HBA-NMO H.B. 96 76(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 96 By: Reyna, Arthur Insurance 2/8/1999 Introduced BACKGROUND AND PURPOSE Currently, health benefit plans may require an enrollee to receive a referral from the enrollee's primary care physician in order to see a specialist physician. This type of system may extend the time to increase treatment and the expense of treatment. H.B. 96 authorizes enrollees in certain health benefit plans to have direct access to a specialist physician. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority is expressly delegated to the Commissioner of Insurance in SECTION 1 (Section 6, Article 21.53Y, Insurance Code) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding Article 21.53Y, as follows: Article 21.53Y. ACCESS TO SPECIALTY HEALTH CARE SERVICES Sec. 1. DEFINITIONS. Defines "enrollee," "health benefit plan," and "physician." Sec. 2. SCOPE OF ARTICLE. (a) Sets forth that this article applies to a health benefit plan (plan) that: (1) is an insurance policy or agreement, a group hospital service contract, or individual or group evidence of coverage offered by an insurance company, a group hospital service corporation (Chapter 20, Insurance Code), a fraternal benefit society (Chapter 10, Insurance Code), a stipulated premium insurance company (Chapter 22, Insurance Code), a health maintenance organization (Chapter 20A, Insurance Code); and to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a plan that is offered by a multiple employer welfare arrangement or another similar benefit arrangement; (2) is offered by an approved nonprofit health corporation that is certified under Section 5.01(a), Medical Practice Act (Article 4495b, V.T.C.S., Certification of Certain Organizations), and that holds a certificate of authority issued by the Commissioner of Insurance (commissioner) under Article 21.52F, Insurance Code (Certification of Certain Nonprofit Health Corporations); or (3) is offered by any other non-licensed entity that contracts directly for health care services on a risk-sharing basis, including an entity that contracts for health care services on a capitation basis. (b) Sets forth that this article applies to health and accident coverage by a risk pool created under Chapter 172, Local Government Code (Texas Political Subdivisions Uniform Group Benefits Program), notwithstanding Section 172.014, Local Government Code. Section 172.014 states that a risk pool created under Chapter 172 is not insurance or an insurer under the laws of this state. (c) Provides that this article does not apply to: (1) a plan that provides coverage only for a specified disease; only for accidental death or dismemberment; for lost wages due to sickness or injury; or as a supplement to liability insurance; (2) a plan written under Chapter 26, Insurance Code (Health Insurance Availability); (3) a Medicare supplement policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss, Certification of medicare supplemental health insurance policies); (4) workers' compensation insurance coverage; (5) medical payment insurance issued as a part of a motor vehicle insurance policy; or (6) a long-term care policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Subsection (a). Sec. 3. ACCESS OF ENROLLEE TO SPECIALTY HEALTH CARE SERVICES. (a) Authorizes an enrollee, who has received a diagnosis from a physician of a disease or condition the treatment of which falls within the scope of a professional specialty practice, to select, in addition to a primary care physician, a properly credentialed specialist physician (specialist) to provide services under the health benefit plan within the scope of that specialty. Provides that this section does not preclude an enrollee from selecting a family, internal medicine, or other qualified physician to provide that care. (b) Provides that a plan that does not include a specialist who is participating in the plan and within whose specialty an enrollee's disease or condition falls must permit the enrollee to select a specialist who is not a participating physician under the plan and provide benefits for the services of that specialist at the same level as would be provided for the services of a participating physician. Sec. 4. DIRECT ACCESS TO SPECIALITY HEALTH CARE SERVICES. (a) Provides that a plan must permit an enrollee who selects a specialist under Section 3 direct access to the services of the specialist without referral by the enrollee's primary care physician or prior authorization or precertification from the plan. (b) Provides that access to health care service required under this article includes diagnosis, treatment, and referral for any disease or condition within the scope of a physician's specialty practice. (c) Prohibits a plan from imposing a copayment or deductible for direct access to the services of a specialist under this article unless an additional cost is imposed for access to other health care services provided under the plan. (d) Provides that this section does not affect the authority of a plan to require the selected specialist to forward information concerning the medical care of the patient to the primary care physician. Prohibits the plan from imposing any financial or other penalty on the specialist or the enrollee because the specialist fails to provide this information if the specialist has made a reasonable and good faith effort to provide the information to the primary care physician. (e) Prohibits a plan from sanctioning or terminating a primary care physician as a result of enrollee's access to specialists under this article. Sec. 5. NOTICE. Requires a person operating a plan to provide each enrollee a timely written notice in clear and accurate language of the direct access requirements of this article. Sec. 6. RULES. Requires the commissioner to adopt rules as necessary to implement this article. Sec. 7. ADMINISTRATIVE PENALTY. Provides that a person who operates a plan in violation of this article is subject to an administrative penalty under Article 1.10E, Insurance Code (Administrative Penalties). SECTION 2. Effective date: September 1, 1999. Makes application of this Act prospective beginning January 1, 2000. SECTION 3. Emergency clause.