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Amend HB 1951 (house committee printing) by adding the following appropriately numbered ARTICLE to the bill and renumbering subsequent ARTICLES of the bill accordingly:
ARTICLE ___. SELECTION OF PRIMARY CARE PHYSICIANS AND PROVIDERS UNDER PREFERRED PROVIDER BENEFIT PLANS AND HEALTH MAINTENANCE ORGANIZATIONS
SECTION __.001. Section 843.203, Insurance Code, is amended by amending Subsection (b) and adding Subsections (d), (e), (f), (g), and (h) to read as follows:
(b) An enrollee shall at all times have the right to select or change a primary care physician or primary care provider within the health maintenance organization network of available primary care physicians and primary care providers[, except that a health maintenance organization may limit an enrollee's request to change physicians or providers to not more than four changes in a 12-month period]. An enrollee may designate any participating primary care physician or primary care provider who is available to accept the individual.
(d) For an enrollee who is a child, the health maintenance organization must allow the child's parent or guardian to designate as the child's primary care physician or primary care provider a participating physician who specializes in pediatrics.
(e) A health maintenance organization shall notify each enrollee of the enrollee's rights under Subsections (b) and (d).
(f) In the case of group health coverage, the notice described in Subsection (e) must be included whenever the health maintenance organization provides an enrollee with a summary plan description or other similar description of benefits under the health care plan.
(g) In the case of individual health coverage, the notice described in Subsection (e) must be included whenever the health maintenance organization plan provides an enrollee with a certificate or contract for the health care plan.
(h) A health maintenance organization may use the model language in 45 C.F.R. Section 147.138(a)(4)(iii) to satisfy the requirements of Subsections (e), (f), and (g).
SECTION __.002. Subchapter D, Chapter 1301, Insurance Code, is amended by adding Section 1301.164 to read as follows:
Sec. 1301.164. SELECTION OF PRIMARY CARE PHYSICIAN OR PROVIDER. (a) If a preferred provider benefit plan requires or provides for designation by an insured of a participating primary care physician or primary care provider, the insurer shall allow an insured to designate any participating primary care physician or primary care provider who is available to accept the individual.
(b) For an enrollee who is a child, the insurer must allow the child's parent or guardian to designate as the child's primary care physician or primary care provider a participating physician who specializes in pediatrics.
(c) An insurer shall notify each insured of the insured's rights under this section.
(d) In the case of group health insurance coverage, the notice described in Subsection (c) must be included whenever the health insurer provides a participant with a summary plan description or other similar description of benefits under the health benefit plan.
(e) In the case of individual health insurance coverage, the notice described in Subsection (c) must be included whenever the health insurer provides a primary insured with a policy, certificate or contract of health insurance.
(f) An insurer may use the model language in 45 C.F.R. Section 147.138(a)(4)(iii) to satisfy the requirements of Subsections (c), (d), and (e).
SECTION __.003. The changes in law to Section 843.203(b), Insurance Code, as amended by this Article, and Sections 843.203(d), (e), (g), and (h), and Section 1301.164, Insurance Code, as added by this Article, apply only to a health insurance policy or contract or health maintenance organization contract or agreement that is delivered or issued for delivery on or after January 1, 2012. An insurance policy or contract or health maintenance organization contract or agreement that is delivered or issued for delivery before January 1, 2012, is governed by the law as it existed immediately before the effective date of this Act, and that law is continued in effect for that purpose.