79R9386 T

By:  Smithee                                                      H.B. No. 2299



A BILL TO BE ENTITLED

AN ACT
	relating to the payment of physicians and providers who do 
not have contractual relationships with a preferred provider 
benefit plan or a health maintenance organization.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:                        
	SECTION 1.  Subchapter A, Chapter 1301, Insurance Code, 
Section 1301.005, as effective April 1, 2005 is amended to read as 
follows:
	§ 1301.005.  AVAILABILITY OF PREFERRED PROVIDERS.  (a)  An 
insurer offering a preferred provider benefit plan shall ensure 
that both preferred provider benefits and basic level benefits are 
reasonably available to all insureds within a designated service 
area.
	(b)  If services are not available through a preferred 
provider within the service area or if services are provided by 
nonpreferred providers within a preferred provider hospital, an 
insurer shall reimburse a physician or health care provider who is 
not a preferred provider at the same percentage level of 
reimbursement as a preferred provider would have been reimbursed 
had the insured been treated by a preferred provider.
	(c)  Subsection (b) does not require reimbursement at a 
preferred level of coverage solely because an insured resides out 
of the service area and chooses to receive services from a provider 
other than a preferred provider for the insured's own convenience.
	(d)  Reimbursement for services provided by a nonpreferred 
provider pursuant to this section shall be calculated based solely 
upon the unadjusted amount as submitted on the claim by the 
nonpreferred provider.
	SECTION 2.  Subchapter D, Chapter 1271, Insurance Code, 
Section 1271.055, as effective April 1, 2005 is amended to read as 
follows:
	§ 1271.055.  OUT-OF-NETWORK SERVICES.  (a)  An evidence of 
coverage must contain a provision regarding non-network physicians 
and providers in accordance with the requirements of this section.
	(b)  If medically necessary covered services are not 
available through network physicians or providers, the health 
maintenance organization, on the request of a network physician or 
provider and within a reasonable period, shall:
		(1)  allow referral to a non-network physician or 
provider; and             
		(2)  fully reimburse the non-network physician or 
provider the amount as submitted on the claim by the non-network 
physician or provider [at the usual and customary rate or at an 
agreed rate].
	(c)  Before denying a request for a referral to a non-network 
physician or provider, a health maintenance organization must 
provide for a review conducted by a specialist of the same or 
similar type of specialty as the physician or provider to whom the 
referral is requested.
	(d)  If medical services are provided by a non-network 
physician or provider within a network provider hospital, the 
health maintenance organization shall fully reimburse the 
non-network physician or provider the amount as submitted on the 
claim by the non-network physician or provider.
	SECTION 3.  Subchapter D, Chapter 1271, Insurance Code, 
Section 1271.155, as effective April 1, 2005 is amended to read as 
follows:
	Sec. 1271.155.  EMERGENCY CARE.  (a)  A health maintenance 
organization shall pay for emergency care performed by non-network 
physicians or providers at the amount submitted on a claim by a 
non-network physician or provider. [usual and customary rate or at 
an agreed rate.]
	(b)  A health care plan of a health maintenance organization 
must provide the following coverage of emergency care:
		(1)  a medical screening examination or other 
evaluation required by state or federal law necessary to determine 
whether an emergency medical condition exists shall be provided to 
covered enrollees in a hospital emergency facility or comparable 
facility;
		(2)  necessary emergency care shall be provided to 
covered enrollees, including the treatment and stabilization of an 
emergency medical condition; and
		(3)  services originated in a hospital emergency 
facility or comparable facility following treatment or 
stabilization of an emergency medical condition shall be provided 
to covered enrollees as approved by the health maintenance 
organization, subject to Subsections (c) and (d).
	(c)  A health maintenance organization shall approve or deny 
coverage of poststabilization care as requested by a treating 
physician or provider within the time appropriate to the 
circumstances relating to the delivery of the services and the 
condition of the patient, but not to exceed one hour from the time 
of the request.
	(d)  A health maintenance organization shall respond to 
inquiries from a treating physician or provider in compliance with 
this provision in the health care plan of the health maintenance 
organization.
	(e)  A health care plan of a health maintenance organization 
shall comply with this section regardless of whether the physician 
or provider furnishing the emergency care has a contractual or 
other arrangement with the health maintenance organization to 
provide items or services to covered enrollees.
	SECTION 4.  This Act takes effect September 1, 2005.