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.