By Gray H.B. No. 180
75R1591 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to access to certain obstetric or gynecological health
1-3 care under a health benefit plan.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.53D to read as follows:
1-7 Art. 21.53D. ACCESS TO CERTAIN OBSTETRIC OR GYNECOLOGICAL
1-8 CARE
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Enrollee" means an individual enrolled in a
1-11 health benefit plan.
1-12 (2) "Health benefit plan" means a plan that provides
1-13 benefits for medical or surgical expenses incurred as a result of a
1-14 health condition, accident, or sickness and that is offered by any
1-15 insurance company, group hospital service corporation, or health
1-16 maintenance organization that delivers or issues for delivery an
1-17 individual, group, blanket, or franchise insurance policy or
1-18 insurance agreement, a group hospital service contract, or an
1-19 evidence of coverage, by a multiple employer welfare arrangement as
1-20 defined by Section 3, Employee Retirement Income Security Act of
1-21 1974 (29 U.S.C. Section 1002), or by any other analogous benefit
1-22 arrangement to the extent permitted by the Employee Retirement
1-23 Income Security Act of 1974 (29 U.S.C. Section 1002). The term
1-24 does not include:
2-1 (A) a plan that provides coverage:
2-2 (i) only for accidental death or
2-3 dismemberment;
2-4 (ii) for wages or payments in lieu of
2-5 wages for a period during which an employee is absent from work
2-6 because of sickness or injury; or
2-7 (iii) as a supplement to liability
2-8 insurance;
2-9 (B) a Medicare supplemental policy as defined by
2-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
2-11 (C) worker's compensation insurance coverage;
2-12 (D) medical payment insurance issued as part of
2-13 a motor vehicle insurance policy; or
2-14 (E) a long-term care policy, including a nursing
2-15 home fixed indemnity policy, unless the commissioner determines
2-16 that the policy provides benefit coverage so comprehensive that the
2-17 policy meets the definition of a health benefit plan.
2-18 (3) "Physician" means a person licensed as a physician
2-19 by the Texas State Board of Medical Examiners.
2-20 (4) "Primary care physician" means a physician
2-21 designated under the terms of a health benefit plan to:
2-22 (A) provide general medical or surgical
2-23 diagnosis and treatment of an illness or injury sustained by an
2-24 enrollee, including an enrollee's chronic medical condition; and
2-25 (B) make appropriate referrals when indicated by
2-26 the enrollee's condition.
2-27 Sec. 2. APPLICATION. This article applies to each health
3-1 benefit plan that requires an enrollee to obtain certain health
3-2 care services through a referral made by a primary care physician
3-3 or other gatekeeper.
3-4 Sec. 3. DESIGNATION OF OBSTETRICIAN OR GYNECOLOGIST AS
3-5 PRIMARY CARE PHYSICIAN; LIMITATIONS. (a) Each health benefit plan
3-6 subject to this article shall include in the classification of
3-7 persons authorized to serve as primary care physicians under the
3-8 plan properly credentialed obstetricians and gynecologists.
3-9 (b) This section does not affect the authority of a health
3-10 benefit plan to establish selection criteria regarding other
3-11 physicians who provide services through the plan.
3-12 (c) This section does not require an individual obstetrician
3-13 or gynecologist who provides services through a health benefit plan
3-14 to accept status in the plan as a primary care physician if the
3-15 obstetrician or gynecologist does not elect to be designated as a
3-16 primary care physician.
3-17 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
3-18 GYNECOLOGIST. (a) In addition to other benefits as authorized by
3-19 the plan, each health benefit plan shall permit a woman who is
3-20 entitled to coverage under the plan but who does not select an
3-21 obstetrician or gynecologist as her primary care physician direct
3-22 access without a referral by a primary care physician to the health
3-23 care services of an obstetrician or gynecologist who is:
3-24 (1) authorized to provide services under the plan; and
3-25 (2) selected by the covered individual.
3-26 (b) The access to health care services required under this
3-27 article includes diagnosis, treatment, and referral for any disease
4-1 or condition within the scope of the professional practice of a
4-2 properly credentialed obstetrician or gynecologist.
4-3 (c) A health benefit plan may not impose a copayment or
4-4 deductible for direct access to the health care services of an
4-5 obstetrician or gynecologist under this section unless such an
4-6 additional cost is imposed for access to other health care services
4-7 provided under the plan.
4-8 Sec. 5. NOTICE. Each health benefit plan shall provide to
4-9 persons covered by the plan a timely written notice in clear and
4-10 accurate language of the direct access to health care services
4-11 required by this article.
4-12 Sec. 6. RULES. The commissioner shall adopt rules as
4-13 necessary to implement this article.
4-14 Sec. 7. ADMINISTRATIVE PENALTY. An insurance company,
4-15 health maintenance organization, or other entity that operates a
4-16 health benefit plan in violation of this article is subject to an
4-17 administrative penalty as provided by Article 1.10E of this code.
4-18 SECTION 2. Article 21.53D, Insurance Code, as added by
4-19 Section 1 of this Act, applies only to an insurance policy,
4-20 contract, or evidence of coverage delivered, issued for delivery,
4-21 or renewed on or after January 1, 1998. A policy, contract, or
4-22 evidence of coverage delivered, issued for delivery, or renewed
4-23 before January 1, 1998, is governed by the law as it existed
4-24 immediately before the effective date of this Act, and that law is
4-25 continued in effect for that purpose.
4-26 SECTION 3. This Act takes effect September 1, 1997.
4-27 SECTION 4. The importance of this legislation and the
5-1 crowded condition of the calendars in both houses create an
5-2 emergency and an imperative public necessity that the
5-3 constitutional rule requiring bills to be read on three several
5-4 days in each house be suspended, and this rule is hereby suspended.