By Janek H.B. No. 609
75R582 MWV-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the freedom of an insured individual to choose a
1-3 doctor.
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. CHOICE OF DOCTOR
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Doctor" means a person licensed by the Texas
1-10 State Board of Medical Examiners under the Medical Practice Act
1-11 (Article 4495b, Vernon's Texas Civil Statutes) to practice medicine
1-12 in this state.
1-13 (2) "Health insurance policy" means an individual,
1-14 group, blanket, or franchise insurance policy, insurance agreement,
1-15 group hospital service contract, or evidence of coverage issued by
1-16 a health maintenance organization that provides benefits for health
1-17 care expenses incurred as a result of an accident or sickness.
1-18 (3) "Health care services" means services furnished to
1-19 a person to prevent, alleviate, or cure illness or injury.
1-20 Sec. 2. PROHIBITED PROVISIONS. (a) A health insurance
1-21 policy that is delivered, renewed, or issued for delivery in this
1-22 state may not:
1-23 (1) prevent a person who is a party to or beneficiary
1-24 of the health insurance policy from selecting a doctor to furnish
2-1 the health care services offered by the policy or interfere with
2-2 selection, provided the doctor is licensed to furnish the health
2-3 care services in this state;
2-4 (2) deny a doctor the right to participate as a
2-5 contracting doctor for the policy, provided the doctor is licensed
2-6 to furnish the health care services offered by the policy;
2-7 (3) authorize a person to interfere in the diagnosis
2-8 or treatment rendered by a doctor to the patient to prevent,
2-9 alleviate, or cure illness or injury within the scope of the
2-10 doctor's license; or
2-11 (4) require that a doctor furnishing health care
2-12 services make or obtain X-rays or any other diagnostic aids to
2-13 prevent, alleviate, or cure illness or injury.
2-14 (b) Subsection (a)(4) of this section does not prohibit
2-15 requests for existing X-rays or other existing diagnostic aids to
2-16 determine benefits payable under a health insurance policy.
2-17 (c) This section does not prohibit the predetermination of
2-18 benefits for health care expenses before treatment by the doctor.
2-19 Sec. 3. DOCTOR SERVICES. A doctor and patient may discuss
2-20 all health care services that may be available to the patient
2-21 including health care services that are not covered by the
2-22 patient's health insurance policy.
2-23 Sec. 4. MANDATORY PROVISIONS. (a) A health insurance
2-24 policy that is delivered, renewed, or issued for delivery in this
2-25 state must:
2-26 (1) disclose, if applicable, that the benefit offered
2-27 is limited to the least costly treatment; and
3-1 (2) define and explain the standard on which the
3-2 payment of benefits or reimbursement for the cost of health care
3-3 services is based or state the amount of the payment or
3-4 reimbursement for health care services to be provided.
3-5 (b) The payment or reimbursement for a noncontracting doctor
3-6 must be the same as the payment or reimbursement for a contracting
3-7 doctor. A health insurance policy is not required to pay or
3-8 reimburse an amount greater than the amount specified under
3-9 Subsection (a)(2) of this section or greater than the fee charged
3-10 by the doctor for the health care services rendered.
3-11 Sec. 5. PROVISIONS IN CONFLICT WITH ARTICLE. A provision in
3-12 a health insurance policy that is delivered, renewed, or issued for
3-13 delivery in this state or in a contract entered into or renewed in
3-14 this state that violates this article is void.
3-15 Sec. 6. CERTAIN EXEMPTIONS AND EXCEPTIONS NOT APPLICABLE.
3-16 The exemptions and exceptions in Article 13.09 of this code do not
3-17 apply to this article.
3-18 Sec. 7. TYPE OF BENEFITS NOT MANDATED. This article does
3-19 not mandate that any type of benefits for health care expenses be
3-20 provided by a health insurance policy.
3-21 Sec. 8. CERTAIN CONDUCT PERMITTED. (a) A doctor may
3-22 contract directly with a patient to furnish health care services to
3-23 the patient.
3-24 (b) A person providing a health insurance policy may:
3-25 (1) make available to its insureds information
3-26 relating to health care services by the distribution of factually
3-27 accurate information regarding health care services, rates, fees,
4-1 location, and hours of service only if the distribution is made on
4-2 the request of a doctor licensed by this state;
4-3 (2) establish an administrative mechanism that
4-4 facilitates payment for health care services by insureds to the
4-5 doctor of their choice; or
4-6 (3) pay or reimburse, on a nondiscriminatory basis,
4-7 its insureds for the cost of health care services rendered by the
4-8 doctor of their choice.
4-9 SECTION 2. (a) This Act takes effect September 1, 1997.
4-10 (b) This Act applies only to a health insurance policy that
4-11 is delivered, renewed, or issued for delivery in this state on or
4-12 after January 1, 1998. A policy delivered, renewed, or issued for
4-13 delivery in this state before January 1, 1998, is governed by the
4-14 law as it existed immediately before the effective date of this
4-15 Act, and that law is continued in effect for that purpose.
4-16 (c) This Act applies only to a contract for the services of
4-17 a doctor that is entered into or renewed on or after January 1,
4-18 1998. A contract that is entered into or renewed before January 1,
4-19 1998, is governed by the law as it existed immediately before the
4-20 effective date of this Act, and that law is continued in effect for
4-21 that purpose.
4-22 SECTION 3. The importance of this legislation and the
4-23 crowded condition of the calendars in both houses create an
4-24 emergency and an imperative public necessity that the
4-25 constitutional rule requiring bills to be read on three several
4-26 days in each house be suspended, and this rule is hereby suspended.