79R1016 KCR-D
By: Averitt S.B. No. 469
A BILL TO BE ENTITLED
AN ACT
relating to time and cost limitations in certain contracts offered
by a health maintenance organization.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 2, Article 3.80, Insurance Code, is
amended by amending Subdivision (2) and adding Subdivision (3) to
read as follows:
(2) "Standard health benefit plan" means an accident
or sickness insurance policy that, in whole or in part, does not
offer or provide state-mandated health benefits, but that provides
creditable coverage as defined by Section 1205.004 [Article
26.035(a)] of this code [or Section 1(H)(4)(b), Chapter 397, Acts
of the 54th Legislature, Regular Session, 1955 (Article 3.70-1,
Vernon's Texas Insurance Code)].
(3) "Exclusive provider benefit plan" means a health
benefit plan offered by a health carrier that:
(A) arranges for or provides benefits to covered
persons through a network of exclusive providers; and
(B) limits or excludes, except in cases of
emergency or approved referral, benefits to covered persons for
services provided by a provider who is not part of the network of
exclusive providers.
SECTION 2. Section 4, Article 3.80, Insurance Code, is
amended by adding Subsection (c) to read as follows:
(c) A health carrier offering a standard health benefit plan
may offer an exclusive provider benefit plan. The following
sections of this code do not apply to an exclusive provider benefit
plan offered under this subsection:
(1) Chapter 1301;
(2) Subchapter C, Chapter 1451; and
(3) Sections 1451.053 and 1451.054.
SECTION 3. Section 1271.151, Insurance Code, is amended to
read as follows:
Sec. 1271.151. PROVISION OF BASIC HEALTH CARE
SERVICES. (a) A health maintenance organization that offers a
basic health care plan shall provide or arrange for basic health
care services to its enrollees as needed and may impose limitations
[without limitation] as to time and cost [other than any limitation
prescribed by rule of the commissioner].
(b) A health maintenance organization may:
(1) impose on enrollees copayment or coinsurance
charges for arranging to provide:
(A) any single care service to its enrollees; or
(B) in the aggregate, all basic health care
services to enrollees; or
(2) charge enrollees a deductible or coinsurance
requirement for a basic, limited, or single health care service.
(c) The commissioner may adopt reasonable copayment,
deductible, and coinsurance restrictions for health benefit plans
offered by a health maintenance organization in amounts or
percentages not to exceed similar restrictions adopted for
preferred provider benefit plans.
SECTION 4. Section 1501.255, Insurance Code, is amended by
adding Subsections (d), (e), and (f) to read as follows:
(d) A health maintenance organization may:
(1) impose on enrollees of a health benefit plan
offered by a health maintenance organization under Subsection
(b)(1) copayment or coinsurance charges for arranging to provide:
(A) any single care service to enrollees of the
health benefit plan; or
(B) in the aggregate, all basic health care
services to enrollees of the health benefit plan; or
(2) charge enrollees of a health benefit plan offered
by a health maintenance organization under Subsection (b)(1) a
deductible or coinsurance requirement for a basic, limited, or
single health care service.
(e) A health benefit plan offered by a health maintenance
organization under Subsection (b)(1) is not subject to any
restrictions or limitations on cost sharing.
(f) The commissioner may adopt reasonable copayment,
deductible, and coinsurance restrictions for health benefit plans
offered by a health maintenance organization under Subsection
(b)(1) in amounts or percentages not to exceed similar restrictions
adopted for preferred provider benefit plans.
SECTION 5. The changes in law made by this Act in amending
Section 1271.151, Insurance Code, apply only to a health
maintenance organization authorized to engage in business in this
state on or after the effective date of this Act. A health
maintenance organization authorized to engage in business in this
state before the effective date of this Act is governed by the law
in effect at the time the health maintenance organization is
authorized to engage in business in this state, and that law is
continued in effect for that purpose.
SECTION 6. The changes in law made by this Act in amending
Section 1501.255, Insurance Code, apply only to a health benefit
plan the contract or evidence of coverage for which is delivered,
issued for delivery, or renewed on or after the effective date of
this Act. A health benefit plan, the contract or evidence of
coverage for which is delivered, issued for delivery, or renewed
before the effective date of this Act, is covered by the law in
effect at the time the contract or evidence of coverage is
delivered, issued for delivery, or renewed, and that law is
continued in effect for that purpose.
SECTION 7. This Act takes effect April 1, 2005, if this Act
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 effect on April
1, 2005, this Act takes effect September 1, 2005.