By Reyna of Bexar H.B. No. 96
76R721 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to access to specialty health care services under a health
1-3 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 21.53Y to read as follows:
1-7 Art. 21.53Y. ACCESS TO SPECIALTY HEALTH CARE SERVICES
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Enrollee" means an individual enrolled in a
1-10 health benefit plan.
1-11 (2) "Health benefit plan" means a plan described in
1-12 Section 2 of this article.
1-13 (3) "Physician" means a person licensed as a physician
1-14 by the Texas State Board of Medical Examiners.
1-15 Sec. 2. SCOPE OF ARTICLE. (a) This article applies to a
1-16 health benefit plan that:
1-17 (1) provides benefits for medical or surgical expenses
1-18 incurred as a result of a health condition, accident, or sickness,
1-19 including:
1-20 (A) an individual, group, blanket, or franchise
1-21 insurance policy or insurance agreement, a group hospital service
1-22 contract, or an individual or group evidence of coverage that is
1-23 offered by:
1-24 (i) an insurance company;
2-1 (ii) a group hospital service corporation
2-2 operating under Chapter 20 of this code;
2-3 (iii) a fraternal benefit society
2-4 operating under Chapter 10 of this code;
2-5 (iv) a stipulated premium insurance
2-6 company operating under Chapter 22 of this code; or
2-7 (v) a health maintenance organization
2-8 operating under the Texas Health Maintenance Organization Act
2-9 (Chapter 20A, Vernon's Texas Insurance Code); and
2-10 (B) to the extent permitted by the Employee
2-11 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-12 seq.), a health benefit plan that is offered by:
2-13 (i) a multiple employer welfare
2-14 arrangement as defined by Section 3, Employee Retirement Income
2-15 Security Act of 1974 (29 U.S.C. Section 1002); or
2-16 (ii) another analogous benefit
2-17 arrangement;
2-18 (2) is offered by an approved nonprofit health
2-19 corporation that is certified under Section 5.01(a), Medical
2-20 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-21 that holds a certificate of authority issued by the commissioner
2-22 under Article 21.52F of this code; or
2-23 (3) is offered by any other entity not licensed under
2-24 this code or another insurance law of this state that contracts
2-25 directly for health care services on a risk-sharing basis,
2-26 including an entity that contracts for health care services on a
2-27 capitation basis.
3-1 (b) Notwithstanding Section 172.014, Local Government Code,
3-2 or any other law, this article applies to health and accident
3-3 coverage provided by a risk pool created under Chapter 172, Local
3-4 Government Code.
3-5 (c) This article does not apply to:
3-6 (1) a plan that provides coverage:
3-7 (A) only for a specified disease;
3-8 (B) only for accidental death or dismemberment;
3-9 (C) for wages or payments in lieu of wages for a
3-10 period during which an employee is absent from work because of
3-11 sickness or injury; or
3-12 (D) as a supplement to liability insurance;
3-13 (2) a plan written under Chapter 26 of this code;
3-14 (3) a Medicare supplemental policy as defined by
3-15 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-16 (4) workers' compensation insurance coverage;
3-17 (5) medical payment insurance issued as a part of a
3-18 motor vehicle insurance policy; or
3-19 (6) a long-term care policy, including a nursing home
3-20 fixed indemnity policy, unless the commissioner determines that the
3-21 policy provides benefit coverage so comprehensive that the policy
3-22 is a health benefit plan as described by Subsection (a) of this
3-23 section.
3-24 Sec. 3. ACCESS OF ENROLLEE TO SPECIALTY HEALTH CARE
3-25 SERVICES. (a) An enrollee who has received a diagnosis from a
3-26 primary care physician or another physician of a disease or
3-27 condition the treatment of which falls within the scope of a
4-1 professional specialty practice may select, in addition to a
4-2 primary care physician, a properly credentialed specialist
4-3 physician to provide under the health benefit plan health care
4-4 services within the scope of that specialty practice. This section
4-5 does not preclude an enrollee from selecting a family physician,
4-6 internal medicine physician, or other qualified physician to
4-7 provide that care.
4-8 (b) A health benefit plan that does not include a properly
4-9 credentialed specialist physician who is participating in the plan
4-10 and within whose professional specialty practice an enrollee's
4-11 disease or condition falls must:
4-12 (1) permit the enrollee to select a properly
4-13 credentialed specialist physician who is not a participating
4-14 physician under the plan; and
4-15 (2) provide benefits for the services of that
4-16 specialist physician at the same level as would be provided for the
4-17 services of a participating physician.
4-18 Sec. 4. DIRECT ACCESS TO SPECIALTY HEALTH CARE SERVICES. (a)
4-19 In addition to other benefits authorized by a health benefit plan,
4-20 the plan must permit an enrollee who selects a specialist physician
4-21 under Section 3 of this article direct access to the health care
4-22 services of the designated specialist without a referral by the
4-23 enrollee's primary care physician or prior authorization or
4-24 precertification from the plan.
4-25 (b) The access to health care services required under this
4-26 article includes diagnosis, treatment, and referral for any disease
4-27 or condition within the scope of a physician's professional
5-1 specialty practice.
5-2 (c) A health benefit plan may not impose a copayment or
5-3 deductible for direct access to the health care services of a
5-4 specialist physician under this article unless an additional cost
5-5 is imposed for access to other health care services provided under
5-6 the plan.
5-7 (d) This section does not affect the authority of a health
5-8 benefit plan to require the selected specialist physician to
5-9 forward information concerning the medical care of the patient to
5-10 the primary care physician. The plan may not impose any financial
5-11 or other penalty on the specialist physician or the enrollee
5-12 because the specialist physician fails to provide this information
5-13 if the specialist physician has made a reasonable and good faith
5-14 effort to provide the information to the primary care physician.
5-15 (e) A health benefit plan may not sanction or terminate a
5-16 primary care physician as a result of enrollees' access to
5-17 specialist physicians under this article.
5-18 Sec. 5. NOTICE. A person operating a health benefit plan
5-19 shall provide to each enrollee a timely written notice in clear and
5-20 accurate language of the direct access requirements of this
5-21 article.
5-22 Sec. 6. RULES. The commissioner shall adopt rules as
5-23 necessary to implement this article.
5-24 Sec. 7. ADMINISTRATIVE PENALTY. A person who operates a
5-25 health benefit plan in violation of this article is subject to an
5-26 administrative penalty under Article 1.10E of this code.
5-27 SECTION 2. This Act takes effect September 1, 1999, and
6-1 applies only to a health benefit plan that is delivered, issued for
6-2 delivery, or renewed on or after January 1, 2000. A health benefit
6-3 plan delivered, issued for delivery, or renewed before January 1,
6-4 2000, is governed by the law as it existed immediately before the
6-5 effective date of this Act, and that law is continued in effect for
6-6 that purpose.
6-7 SECTION 3. The importance of this legislation and the
6-8 crowded condition of the calendars in both houses create an
6-9 emergency and an imperative public necessity that the
6-10 constitutional rule requiring bills to be read on three several
6-11 days in each house be suspended, and this rule is hereby suspended.