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Amend SB 23 (house committee printing) by inserting the
following appropriately numbered article and renumbering articles
of the bill accordingly:
ARTICLE ____. PROMOTION OF AVAILABILITY OF COVERAGE FOR
NON-NETWORK PROVIDERS
SECTION ____.01. Subtitle F, Title 8, Insurance Code, is
amended by adding Chapter 1458 to read as follows:
CHAPTER 1458. PROMOTION OF AVAILABILITY OF COVERAGE TO NON-NETWORK
HEALTH CARE PROVIDERS
Sec. 1458.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual who is eligible to
receive health care services through a health benefit plan.
(2) "Health care facility" means a hospital, emergency
clinic, outpatient clinic, or other facility providing health care
services.
(3) "Health care practitioner" means an individual who
is licensed to provide and provides health care services, including
a physician.
(4) "Health care provider" means a health care
facility or health care practitioner.
(5) "Participating provider" means a health care
provider who has a contract with a health benefit plan to provide
medical or health care services to enrollees.
(6) "Non-participating provider" means a health care
provider who does not have a contract with a health benefit plan to
provide medical or health care services to enrollees.
Sec. 1458.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies to any health benefit plan that:
(1) provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884;
(E) a health maintenance organization operating
under Chapter 843;
(F) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844;
(H) a preferred provider benefit plan operating
under Chapter 1301; or,
(I) an entity not authorized under this code or
another insurance law of this state that contracts directly for
health care services on a risk-sharing basis, including a
capitation basis; or
(2) provides health and accident coverage through a
risk pool created under Chapter 172, Local Government Code,
notwithstanding Section 172.014, Local Government Code, or any
other law.
(b) This chapter does not apply to health benefit plans that
contract with the Health and Human Services Commission for the
provision of:
(1) medical assistance under Chapter 32, Human
Resources Code; or
(2) health benefits under the state child health plan.
Sec. 1458.003. ACCESS TO NONPARTICIPATING PROVIDERS. A
health benefit plan that provides, through its health insurance
policy, for the payment of a level of coverage that is different
from a basic level of coverage provided by the health insurance
policy if the enrollee uses a participating provider:
(1) must provide a level of coverage and reimbursement
sufficient to ensure that each enrollee has reasonable access to
medical and health care provided by participating and
nonparticipating providers; and
(2) may not set a deductible, copayment, coinsurance,
or other method of cost sharing so as to deny an enrollee reasonable
access to medical and health care from nonparticipating providers.
Sec. 1458.004. HEALTH CARE PROVIDER RIGHTS. (a) A health
benefit plan may not in any manner prohibit, attempt to prohibit,
penalize, terminate, or otherwise restrict a participating
provider from discussing with or communicating with an enrollee
regarding the availability of nonparticipating providers for the
provision of the enrollee's medical or health care services.
(b) A health benefit plan may not terminate the contract of
or otherwise penalize a participating provider because the
participating provider's patients use nonparticipating providers
for medical or health care services.
(c) A participating provider who is terminated by a health
benefit plan is entitled, on request, to all information used by the
health benefit plan as reasons for the termination, including the
economic profile of the terminated participating provider, the
standards by which the terminated participating provider was
measured, and any statistics underlying any economic profiling and
standards.
(d) Notwithstanding any other law, a health benefit plan may
not use economic credentialing as a basis for refusing to contract
with a health care provider or terminating the contract of a
participating provider unless the economic credentialing
demonstrates materially higher costs incurred for patients of the
health care provider or participating provider.
(e) A health benefit plan may not enter into a contract with
a participating provider on the condition that another health care
provider be excluded from participating as a participating
provider.
(f) Notwithstanding any other law, a health care provider
may voluntarily waive a deductible, copayment, or coinsurance
established by a health benefit plan.
SECTION ____.02. (a) Section 1458.003, Insurance Code, as
added by this article, applies only to a health benefit plan
insurance policy or contract delivered, issued for delivery, or
renewed on or after January 1, 2008. A health benefit plan policy or
contract issued before that date is governed by the law in effect
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
(b) Section 1458.004, Insurance Code, as added by this
article, applies only to a contract entered into or renewed by a
health care provider and an issuer of a health benefit plan on or
after the effective date of this Act. A contract entered into or
renewed before the effective date of this Act is governed by the law
in effect immediately before that date, and that law is continued in
effect for that purpose.