By Longoria H.B. No. 190
76R970 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to a prohibition on certain restrictions imposed by
1-3 insurers on the performance of professional health care services by
1-4 health care practitioners.
1-5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-6 SECTION 1. Subchapter E, Chapter 21, Insurance Code, is
1-7 amended by adding Article 21.52L to read as follows:
1-8 Art. 21.52L. RESTRICTIONS BY INSURERS ON PERFORMANCE OF
1-9 CERTAIN PROFESSIONAL HEALTH CARE SERVICES PROHIBITED
1-10 Sec. 1. DEFINITIONS. In this article:
1-11 (1) "Enrollee" means a person entitled to coverage
1-12 under a health benefit plan.
1-13 (2) "Health benefit plan" means a plan described by
1-14 Section 2 of this article.
1-15 (3) "Health care practitioner" means an individual who
1-16 is licensed, registered, or certified in this state to provide
1-17 health care.
1-18 Sec. 2. SCOPE OF ARTICLE. (a) This article applies only to
1-19 a health benefit plan that:
1-20 (1) provides benefits for medical or surgical expenses
1-21 incurred as a result of a health condition, accident, or sickness,
1-22 including:
1-23 (A) an individual, group, blanket, or franchise
1-24 insurance policy or insurance agreement, a group hospital service
2-1 contract, or an individual or group evidence of coverage that is
2-2 offered by:
2-3 (i) an insurance company;
2-4 (ii) a group hospital service corporation
2-5 operating under Chapter 20 of this code;
2-6 (iii) a fraternal benefit society
2-7 operating under Chapter 10 of this code;
2-8 (iv) a stipulated premium insurance
2-9 company operating under Chapter 22 of this code; or
2-10 (v) a health maintenance organization
2-11 operating under the Texas Health Maintenance Organization Act
2-12 (Chapter 20A, Vernon's Texas Insurance Code); or
2-13 (B) to the extent permitted by the Employee
2-14 Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et
2-15 seq.), a health benefit plan that is offered by:
2-16 (i) a multiple employer welfare
2-17 arrangement as defined by Section 3, Employee Retirement Income
2-18 Security Act of 1974 (29 U.S.C. Section 1002); or
2-19 (ii) another analogous benefit
2-20 arrangement;
2-21 (2) is offered by an approved nonprofit health
2-22 corporation that is certified under Section 5.01(a), Medical
2-23 Practice Act (Article 4495b, Vernon's Texas Civil Statutes), and
2-24 that holds a certificate of authority issued by the commissioner
2-25 under Article 21.52F of this code; or
2-26 (3) is offered by any other entity not licensed under
2-27 this code or another insurance law of this state that contracts
3-1 directly for health care services on a risk-sharing basis,
3-2 including an entity that contracts for health care services on a
3-3 capitation basis.
3-4 (b) This article applies to a health benefit plan that
3-5 provides coverage only for a specific disease or condition or for
3-6 hospitalization.
3-7 (c) Notwithstanding Section 172.014, Local Government Code,
3-8 or any other law, this article applies to health and accident
3-9 coverage provided by a risk pool created under Chapter 172, Local
3-10 Government Code.
3-11 (d) This article does not apply to:
3-12 (1) a plan that provides coverage:
3-13 (A) only for accidental death or dismemberment;
3-14 (B) for wages or payments in lieu of wages for a
3-15 period during which an employee is absent from work because of
3-16 sickness or injury; or
3-17 (C) as a supplement to liability insurance;
3-18 (2) a small-employer plan written under Chapter 26 of
3-19 this code;
3-20 (3) a Medicare supplemental policy as defined by
3-21 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
3-22 (4) workers' compensation insurance coverage;
3-23 (5) medical payment insurance issued as part of a
3-24 motor vehicle insurance policy; or
3-25 (6) a long-term care policy, including a nursing home
3-26 fixed indemnity policy, unless the commissioner determines that the
3-27 policy provides benefit coverage so comprehensive that the policy
4-1 is a health benefit plan as described by Subsection (a) of this
4-2 section.
4-3 Sec. 3. RESTRICTIONS PROHIBITED. (a) A health benefit plan
4-4 may not include in a contract with a health care practitioner who
4-5 provides professional services to an enrollee under the plan any
4-6 provision that penalizes the health care practitioner for:
4-7 (1) referring an enrollee for additional diagnosis or
4-8 treatment by a specialist; or
4-9 (2) otherwise using the practitioner's own best
4-10 professional judgment in prescribing a particular medication,
4-11 treatment, or device for use by an enrollee.
4-12 (b) This section does not preclude a health benefit plan
4-13 from using utilization review in a manner that complies with
4-14 Article 21.58A of this code.
4-15 Sec. 4. ADMINISTRATIVE PENALTY. An insurance company,
4-16 health maintenance organization, or other entity that operates a
4-17 health benefit plan in violation of this article is subject to an
4-18 administrative penalty as provided by Article 1.10E of this code.
4-19 SECTION 2. Article 21.52L, Insurance Code, as added by
4-20 Section 1 of this Act, takes effect September 1, 1999, and applies
4-21 only to an insurance policy or evidence of coverage that is
4-22 delivered, issued for delivery, or renewed on or after January 1,
4-23 2000. A policy or evidence of coverage that is delivered, issued
4-24 for delivery, or renewed before January 1, 2000, is governed by the
4-25 law as it existed immediately before the effective date of this
4-26 Act, and that law is continued in effect for this purpose.
4-27 SECTION 3. The importance of this legislation and the
5-1 crowded condition of the calendars in both houses create an
5-2 emergency and an imperative public necessity that the
5-3 constitutional rule requiring bills to be read on three several
5-4 days in each house be suspended, and this rule is hereby suspended.