By Shapiro S.B. No. 54
75R1839 PB-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to access to certain obstetric or gynecological health
1-3 care under a health benefit 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 21.53D to read as follows:
1-7 Art. 21.53D. ACCESS TO CERTAIN OBSTETRIC 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 that provides
1-13 benefits for medical or surgical expenses incurred as a result of a
1-14 health condition, accident, or sickness and that is offered by any
1-15 insurance company, group hospital service corporation, or health
1-16 maintenance organization that delivers or issues for delivery an
1-17 individual, group, blanket, or franchise insurance policy or
1-18 insurance agreement, a group hospital service contract, or an
1-19 evidence of coverage, by a multiple employer welfare arrangement as
1-20 defined by Section 3, Employee Retirement Income Security Act of
1-21 1974 (29 U.S.C. Section 1002), or by any other analogous benefit
1-22 arrangement to the extent permitted by the Employee Retirement
1-23 Income Security Act of 1974 (29 U.S.C. Section 1002). The term
1-24 does not include:
2-1 (A) a plan that provides coverage:
2-2 (i) only for accidental death or
2-3 dismemberment;
2-4 (ii) for wages or payments in lieu of
2-5 wages for a period during which an employee is absent from work
2-6 because of sickness or injury; or
2-7 (iii) as a supplement to liability
2-8 insurance;
2-9 (B) a Medicare supplemental policy as defined by
2-10 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
2-11 (C) worker's compensation insurance coverage;
2-12 (D) medical payment insurance issued as part of
2-13 a motor vehicle insurance policy; or
2-14 (E) a long-term care policy, including a nursing
2-15 home fixed indemnity policy, unless the commissioner determines
2-16 that the policy provides benefit coverage so comprehensive that the
2-17 policy meets the definition of a health benefit plan.
2-18 (3) "Physician" means a person licensed as a physician
2-19 by the Texas State Board of Medical Examiners.
2-20 (4) "Primary care physician" means a physician
2-21 designated under the terms of a health benefit plan to provide
2-22 general medical or surgical diagnosis and treatment of an illness
2-23 or injury sustained by an enrollee, including an enrollee's chronic
2-24 medical condition.
2-25 Sec. 2. APPLICATION. This article applies to each health
2-26 benefit plan that requires an enrollee to obtain certain specialty
2-27 health care services through a referral made by a primary care
3-1 physician or another person.
3-2 Sec. 3. DESIGNATION OF OBSTETRICIAN OR GYNECOLOGIST. (a)
3-3 Each health benefit plan subject to this article shall permit a
3-4 woman who is entitled to coverage under the plan to select, in
3-5 addition to a primary care physician, an obstetrician or
3-6 gynecologist to provide health care services within the scope of
3-7 the professional specialty practice of a properly credentialed
3-8 obstetrician or gynecologist.
3-9 (b) The plan shall include in the classification of persons
3-10 authorized to provide medical services under the plan a number of
3-11 properly credentialed obstetricians and gynecologists sufficient to
3-12 ensure access to the services that fall within the scope of that
3-13 credential.
3-14 Sec. 4. DIRECT ACCESS. A woman who designates an
3-15 obstetrician or gynecologist as provided under Section 3 of this
3-16 article is entitled to direct access without a referral by the
3-17 woman's primary care physician to the health care services of that
3-18 obstetrician or gynecologist.
3-19 Sec. 5. NOTICE. Each health benefit plan shall provide
3-20 appropriate written notice to persons covered by the plan of the
3-21 access to health care services required by this article.
3-22 Sec. 6. RULES. The commissioner shall adopt rules as
3-23 necessary to implement this article.
3-24 SECTION 2. Article 21.53D, Insurance Code, as added by
3-25 Section 1 of this Act, applies only to an insurance policy,
3-26 contract, or evidence of coverage delivered, issued for delivery,
3-27 or renewed on or after January 1, 1998. A policy, contract, or
4-1 evidence of coverage delivered, issued for delivery, or renewed
4-2 before January 1, 1998, is governed by the law as it existed
4-3 immediately before the effective date of this Act, and that law is
4-4 continued in effect for that purpose.
4-5 SECTION 3. This Act takes effect September 1, 1997.
4-6 SECTION 4. The importance of this legislation and the
4-7 crowded condition of the calendars in both houses create an
4-8 emergency and an imperative public necessity that the
4-9 constitutional rule requiring bills to be read on three several
4-10 days in each house be suspended, and this rule is hereby suspended.