79R5865 PB-D

By:  Smith of Tarrant                                             H.B. No. 3188



A BILL TO BE ENTITLED

AN ACT

relating to provision of health care services by health maintenance 
organizations and preferred provider benefit plans.
	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:                        
	SECTION 1.  Section 843.101, Insurance Code, is amended by 
adding Subsection (e) to read as follows:
	(e)  In providing or arranging for the provision of health 
care services, each health maintenance organization shall make all 
reasonable efforts to ensure that the organization's  network 
includes physicians and providers under contract with the 
organization in numbers sufficient to provide services to enrollees 
through those network physicians and providers.  The health 
maintenance organization must provide reasonable notice to its 
enrollees, in the manner prescribed by the commissioner, regarding:
		(1)  the efforts of the health maintenance organization 
to ensure the availability to its enrollees of a sufficient number 
of network physicians and providers to provide health care services 
to those enrollees; and
		(2)  the rights of enrollees under Section 843.361.                    
	SECTION 2.  Section 843.361, Insurance Code, is amended to 
read as follows:  
	Sec. 843.361.  ENROLLEES HELD HARMLESS.  (a) A contract or 
other agreement between a health maintenance organization and a 
physician or provider must specify that the physician or provider 
will hold an enrollee harmless for payment of the cost of covered 
health care services if the health maintenance organization does 
not pay the physician or provider for those services.
	(b)  A non-network physician or provider may not charge an 
enrollee for a portion of a bill for health care services provided 
to the enrollee in a hospital that is a member of the health 
maintenance organization's network that is not paid by the health 
maintenance organization unless the physician or provider notifies 
the enrollee, in the manner prescribed by commissioner rule and 
before services are provided, that the physician or provider is not 
a member of the network.
	SECTION 3.  Subchapter D, Chapter 1301, Insurance Code, as 
effective April 1, 2005, is amended by adding Sections 1301.163 and 
1301.164 to read as follows:
	Sec. 1301.163.  PROVIDING OR ARRANGING FOR CARE.  In 
providing or arranging for the provision of health care services, 
each insurer offering a preferred provider benefit plan shall make 
all reasonable efforts to ensure that the preferred provider 
network includes physicians and health care providers under 
contract with the insurer in numbers sufficient to provide services 
to insureds through those network physicians and providers.  The 
insurer must provide reasonable notice to its insureds, in the 
manner prescribed by the commissioner, regarding:
		(1)  the efforts of the insurer to ensure the 
availability to its insureds in a preferred provider plan of a 
sufficient number of network physicians and health care providers 
to provide health care services to those insureds; and
		(2)  the rights of insureds under Section 1301.164.                    
	Sec. 1301.164.  INSURED HELD HARMLESS.  A nonpreferred 
provider may not charge an insured for a portion of a bill for 
medical care or health care services provided to the insured in a 
hospital that is a preferred provider that are not paid by the 
insurer unless the nonpreferred provider notifies the insured, in 
the manner prescribed by commissioner rule and before services are 
provided, that the provider is not a member of the insured's 
preferred provider benefit plan.
	SECTION 4.  This Act takes effect immediately if it receives 
a vote of two-thirds of all the members elected to each house, as 
provided by Section 39, Article III, Texas Constitution.  If this 
Act does not receive the vote necessary for immediate effect, this 
Act takes effect September 1, 2005.