By Van de Putte H.B. No. 261
75R1858 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 1001 et seq.). The
1-24 term 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) workers' 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 Sec. 2. APPLICATION. This article applies to each health
2-21 benefit plan that requires an enrollee to obtain certain specialty
2-22 health care services through a referral made by a person,
2-23 regardless of whether the health benefit plan refers to that person
2-24 as a primary care physician or by some other title or designation.
2-25 Sec. 3. DESIGNATION OF OBSTETRICIAN OR GYNECOLOGIST AS
2-26 PRIMARY CARE PHYSICIAN; LIMITATIONS. (a) Each health benefit plan
2-27 subject to this article shall include in the classification of
3-1 persons authorized to serve as primary care physicians under the
3-2 plan properly credentialed obstetricians and gynecologists.
3-3 (b) This section does not affect the authority of a health
3-4 benefit plan to establish credentialing and other selection
3-5 criteria regarding other physicians who provide services through
3-6 the plan.
3-7 (c) This section does not require an individual obstetrician
3-8 or gynecologist who provides services through a health benefit plan
3-9 to accept status in the plan as a primary care physician if the
3-10 obstetrician or gynecologist does not elect to be designated as a
3-11 primary care physician.
3-12 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
3-13 GYNECOLOGIST. (a) In addition to other benefits as authorized by
3-14 the plan, each health benefit plan shall permit a woman who is
3-15 entitled to coverage under the plan but who does not select an
3-16 obstetrician or gynecologist as her primary care physician direct
3-17 access at all times as provided by Subsection (b) of this section
3-18 to the health care services of an obstetrician or gynecologist who
3-19 is:
3-20 (1) authorized to provide services under the plan; and
3-21 (2) selected by the covered individual.
3-22 (b) The access to health care services required under this
3-23 article includes diagnosis, treatment, and referral for any disease
3-24 or condition within the scope of the professional specialty
3-25 practice of a properly accredited obstetrician or gynecologist.
3-26 Sec. 5. NOTICE. Each health benefit plan shall provide
3-27 appropriate written notice to persons covered by the plan of the
4-1 direct access to health care services required by this article.
4-2 Sec. 6. EFFECT OF VIOLATION. The failure of an insurance
4-3 company or a health maintenance organization to comply with the
4-4 requirements of this article constitutes grounds for the revocation
4-5 of the certificate of authority of the insurance company or health
4-6 maintenance organization.
4-7 Sec. 7. RULES. The commissioner shall adopt rules as
4-8 necessary to implement this article.
4-9 SECTION 2. Article 21.53D, Insurance Code, as added by this
4-10 Act, applies only to an insurance policy, contract, or evidence of
4-11 coverage delivered, issued for delivery, or renewed on or after
4-12 January 1, 1998. A policy, contract, or evidence of coverage
4-13 delivered, issued for delivery, or renewed before January 1, 1998,
4-14 is governed by the law as it existed immediately before the
4-15 effective date of this Act, and that law is continued in effect for
4-16 that purpose.
4-17 SECTION 3. This Act takes effect September 1, 1997.
4-18 SECTION 4. The importance of this legislation and the
4-19 crowded condition of the calendars in both houses create an
4-20 emergency and an imperative public necessity that the
4-21 constitutional rule requiring bills to be read on three several
4-22 days in each house be suspended, and this rule is hereby suspended.