By Longoria H.B. No. 343
77R954 AJA-D
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to a prohibition on certain restrictions imposed by health
1-3 benefit plans on the performance of professional health care
1-4 services by 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 HEALTH BENEFIT PLAN ON
1-9 PERFORMANCE OF 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 care practitioner" means an individual who
1-14 is licensed, registered, or certified in this state to provide
1-15 health care.
1-16 Sec. 2. APPLICABILITY OF ARTICLE. (a) This article
1-17 applies only to a health benefit plan that provides benefits for
1-18 medical or surgical expenses incurred as a result of a health
1-19 condition, accident, or sickness, including an individual, group,
1-20 blanket, or franchise insurance policy or insurance agreement, a
1-21 group hospital service contract, or an individual or group evidence
1-22 of coverage or similar coverage document that is offered by:
1-23 (1) an insurance company;
1-24 (2) a group hospital service corporation operating
2-1 under Chapter 20 of this code;
2-2 (3) a fraternal benefit society operating under
2-3 Chapter 10 of this code;
2-4 (4) a stipulated premium insurance company operating
2-5 under Chapter 22 of this code;
2-6 (5) a health maintenance organization operating under
2-7 the Texas Health Maintenance Organization Act (Chapter 20A,
2-8 Vernon's Texas Insurance Code);
2-9 (6) a multiple employer welfare arrangement that holds
2-10 a certificate of authority under Article 3.95-2 of this code;
2-11 (7) an approved nonprofit health corporation that
2-12 holds a certificate of authority under Article 21.52F of this code;
2-13 or
2-14 (8) any other entity not licensed under this code or
2-15 another insurance law of this state that contracts directly for
2-16 health care services on a risk-sharing basis, including an entity
2-17 that contracts for health care services on a capitation basis.
2-18 (b) This article applies to a health benefit plan that
2-19 provides coverage only for a specific disease or condition or for
2-20 hospitalization.
2-21 (c) Notwithstanding Section 172.014, Local Government Code,
2-22 or any other law, this article applies to health and accident
2-23 coverage provided by a risk pool created under Chapter 172, Local
2-24 Government Code.
2-25 (d) This article does not apply to:
2-26 (1) a plan that provides coverage:
2-27 (A) only for accidental death or dismemberment;
3-1 (B) for wages or payments in lieu of wages for a
3-2 period during which an employee is absent from work because of
3-3 sickness or injury; or
3-4 (C) as a supplement to a liability insurance
3-5 policy;
3-6 (2) a small-employer plan written under Chapter 26 of
3-7 this code;
3-8 (3) a Medicare supplemental policy as defined by
3-9 Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss),
3-10 as amended;
3-11 (4) a workers' compensation insurance policy;
3-12 (5) medical payment insurance coverage provided under
3-13 a motor vehicle insurance policy; or
3-14 (6) a long-term care insurance policy, including a
3-15 nursing home fixed indemnity policy, unless the commissioner
3-16 determines that the policy provides benefit coverage so
3-17 comprehensive that the policy is a health benefit plan as described
3-18 by Subsection (a) of this section.
3-19 Sec. 3. RESTRICTIONS PROHIBITED. (a) A health benefit plan
3-20 may not include in a contract with a health care practitioner who
3-21 provides professional services to an enrollee under the plan any
3-22 provision that penalizes the health care practitioner for:
3-23 (1) referring an enrollee for additional diagnosis or
3-24 treatment by a specialist; or
3-25 (2) otherwise using the practitioner's own best
3-26 professional judgment in prescribing a particular medication,
3-27 treatment, or device for an enrollee.
4-1 (b) This section does not preclude a health benefit plan
4-2 from using utilization review in a manner that complies with
4-3 Article 21.58A of this code.
4-4 Sec. 4. ADMINISTRATIVE PENALTY. An insurance company, health
4-5 maintenance organization, or other entity that operates a health
4-6 benefit plan in violation of this article is subject to an
4-7 administrative penalty as provided by Chapter 84 of this code.
4-8 SECTION 2. Article 21.52L, Insurance Code, as added by this
4-9 Act, takes effect September 1, 2001, and applies only to an
4-10 insurance policy or evidence of coverage that is delivered, issued
4-11 for delivery, or renewed on or after January 1, 2002. A policy or
4-12 evidence of coverage that is delivered, issued for delivery, or
4-13 renewed before January 1, 2002, is governed by the law as it
4-14 existed immediately before the effective date of this Act, and that
4-15 law is continued in effect for this purpose.