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) Notwithstanding Section 172.014, Local Government Code,
3-6 or any other law, this article applies to health and accident
3-7 coverage provided by a risk pool created under Chapter 172, Local
3-8 Government Code.
3-9 (c) This article does not apply to:
3-10 (1) a plan that provides coverage:
3-11 (A) only for a specified disease;
3-12 (B) only for accidental death or dismemberment;
3-13 (C) for wages or payments in lieu of wages for a
3-14 period during which an employee is absent from work because of
3-15 sickness or injury; or
3-16 (D) as a supplement to liability insurance;
3-17 (2) a plan written under Chapter 26 of this code;
3-18 (3) a Medicare supplemental policy as defined by
3-19 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-20 (4) workers' compensation insurance coverage;
3-21 (5) medical payment insurance issued as a part of a
3-22 motor vehicle insurance policy;
3-23 (6) a long-term care policy, including a nursing home
3-24 fixed indemnity policy, unless the commissioner determines that the
3-25 policy provides benefit coverage so comprehensive that the policy
4-1 is a health benefit plan as described by Subsection (a) of this
4-2 section;
4-3 (7) any health benefit plan that does not provide
4-4 pregnancy-related benefits; or
4-5 (8) any health benefit plan that does not provide
4-6 well-woman care benefits.
4-7 (d) This article applies to each health benefit plan that
4-8 requires an enrollee to obtain certain specialty health care
4-9 services through a referral made by a primary care physician or
4-10 other gatekeeper.
4-11 Sec. 3. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. (a) Each
4-12 health benefit plan subject to this article shall permit a woman
4-13 who is entitled to coverage under the plan to select, in addition
4-14 to a primary care physician, an obstetrician or gynecologist to
4-15 provide health care services within the scope of the professional
4-16 specialty practice of a properly credentialed obstetrician or
4-17 gynecologist. This section does not preclude a woman from
4-18 selecting a family physician, internal medicine physician, or other
4-19 qualified physician to provide that care.
4-20 (b) The plan shall include in the classification of persons
4-21 authorized to provide medical services under the plan a number of
4-22 properly credentialed obstetricians and gynecologists sufficient to
4-23 ensure access to the services that fall within the scope of that
4-24 credential.
4-25 (c) This section does not affect the authority of a health
5-1 benefit plan to establish selection criteria regarding other
5-2 physicians who provide services through the plan.
5-3 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
5-4 GYNECOLOGIST. (a) In addition to other benefits authorized by the
5-5 plan, each health benefit plan shall permit a woman who designates
5-6 an obstetrician or gynecologist as provided under Section 3 of this
5-7 article direct access to the health care services of the designated
5-8 obstetrician or gynecologist without a referral by the woman's
5-9 primary care physician or prior authorization or precertification
5-10 from a health benefit plan.
5-11 (b) The access to health care services required under this
5-12 article includes, but is not limited to:
5-13 (1) one well-woman examination per year;
5-14 (2) care related to pregnancy;
5-15 (3) care for all active gynecological conditions; and
5-16 (4) diagnosis, treatment, and referral for any disease
5-17 or condition within the scope of the professional practice of a
5-18 properly credentialed obstetrician or gynecologist.
5-19 (c) A health benefit plan may not impose a copayment or
5-20 deductible for direct access to the health care services of an
5-21 obstetrician or gynecologist under this section unless such an
5-22 additional cost is imposed for access to other health care services
5-23 provided under the plan.
5-24 (d) This section does not affect the authority of a health
5-25 benefit plan to require the designated obstetrician or gynecologist
6-1 to forward information concerning the medical care of the patient
6-2 to the primary care physician. Failure to provide this information
6-3 may not result in any penalty, financial or otherwise, being
6-4 imposed upon the obstetrician or gynecologist or the patient by the
6-5 health benefit plan if the obstetrician or gynecologist has made a
6-6 reasonable and good-faith effort to provide the information to the
6-7 primary care physician.
6-8 (e) In implementing the access required under Section 3 of
6-9 this article, a health benefit plan may limit a woman enrolled in
6-10 the plan to self-referral to one participating obstetrician and
6-11 gynecologist for both gynecological care and obstetrical care.
6-12 This subsection does not affect the right of the woman to select
6-13 the physician who provides that care.
6-14 (f) A health benefit plan shall not sanction or terminate
6-15 primary care physicians as a result of female enrollees' access to
6-16 participating obstetricians and gynecologists under this section.
6-17 Sec. 5. NOTICE. Each health benefit plan shall provide to
6-18 persons covered by the plan a timely written notice in clear and
6-19 accurate language of the choices of types of physician providers
6-20 for the direct access to health care services required by this
6-21 article.
6-22 Sec. 6. RULES. The commissioner shall adopt rules as
6-23 necessary to implement this article.
6-24 Sec. 7. ADMINISTRATIVE PENALTY. An insurance company,
6-25 health maintenance organization, or other entity that operates a
7-1 health benefit plan in violation of this article is subject to an
7-2 administrative penalty as provided by Article 1.10E of this code.
7-3 SECTION 2. Article 21.53D, Insurance Code, as added by
7-4 Section 1 of this Act, applies only to an insurance policy,
7-5 contract, or evidence of coverage delivered, issued for delivery,
7-6 or renewed on or after January 1, 1998. A policy, contract, or
7-7 evidence of coverage delivered, issued for delivery, or renewed
7-8 before January 1, 1998, is governed by the law as it existed
7-9 immediately before the effective date of this Act, and that law is
7-10 continued in effect for that purpose.
7-11 SECTION 3. This Act takes effect September 1, 1997.
7-12 SECTION 4. The importance of this legislation and the
7-13 crowded condition of the calendars in both houses create an
7-14 emergency and an imperative public necessity that the
7-15 constitutional rule requiring bills to be read on three several
7-16 days in each house be suspended, and this rule is hereby suspended.
_______________________________ _______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 54 passed the Senate on
March 5, 1997, by a viva-voce vote; and that the Senate concurred
in House amendments on May 26, 1997, by a viva-voce vote.
_______________________________
Secretary of the Senate
I hereby certify that S.B. No. 54 passed the House, with
amendments, on May 23, 1997, by a non-record vote.
_______________________________
Chief Clerk of the House
Approved:
_______________________________
Date
_______________________________
Governor