75R11365 DLF-D
By Shapiro, et al. S.B. No. 54
Substitute the following for S.B. No. 54:
By Van de Putte C.S.S.B. No. 54
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to access to certain obstetrical or gynecological health
1-3 care under a health benefit plan; providing administrative
1-4 penalties.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.53D to read as follows:
1-8 Art. 21.53D. ACCESS TO CERTAIN OBSTETRICAL OR GYNECOLOGICAL
1-9 CARE
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Enrollee" means an individual enrolled in a
1-12 health benefit plan.
1-13 (2) "Health benefit plan" means a plan described in
1-14 Section 2 of this article.
1-15 (3) "Physician" means a person licensed as a physician
1-16 by the Texas State Board of Medical Examiners.
1-17 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
1-18 health benefit plan that:
1-19 (1) provides benefits for medical or surgical expenses
1-20 incurred as a result of a health condition, accident, or sickness,
1-21 including:
1-22 (A) an individual, group, blanket, or franchise
1-23 insurance policy or insurance agreement, a group hospital service
1-24 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
2-26 this code or another insurance law of this state that contracts
2-27 directly for health care services on a risk-sharing basis,
3-1 including an entity that contracts for health care services on a
3-2 capitation basis.
3-3 (b) This article does not apply to:
3-4 (1) a plan that provides coverage:
3-5 (A) only for a specified disease;
3-6 (B) only for accidental death or dismemberment;
3-7 (C) for wages or payments in lieu of wages for a
3-8 period during which an employee is absent from work because of
3-9 sickness or injury; or
3-10 (D) as a supplement to liability insurance;
3-11 (2) a plan written under Chapter 26 of this code;
3-12 (3) a Medicare supplemental policy as defined by
3-13 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-14 (4) workers' compensation insurance coverage;
3-15 (5) medical payment insurance issued as a part of a
3-16 motor vehicle insurance policy;
3-17 (6) a long-term care policy, including a nursing home
3-18 fixed indemnity policy, unless the commissioner determines that the
3-19 policy provides benefit coverage so comprehensive that the policy
3-20 is a health benefit plan as described by Subsection (a) of this
3-21 section;
3-22 (7) any health benefit plan that does not provide
3-23 pregnancy-related benefits; or
3-24 (8) any health benefit plan that does not provide
3-25 well-woman care benefits.
3-26 (c) This article applies to each health benefit plan that
3-27 requires an enrollee to obtain certain specialty health care
4-1 services through a referral made by a primary care physician or
4-2 other gatekeeper.
4-3 Sec. 3. ACCESS OF FEMALE ENROLLEE TO HEALTH CARE. (a) Each
4-4 health benefit plan subject to this article shall permit a woman
4-5 who is entitled to coverage under the plan to select, in addition
4-6 to a primary care physician, an obstetrician or gynecologist to
4-7 provide health care services within the scope of the professional
4-8 specialty practice of a properly credentialed obstetrician or
4-9 gynecologist. This section does not preclude a woman from
4-10 selecting a family physician, internal medicine physician, or other
4-11 qualified physician to provide that care.
4-12 (b) The plan shall include in the classification of persons
4-13 authorized to provide medical services under the plan a number of
4-14 properly credentialed obstetricians and gynecologists sufficient to
4-15 ensure access to the services that fall within the scope of that
4-16 credential.
4-17 (c) This section does not affect the authority of a health
4-18 benefit plan to establish selection criteria regarding other
4-19 physicians who provide services through the plan.
4-20 Sec. 4. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
4-21 GYNECOLOGIST. (a) In addition to other benefits authorized by the
4-22 plan, each health benefit plan shall permit a woman who designates
4-23 an obstetrician or gynecologist as provided under Section 3 of this
4-24 article direct access to the health care services of the designated
4-25 obstetrician or gynecologist without a referral by the woman's
4-26 primary care physician or prior authorization or precertification
4-27 from a health benefit plan.
5-1 (b) The access to health care services required under this
5-2 article includes, but is not limited to:
5-3 (1) one well-woman examination per year;
5-4 (2) care related to pregnancy;
5-5 (3) care for all active gynecological conditions; and
5-6 (4) diagnosis, treatment, and referral for any disease
5-7 or condition within the scope of the professional practice of a
5-8 properly credentialed obstetrician or gynecologist.
5-9 (c) A health benefit plan may not impose a copayment or
5-10 deductible for direct access to the health care services of an
5-11 obstetrician or gynecologist under this section unless such an
5-12 additional cost is imposed for access to other health care services
5-13 provided under the plan.
5-14 (d) This section does not affect the authority of a health
5-15 benefit plan to require the designated obstetrician or gynecologist
5-16 to forward information concerning the medical care of the patient
5-17 to the primary care physician. Failure to provide this information
5-18 may not result in any penalty, financial or otherwise, being
5-19 imposed upon the obstetrician or gynecologist or the patient by the
5-20 health benefit plan if the obstetrician or gynecologist has made a
5-21 reasonable and good-faith effort to provide the information to the
5-22 primary care physician.
5-23 (e) In implementing the access required under Section 3 of
5-24 this article, a health benefit plan may limit a woman enrolled in
5-25 the plan to self-referral to one participating obstetrician and
5-26 gynecologist for both gynecological care and obstetrical care.
5-27 This subsection does not affect the right of the woman to select
6-1 the physician who provides that care.
6-2 (f) A health benefit plan shall not sanction or terminate
6-3 primary care physicians as a result of female enrollees' access to
6-4 participating obstetricians and gynecologists under this section.
6-5 Sec. 5. NOTICE. Each health benefit plan shall provide to
6-6 persons covered by the plan a timely written notice in clear and
6-7 accurate language of the choices of types of physician providers
6-8 for the direct access to health care services required by this
6-9 article.
6-10 Sec. 6. RULES. The commissioner shall adopt rules as
6-11 necessary to implement this article.
6-12 Sec. 7. ADMINISTRATIVE PENALTY. An insurance company,
6-13 health maintenance organization, or other entity that operates a
6-14 health benefit plan in violation of this article is subject to an
6-15 administrative penalty as provided by Article 1.10E of this code.
6-16 SECTION 2. Article 21.53D, Insurance Code, as added by
6-17 Section 1 of this Act, applies only to an insurance policy,
6-18 contract, or evidence of coverage delivered, issued for delivery,
6-19 or renewed on or after January 1, 1998. A policy, contract, or
6-20 evidence of coverage delivered, issued for delivery, or renewed
6-21 before January 1, 1998, is governed by the law as it existed
6-22 immediately before the effective date of this Act, and that law is
6-23 continued in effect for that purpose.
6-24 SECTION 3. This Act takes effect September 1, 1997.
6-25 SECTION 4. The importance of this legislation and the
6-26 crowded condition of the calendars in both houses create an
6-27 emergency and an imperative public necessity that the
7-1 constitutional rule requiring bills to be read on three several
7-2 days in each house be suspended, and this rule is hereby suspended.