By Davila H.B. No. 3188
75R7353 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the relationship of physicians and health care
1-3 providers to enrollees in a managed care 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 21.52K to read as follows:
1-7 Art. 21.52K. PHYSICIAN AND PROVIDER COMMUNICATION AND
1-8 ASSISTANCE TO ENROLLEES
1-9 Sec. 1. DEFINITIONS. In this article:
1-10 (1) "Enrollee" means an individual who is enrolled in
1-11 a managed care plan. The term includes a dependent of an enrollee
1-12 who is covered under the plan.
1-13 (2) "Managed care entity" means an entity described by
1-14 Section 2 of this article.
1-15 (3) "Managed care plan" means a health benefit plan:
1-16 (A) under which medical care or health care
1-17 services are provided to enrollees through contracts with
1-18 physicians and health care providers; and
1-19 (B) that provides financial incentives to
1-20 enrollees in the plan to use the participating physicians and
1-21 health care providers and procedures covered by the plan.
1-22 (4) "Physician" means a person licensed to practice
1-23 medicine in this state.
1-24 (5) "Health care provider" means a provider, as that
2-1 term is defined by Section 2, Texas Health Maintenance Organization
2-2 Act (Section 20A.02, Vernon's Texas Insurance Code). The term
2-3 includes a dentist.
2-4 Sec. 2. SCOPE OF ARTICLE. This article applies to a health
2-5 maintenance organization organized under the Texas Health
2-6 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance
2-7 Code), a preferred provider organization, an approved nonprofit
2-8 health corporation that holds a certificate of authority issued by
2-9 the commissioner under Article 21.52F of this code, or any other
2-10 entity that offers a managed care plan, including:
2-11 (1) an insurance company;
2-12 (2) a group hospital service corporation operating
2-13 under Chapter 20 of this code;
2-14 (3) a fraternal benefit society operating under
2-15 Chapter 10 of this code;
2-16 (4) a stipulated premium insurance company operating
2-17 under Chapter 22 of this code; or
2-18 (5) to the extent permitted by the Employee Retirement
2-19 Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.):
2-20 (A) a multiple employer welfare arrangement as
2-21 defined by Section 3, Employee Retirement Income Security Act of
2-22 1974 (29 U.S.C. Section 1002), or another analogous benefit
2-23 arrangement; or
2-24 (B) any other entity not licensed under this
2-25 code or another insurance law of this state that contracts directly
2-26 for medical care or health care services on a risk-sharing basis,
2-27 including an entity that contracts for medical care or health care
3-1 services under a capitation method.
3-2 Sec. 3. PHYSICIAN AND PROVIDER COMMUNICATION. A managed
3-3 care entity may not, by contract or otherwise, restrict a
3-4 physician's or health care provider's ability to communicate with
3-5 an enrollee with respect to:
3-6 (1) the enrollee's coverage under the managed care
3-7 plan;
3-8 (2) any subject related to the medical care or health
3-9 care services to be provided to the enrollee, including treatment
3-10 options that are not provided under the managed care plan;
3-11 (3) the availability or desirability of another health
3-12 benefit plan or insurance or similar coverage;
3-13 (4) the financial arrangement between the physician or
3-14 health care provider and the managed care entity; or
3-15 (5) the fact that the physician's or provider's
3-16 contract with the managed care plan has terminated or that the
3-17 physician or provider will otherwise no longer be providing medical
3-18 care or health care services under the health benefit plan.
3-19 Sec. 4. APPEAL OF DETERMINATION. A physician or health care
3-20 provider may participate, on behalf of an enrollee, in any appeal
3-21 or review of a determination made by a managed care entity that,
3-22 concurrently or prospectively, denies benefits for a treatment
3-23 recommended or prescribed by the physician or health care provider
3-24 for the enrollee in the course of providing medical care or health
3-25 care to the enrollee under the managed care plan.
3-26 Sec. 5. RETALIATION PROHIBITED. A managed care entity may
3-27 not terminate the contract of a physician or health care provider
4-1 or take any other retaliatory action against the physician or
4-2 provider because the physician or health care provider has
4-3 exercised the physician's or provider's rights under this article.
4-4 Sec. 6. CONTRACT VOID. A contract provision that violates
4-5 this article is void.
4-6 SECTION 2. This Act takes effect September 1, 1997, and
4-7 applies only to a contract between a physician or health care
4-8 provider and a managed care entity entered into or renewed on or
4-9 after that date. A contract between a physician or health care
4-10 provider and a managed care entity entered into or renewed before
4-11 September 1, 1997, is governed by the law as it existed immediately
4-12 before the effective date of this Act, and that law is continued in
4-13 effect for that purpose.
4-14 SECTION 3. The importance of this legislation and the
4-15 crowded condition of the calendars in both houses create an
4-16 emergency and an imperative public necessity that the
4-17 constitutional rule requiring bills to be read on three several
4-18 days in each house be suspended, and this rule is hereby suspended.