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. 3-30 * * * * *