By: Berlanga H.B. No. 3269
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the provision of medically necessary services by a
1-3 Health Maintenance Organization using non-network physicians.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Section 9(a), Texas Health Maintenance
1-6 Organization Act (Article 20A.09(a), Vernon's Texas Insurance
1-7 Code), as amended by Chapters 1091 and 1096, Acts of the 70th
1-8 Legislature, Regular Session, 1987, is amended to read as follows:
1-9 Sec. 9. Evidence of Coverage and Charges. (a)(1) Every
1-10 enrollee residing in this state is entitled to evidence of coverage
1-11 under a health care plan. If the enrollee obtains coverage under a
1-12 health care plan through an insurance policy or a contract issued
1-13 by a group hospital service corporation, whether by option or
1-14 otherwise, the insurer or the group hospital service corporation
1-15 shall issue the evidence of coverage. Otherwise, the health
1-16 maintenance organization shall issue the evidence of coverage.
1-17 (2) No evidence of coverage, or amendment thereto,
1-18 shall be issued or delivered to any person in this state until a
1-19 copy of the form of evidence of coverage, or amendment thereto, has
1-20 been filed with and approved by the commissioner.
1-21 (3) An evidence of coverage shall contain:
1-22 (A) no provisions or statements which are
2-1 unjust, unfair, inequitable, misleading, deceptive, which encourage
2-2 misrepresentation, or which are untrue, misleading, or deceptive as
2-3 defined in Section 14 of this Act; [and]
2-4 (B) a clear and complete statement, if a
2-5 contract, or a reasonably complete facsimile, if a certificate, of:
2-6 (i) the medical, health care services, or
2-7 single health care service and the issuance of other benefits, if
2-8 any, to which the enrollee is entitled under the health care plan
2-9 or single health care service plan;
2-10 (ii) any limitation on the services, kinds
2-11 of services, benefits, or kinds of benefits to be provided,
2-12 including any deductible or co-payment feature;
2-13 (iii) where and in what manner information
2-14 is available as to how services may be obtained; and
2-15 (iv) a clear and understandable
2-16 description of the health maintenance organization's methods for
2-17 resolving enrollee complaints. Any subsequent changes may be
2-18 evidenced in a separate document issued to the enrollee;
2-19 (C) a provision that, if medically necessary
2-20 covered services are not available through network physicians or
2-21 providers, the health maintenance organization must, on the request
2-22 of a network physician or provider, within a reasonable time period
2-23 allow referral to a nonnetwork physician or provider and shall
2-24 fully reimburse the nonnetwork physician or provider at the usual
2-25 and customary or an agreed rate; each contract must further provide
2-26 for a review by a specialist of the same, or a similar, specialty
2-27 as the type of physician or provider to whom a referral is
3-1 requested before the health maintenance organization may deny a
3-2 referral;
3-3 (D) a provision to allow enrollees with chronic,
3-4 disabling, or life-threatening illnesses to apply to the health
3-5 maintenance organization's medical director to utilize a nonprimary
3-6 care physician specialist as a primary care physician, provided
3-7 that:
3-8 (i) the request includes information
3-9 specified by the health maintenance organization, including but not
3-10 limited to certification of medical need, and is signed by the
3-11 enrollee and the nonprimary care physician specialist interested in
3-12 serving as the primary care physician;
3-13 (ii) the nonprimary care physician
3-14 specialist meets the health maintenance organization's requirements
3-15 for primary care physician participation; and
3-16 (iii) the nonprimary care physician
3-17 specialist is willing to accept the coordination of all of the
3-18 enrollee's health care needs;
3-19 (E) a provision that if the request for special
3-20 consideration specified in Paragraph D of this subdivision is
3-21 denied, an enrollee may appeal the decision through the health
3-22 maintenance organization's established complaint and appeals
3-23 process; and
3-24 (F) a provision that the effective date of the
3-25 new designation of a nonprimary care physician specialist as set
3-26 out in Paragraph D of this subdivision shall not be retroactive;
3-27 the health maintenance organization may not reduce the amount of
4-1 compensation owed to the original primary care physician beyond the
4-2 date of the new designation.
4-3 (4) Any form of the evidence of coverage or group
4-4 contract to be used in this state, and any amendments thereto, are
4-5 subject to the filing and approval requirements of Subsection (c)
4-6 of this section, unless it is subject to the jurisdiction of the
4-7 commissioner under the laws governing health insurance or group
4-8 hospital service corporations, in which event the filing and
4-9 approval provisions of such law shall apply. To the extent,
4-10 however, that such provisions do not apply to the requirements of
4-11 Subdivision (3), Subsection (a) of this section, the requirements
4-12 of subdivision (3) shall be applicable.
4-13 SUBSECTION 2. The importance of this legislation and the
4-14 crowded condition of the calendars in both houses create an
4-15 emergency and an imperative public necessity that the
4-16 constitutional rule requiring bills to be read on three several
4-17 days in each house be suspended, and this rule is hereby suspended,
4-18 and that this Act take effect and be in force from and after its
4-19 passage, and it is so enacted.