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.