS ON PERFORMANCE OF
1-9 CERTAIN PROFESSIONAL HEALTH CARE SERVICES PROHIBITED
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Enrollee" means an insured, a subscriber, an
1-12 employee, a member, or another person covered under a health
1-13 benefit plan.
1-14 (2) "Health benefit plan" means:
1-15 (A) a plan that provides benefits for medical or
1-16 surgical expenses incurred as a result of a health condition,
1-17 accident, or sickness and that is offered by:
1-18 (i) any insurer who delivers or issues for
1-19 delivery an individual, group, blanket, or franchise insurance
1-20 policy or insurance agreement, a group hospital service contract,
1-21 or an evidence of coverage; or
1-22 (ii) a multiple employer welfare
1-23 arrangement as defined by Section 3, Employee Retirement Income
1-24 Security Act of 1974 (29 U.S.C. Section 1002), to the extent
2-1 permitted by the Employee Retirement Income Security Act of 1974
2-2 (29 U.S.C. Section 1001 et seq.); or
2-3 (B) any other analogous benefit arrangement.
2-4 (3) "Health care practitioner" means an individual who
2-5 is licensed, registered, or certified in this state to provide
2-6 health care.
2-7 (4) "Insurer" means:
2-8 (A) an insurance company;
2-9 (B) a group hospital service corporation subject
2-10 to Chapter 20 of this code;
2-11 (C) a health maintenance organization subject to
2-12 the Texas Health Maintenance Organization Act (Chapter 20A,
2-13 Vernon's Texas Insurance Code); or
2-14 (D) a preferred provider organization.
2-15 Sec. 2. RESTRICTIONS PROHIBITED. (a) A health benefit plan
2-16 may not include in a contract with a health care practitioner who
2-17 provides professional services to an enrollee under the plan any
2-18 provision that penalizes the health care practitioner for:
2-19 (1) referring an enrollee for additional diagnosis or
2-20 treatment by a specialist; or
2-21 (2) otherwise using the practitioner's own best
2-22 professional judgment in prescribing a particular medication,
2-23 treatment, or device for use by an enrollee.
2-24 (b) This section does not preclude an insurer from using
2-25 utilization review in a manner that complies with Article 21.58A of
2-26 this code in the operation of a health benefit plan offered by that
2-27 insurer.
3-1 Sec. 3. ADMINISTRATIVE PENALTY. An insurer who violates
3-2 this article in the operation of a health benefit plan offered by
3-3 that insurer is subject to an administrative penalty as provided by
3-4 Article 1.10E of this code.
3-5 SECTION 2. Article 21.52G, Insurance Code, as added by
3-6 Section 1 of this Act, applies only to an insurance policy or
3-7 evidence of coverage that is delivered, issued for delivery, or
3-8 renewed on or after January 1, 1998. A policy or evidence of
3-9 coverage that is delivered, issued for delivery, or renewed before
3-10 January 1, 1998, is governed by the law as it existed immediately
3-11 before the effective date of this Act, and that law is continued in
3-12 effect for this purpose.
3-13 SECTION 3. The importance of this legislation and the
3-14 crowded condition of the calendars in both houses create an
3-15 emergency and an imperative public necessity that the
3-16 constitutional rule requiring bills to be read on three several
3-17 days in each house be suspended, and this rule is hereby suspended.