By Siebert H.B. No. 266
76R1254 DLF-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the availability of certain specialists under a health
1-3 care plan offered by a health maintenance organization.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. The Texas Health Maintenance Organization Act
1-6 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding
1-7 Section 39 to read as follows:
1-8 Sec. 39. AVAILABILITY OF OUT-OF-NETWORK SPECIALISTS. (a)
1-9 In this section:
1-10 (1) "Network specialist" means a specialist who is
1-11 participating in the health maintenance organization delivery
1-12 network.
1-13 (2) "Out-of-network specialist" means a specialist who
1-14 is not participating in the health maintenance organization
1-15 delivery network.
1-16 (3) "Specialist" means:
1-17 (A) a properly credentialed physician who is
1-18 practicing in a recognized specialty practice; or
1-19 (B) another health care provider who is licensed
1-20 or otherwise authorized by this state to provide specialized health
1-21 care services.
1-22 (b) An enrollee may select an out-of-network specialist to
1-23 provide a health care service if, under the enrollee's health care
1-24 plan, a network specialist is compensated for a similar service on
2-1 the basis of each service actually provided and is not compensated
2-2 for the service on a capitated or other similar basis.
2-3 (c) The health maintenance organization shall pay the
2-4 out-of-network specialist an amount equal to the amount the health
2-5 maintenance organization would pay to a network specialist for the
2-6 same service. Notwithstanding any other law, an enrollee who
2-7 selects an out-of-network specialist under Subsection (b) of this
2-8 section is responsible for any amount charged for the service by
2-9 that specialist that exceeds the amount paid by the health
2-10 maintenance organization.
2-11 (d) This section does not affect the duty of a health
2-12 maintenance organization to:
2-13 (1) assure the availability of adequate personnel
2-14 under Section 5 of this Act and applicable rules of the department;
2-15 or
2-16 (2) provide a referral and reimbursement under Section
2-17 9(f) of this Act, as added by Chapter 905, Acts of the 75th
2-18 Legislature, Regular Session, 1997.
2-19 (e) This section does not require a health maintenance
2-20 organization to provide benefits for a service:
2-21 (1) for which benefits would not otherwise be provided
2-22 under the evidence of coverage; or
2-23 (2) without referral from the enrollee's primary care
2-24 physician or without prior authorization or precertification from
2-25 the health care plan, if the referral, preauthorization, or
2-26 precertification is required under the health care plan.
2-27 (f) The department shall adopt rules to implement this
3-1 section.
3-2 SECTION 2. This Act takes effect September 1, 1999, and
3-3 applies only to an evidence of coverage for a health care plan that
3-4 is delivered, issued for delivery, or renewed on or after January
3-5 1, 2000. An evidence of coverage for a health care plan that is
3-6 delivered, issued for delivery, or renewed before January 1, 2000,
3-7 is governed by the law as it existed immediately before the
3-8 effective date of this Act, and that law is continued in effect for
3-9 this purpose.
3-10 SECTION 3. The importance of this legislation and the
3-11 crowded condition of the calendars in both houses create an
3-12 emergency and an imperative public necessity that the
3-13 constitutional rule requiring bills to be read on three several
3-14 days in each house be suspended, and this rule is hereby suspended.