1-1           By:  Shapiro                                      S.B. No. 54

 1-2           (In the Senate - Filed November 12, 1996; January 14, 1997,

 1-3     read first time and referred to Committee on Economic Development;

 1-4     March 3, 1997, reported adversely, with favorable Committee

 1-5     Substitute by the following vote:  Yeas 7, Nays 0; March 3, 1997,

 1-6     sent to printer.)

 1-7     COMMITTEE SUBSTITUTE FOR S.B. No. 54                   By:  Shapiro

 1-8                            A BILL TO BE ENTITLED

 1-9                                   AN ACT

1-10     relating to access to certain obstetrical or gynecological health

1-11     care under a health benefit plan; providing administrative

1-12     penalties.

1-13           BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

1-14           SECTION 1.  Subchapter E, Chapter 21, Insurance Code, is

1-15     amended by adding Article 21.53D to read as follows:

1-16           Art. 21.53D.  ACCESS TO CERTAIN OBSTETRICAL OR GYNECOLOGICAL

1-17     CARE

1-18           Sec. 1.  DEFINITIONS.  In this article:

1-19                 (1)  "Enrollee" means an individual enrolled in a

1-20     health benefit plan.

1-21                 (2)  "Health benefit plan" means a plan described in

1-22     Section 2 of this article.

1-23                 (3)  "Physician" means a person licensed as a physician

1-24     by the Texas State Board of Medical Examiners.

1-25           Sec. 2.  SCOPE OF ARTICLE.  (a)  This article applies to a

1-26     health benefit plan that:

1-27                 (1)  provides benefits for medical or surgical expenses

1-28     incurred as a result of a health condition, accident, or sickness,

1-29     including:

1-30                       (A)  an individual, group, blanket, or franchise

1-31     insurance policy or insurance agreement, a group hospital service

1-32     contract, or an individual or group evidence of coverage that is

1-33     offered by:

1-34                             (i)  an insurance company;

1-35                             (ii)  a group hospital service corporation

1-36     operating under Chapter 20 of this code;

1-37                             (iii)  a fraternal benefit society

1-38     operating under Chapter 10 of this code;

1-39                             (iv)  a stipulated premium insurance

1-40     company operating under Chapter 22 of this code; or

1-41                             (v)  a health maintenance organization

1-42     operating under the Texas Health Maintenance Organization Act

1-43     (Chapter 20A, Vernon's Texas Insurance Code); and

1-44                       (B)  to the extent permitted by the Employee

1-45     Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et

1-46     seq.), a health benefit plan that is offered by:

1-47                             (i)  a multiple employer welfare

1-48     arrangement as defined by Section 3, Employee Retirement Income

1-49     Security Act of 1974 (29 U.S.C. Section 1002); or

1-50                             (ii)  another analogous benefit

1-51     arrangement;

1-52                 (2)  is offered by an approved nonprofit health

1-53     corporation that is certified under Section 5.01(a), Medical

1-54     Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and

1-55     that holds a certificate of authority issued by the commissioner

1-56     under Article 21.52F of this code; or

1-57                 (3)  is offered by any other entity not licensed under

1-58     this code or another insurance law of this state that contracts

1-59     directly for health care services on a risk-sharing basis,

1-60     including an entity that contracts for health care services on a

1-61     capitation basis.

1-62           (b)  This article does not apply to:

1-63                 (1)  a plan that provides coverage:

1-64                       (A)  only for a specified disease;

 2-1                       (B)  only for accidental death or dismemberment;

 2-2                       (C)  for wages or payments in lieu of wages for a

 2-3     period during which an employee is absent from work because of

 2-4     sickness or injury; or

 2-5                       (D)  as a supplement to liability insurance;

 2-6                 (2)  a plan written under Chapter 26 of this code;

 2-7                 (3)  a Medicare supplemental policy as defined by

 2-8     Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

 2-9                 (4)  workers' compensation insurance coverage;

2-10                 (5)  medical payment insurance issued as a part of a

2-11     motor vehicle insurance policy;

2-12                 (6)  a long-term care policy, including a nursing home

2-13     fixed indemnity policy, unless the commissioner determines that the

2-14     policy provides benefit coverage so comprehensive that the policy

2-15     is a health benefit plan as described by Subsection (a) of this

2-16     section; or

2-17                 (7)  any health benefit plan that does not provide

2-18     pregnancy-related benefits.

2-19           (c)  This article applies to each health benefit plan that

2-20     requires an enrollee to obtain certain specialty health care

2-21     services through a referral made by a primary care physician or

2-22     other gatekeeper.

2-23           Sec. 3.  ACCESS OF FEMALE ENROLLEE TO HEALTH CARE.  (a)  Each

2-24     health benefit plan subject to this article shall permit a woman

2-25     who is entitled to coverage under the plan to select, in addition

2-26     to a primary care physician, an obstetrician or gynecologist to

2-27     provide health care services within the scope of the professional

2-28     specialty practice of a properly credentialed obstetrician or

2-29     gynecologist.

2-30           (b)  The plan shall include in the classification of persons

2-31     authorized to provide medical services under the plan a number of

2-32     properly credentialed obstetricians and gynecologists sufficient to

2-33     ensure access to the services that fall within the scope of that

2-34     credential.

2-35           (c)  This section does not affect the authority of a health

2-36     benefit plan to establish selection criteria regarding other

2-37     physicians who provide services through the plan.

2-38           Sec. 4.  DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR

2-39     GYNECOLOGIST.  (a)  In addition to other benefits authorized by the

2-40     plan, each health benefit plan shall permit a woman who designates

2-41     an obstetrician or gynecologist as provided under Section 3 of this

2-42     article direct access to the health care services of the designated

2-43     obstetrician or gynecologist without a referral by the woman's

2-44     primary care physician or prior authorization or precertification

2-45     from a health benefit plan.

2-46           (b)  The access to health care services required under this

2-47     article includes, but is not limited to:

2-48                 (1)  one well-woman examination per year;

2-49                 (2)  care related to pregnancy;

2-50                 (3)  care for all active gynecological conditions; and

2-51                 (4)  diagnosis, treatment, and referral for any disease

2-52     or condition within the scope of the professional practice of a

2-53     properly credentialed obstetrician or gynecologist.

2-54           (c)  A health benefit plan may not impose a copayment or

2-55     deductible for direct access to the health care services of an

2-56     obstetrician or gynecologist under this section unless such an

2-57     additional cost is imposed for access to other health care services

2-58     provided under the plan.

2-59           (d)  This section does not affect the authority of a health

2-60     benefit plan to require the designated obstetrician or gynecologist

2-61     to forward information concerning the medical care of the patient

2-62     to the primary care physician; however, failure to provide such

2-63     information shall not result in any penalty, financial or

2-64     otherwise, being imposed upon the obstetrician or gynecologist or

2-65     the patient by the health benefit plan.

2-66           (e)  In implementing the access required under Section 3 of

2-67     this article, a health benefit plan may limit a woman enrolled in

2-68     the plan to self-referral to one participating obstetrician and

2-69     gynecologist for both gynecological care and obstetrical care.

 3-1     This subsection does not affect the right of the woman to select

 3-2     the physician who provides that care.

 3-3           (f)  A health benefit plan shall not sanction or terminate

 3-4     primary care physicians as a result of female enrollees' access to

 3-5     participating obstetricians and gynecologists under this section.

 3-6           Sec. 5.  NOTICE.  Each health benefit plan shall provide to

 3-7     persons covered by the plan a timely written notice in clear and

 3-8     accurate language of the direct access to health care services

 3-9     required by this article.

3-10           Sec. 6.  RULES.  The commissioner shall adopt rules as

3-11     necessary to implement this article.

3-12           Sec. 7.  ADMINISTRATIVE PENALTY.  An insurance company,

3-13     health maintenance organization, or other entity that operates a

3-14     health benefit plan in violation of this article is subject to an

3-15     administrative penalty as provided by Article 1.10E of this code.

3-16           SECTION 2.  Article 21.53D, Insurance Code, as added by

3-17     Section 1 of this Act, applies only to an insurance policy,

3-18     contract, or evidence of coverage delivered, issued for delivery,

3-19     or renewed on or after January 1, 1998.  A policy, contract, or

3-20     evidence of coverage delivered, issued for delivery, or renewed

3-21     before January 1, 1998, is governed by the law as it existed

3-22     immediately before the effective date of this Act, and that law is

3-23     continued in effect for that purpose.

3-24           SECTION 3.  This Act takes effect September 1, 1997.

3-25           SECTION 4.  The importance of this legislation and the

3-26     crowded condition of the calendars in both houses create an

3-27     emergency and an imperative public necessity that the

3-28     constitutional rule requiring bills to be read on three several

3-29     days in each house be suspended, and this rule is hereby suspended.

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