By: Shapiro, Shapleigh S.B. No. 54
A BILL TO BE ENTITLED
AN ACT
1-1 relating to access to certain obstetrical or gynecological health
1-2 care under a health benefit plan; providing administrative
1-3 penalties.
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 OBSTETRICAL 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 described in
1-13 Section 2 of this article.
1-14 (3) "Physician" means a person licensed as a physician
1-15 by the Texas State Board of Medical Examiners.
1-16 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
1-17 health benefit plan that:
1-18 (1) provides benefits for medical or surgical expenses
1-19 incurred as a result of a health condition, accident, or sickness,
1-20 including:
1-21 (A) an individual, group, blanket, or franchise
1-22 insurance policy or insurance agreement, a group hospital service
1-23 contract, or an individual or group evidence of coverage that is
2-1 offered by:
2-2 (i) an insurance company;
2-3 (ii) a group hospital service corporation
2-4 operating under Chapter 20 of this code;
2-5 (iii) a fraternal benefit society
2-6 operating under Chapter 10 of this code;
2-7 (iv) a stipulated premium insurance
2-8 company operating under Chapter 22 of this code; or
2-9 (v) a health maintenance organization
2-10 operating under the Texas Health Maintenance Organization Act
2-11 (Chapter 20A, Vernon's Texas Insurance Code); and
2-12 (B) to the extent permitted by the Employee
2-13 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-14 seq.), a health benefit plan that is offered by:
2-15 (i) a multiple employer welfare
2-16 arrangement as defined by Section 3, Employee Retirement Income
2-17 Security Act of 1974 (29 U.S.C. Section 1002); or
2-18 (ii) another analogous benefit
2-19 arrangement;
2-20 (2) is offered by an approved nonprofit health
2-21 corporation that is certified under Section 5.01(a), Medical
2-22 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-23 that holds a certificate of authority issued by the commissioner
2-24 under Article 21.52F of this code; or
2-25 (3) is offered by any other entity not licensed under
3-1 this code or another insurance law of this state that contracts
3-2 directly for health care services on a risk-sharing basis,
3-3 including an entity that contracts for health care services on a
3-4 capitation basis.
3-5 (b) This article does not apply to:
3-6 (1) a plan that provides coverage:
3-7 (A) only for a specified disease;
3-8 (B) only for accidental death or dismemberment;
3-9 (C) for wages or payments in lieu of wages for a
3-10 period during which an employee is absent from work because of
3-11 sickness or injury; or
3-12 (D) as a supplement to liability insurance;
3-13 (2) a plan written under Chapter 26 of this code;
3-14 (3) a Medicare supplemental policy as defined by
3-15 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-16 (4) workers' compensation insurance coverage;
3-17 (5) medical payment insurance issued as a part of a
3-18 motor vehicle insurance policy;
3-19 (6) a long-term care policy, including a nursing home
3-20 fixed indemnity policy, unless the commissioner determines that the
3-21 policy provides benefit coverage so comprehensive that the policy
3-22 is a health benefit plan as described by Subsection (a) of this
3-23 section;
3-24 (7) any health benefit plan that does not provide
3-25 pregnancy-related benefits; or
4-1 (8) any health benefit plan that does not provide
4-2 well-woman care benefits.
4-3 (c) This article applies to each health benefit plan that
4-4 requires an enrollee to obtain certain specialty health care
4-5 services through a referral made by a primary care physician or
4-6 other gatekeeper.
4-7 Sec. 3. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. (a) Each
4-8 health benefit plan subject to this article shall permit a woman
4-9 who is entitled to coverage under the plan to select, in addition
4-10 to a primary care physician, an obstetrician or gynecologist to
4-11 provide health care services within the scope of the professional
4-12 specialty practice of a properly credentialed obstetrician or
4-13 gynecologist.
4-14 (b) The plan shall include in the classification of persons
4-15 authorized to provide medical services under the plan a number of
4-16 properly credentialed obstetricians and gynecologists sufficient to
4-17 ensure access to the services that fall within the scope of that
4-18 credential.
4-19 (c) This section does not affect the authority of a health
4-20 benefit plan to establish selection criteria regarding other
4-21 physicians who provide services through the plan.
4-22 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
4-23 GYNECOLOGIST. (a) In addition to other benefits authorized by the
4-24 plan, each health benefit plan shall permit a woman who designates
4-25 an obstetrician or gynecologist as provided under Section 3 of this
5-1 article direct access to the health care services of the designated
5-2 obstetrician or gynecologist without a referral by the woman's
5-3 primary care physician or prior authorization or precertification
5-4 from a health benefit plan.
5-5 (b) The access to health care services required under this
5-6 article includes, but is not limited to:
5-7 (1) one well-woman examination per year;
5-8 (2) care related to pregnancy;
5-9 (3) care for all active gynecological conditions; and
5-10 (4) diagnosis, treatment, and referral for any disease
5-11 or condition within the scope of the professional practice of a
5-12 properly credentialed obstetrician or gynecologist.
5-13 (c) A health benefit plan may not impose a copayment or
5-14 deductible for direct access to the health care services of an
5-15 obstetrician or gynecologist under this section unless such an
5-16 additional cost is imposed for access to other health care services
5-17 provided under the plan.
5-18 (d) This section does not affect the authority of a health
5-19 benefit plan to require the designated obstetrician or gynecologist
5-20 to forward information concerning the medical care of the patient
5-21 to the primary care physician; however, failure to provide such
5-22 information shall not result in any penalty, financial or
5-23 otherwise, being imposed upon the obstetrician or gynecologist or
5-24 the patient by the health benefit plan.
5-25 (e) In implementing the access required under Section 3 of
6-1 this article, a health benefit plan may limit a woman enrolled in
6-2 the plan to self-referral to one participating obstetrician and
6-3 gynecologist for both gynecological care and obstetrical care.
6-4 This subsection does not affect the right of the woman to select
6-5 the physician who provides that care.
6-6 (f) A health benefit plan shall not sanction or terminate
6-7 primary care physicians as a result of female enrollees' access to
6-8 participating obstetricians and gynecologists under this section.
6-9 Sec. 5. NOTICE. Each health benefit plan shall provide to
6-10 persons covered by the plan a timely written notice in clear and
6-11 accurate language of the direct access to health care services
6-12 required by this article.
6-13 Sec. 6. RULES. The commissioner shall adopt rules as
6-14 necessary to implement this article.
6-15 Sec. 7. ADMINISTRATIVE PENALTY. An insurance company,
6-16 health maintenance organization, or other entity that operates a
6-17 health benefit plan in violation of this article is subject to an
6-18 administrative penalty as provided by Article 1.10E of this code.
6-19 SECTION 2. Article 21.53D, Insurance Code, as added by
6-20 Section 1 of this Act, applies only to an insurance policy,
6-21 contract, or evidence of coverage delivered, issued for delivery,
6-22 or renewed on or after January 1, 1998. A policy, contract, or
6-23 evidence of coverage delivered, issued for delivery, or renewed
6-24 before January 1, 1998, is governed by the law as it existed
6-25 immediately before the effective date of this Act, and that law is
7-1 continued in effect for that purpose.
7-2 SECTION 3. This Act takes effect September 1, 1997.
7-3 SECTION 4. The importance of this legislation and the
7-4 crowded condition of the calendars in both houses create an
7-5 emergency and an imperative public necessity that the
7-6 constitutional rule requiring bills to be read on three several
7-7 days in each house be suspended, and this rule is hereby suspended.