83R9808 AJA-D

By: West S.B. No. 1118

A BILL TO BE ENTITLED

AN ACT

relating to access to specialist physicians under managed care health benefit plans.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Chapter 1451, Insurance Code, is amended by adding Subchapter J to read as follows:

SUBCHAPTER J. ACCESS TO SPECIALIST PHYSICIAN UNDER MANAGED CARE

PLAN

Sec. 1451.451. DEFINITION. In this subchapter, "enrollee" means an individual enrolled in a health benefit plan.

Sec. 1451.452. APPLICABILITY OF SUBCHAPTER. (a) This subchapter applies only to a health benefit plan that requires an enrollee to obtain certain specialty health care services through a referral made by a primary care physician or other gatekeeper and 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; or

(G) an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; 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) Notwithstanding Section 1501.251 or any other law, this subchapter applies to a small employer health benefit plan written under Chapter 1501.

Sec. 1451.453. EXCEPTION. This subchapter does not apply to:

(1) a plan that provides coverage:

(A) only for a specified disease;

(B) only for accidental death or dismemberment;

(C) for wages or payments instead of wages for a period during which an employee is absent from work because of sickness or injury; or

(D) as a supplement to a liability insurance policy;

(2) a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(3) a workers' compensation insurance policy;

(4) medical payment insurance coverage provided under a motor vehicle insurance policy; or

(5) a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1451.452.

Sec. 1451.454. ACCESS TO SPECIALIST PHYSICIAN. (a) An enrollee who has received a diagnosis from a primary care physician or another physician of a disease or condition the treatment of which falls within the scope of a professional specialty practice may select, in addition to a primary care physician, a properly credentialed specialist physician to provide under the health benefit plan health care services within the scope of that specialty practice. This section does not preclude an enrollee from selecting a family physician, internal medicine physician, or other qualified physician to provide that care.

(b) A health benefit plan that does not include a properly credentialed specialist physician who is participating in the plan and within whose professional specialty practice an enrollee's disease or condition falls must:

(1) permit the enrollee to select a properly credentialed specialist physician who is not a participating physician under the plan; and

(2) provide benefits for the services of that specialist physician at the same level as would be provided for the services of a participating physician.

Sec. 1451.455. DIRECT ACCESS TO SPECIALTY HEALTH CARE SERVICES. (a) In addition to other benefits authorized by a health benefit plan, the plan must permit an enrollee who selects a specialist physician under Section 1451.454 direct access to the health care services of the designated specialist without a referral by the enrollee's primary care physician or prior authorization or precertification from the plan.

(b) The access to health care services required under this subchapter includes diagnosis, treatment, and referral for any disease or condition within the scope of a physician's professional specialty practice.

(c) A health benefit plan may not impose a copayment or deductible for direct access to the health care services of a specialist physician under this subchapter unless an additional cost is imposed for access to other health care services provided under the plan.

SECTION 2. Section 1507.004, Insurance Code, is amended by adding Subsection (c) to read as follows:

(c) A standard health benefit plan that requires an enrollee to obtain specialty health care services through a referral made by a primary care physician or other gatekeeper must include coverage for direct access to a specialist physician as required by Subchapter J, Chapter 1451.

SECTION 3. Section 1507.054, Insurance Code, is amended to read as follows:

Sec. 1507.054. STANDARD HEALTH BENEFIT PLANS AUTHORIZED; MINIMUM REQUIREMENT. (a) A health maintenance organization authorized to issue an evidence of coverage in this state may offer one or more standard health benefit plans.

(b) A standard health benefit plan offered by a health maintenance organization must include coverage for direct access to a specialist physician as required by Subchapter J, Chapter 1451.

SECTION 4. The change in law made by this Act applies only to a health benefit plan delivered, issued for delivery, or renewed on or after January 1, 2014.

SECTION 5. This Act takes effect September 1, 2013.