83R7384 PMO-F
 
  By: Lucio S.B. No. 1347
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the operation of certain managed care plans with
  respect to health care providers.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 843.306, Insurance Code, is amended by
  adding Subsection (f) to read as follows:
         (f)  A health maintenance organization may not terminate
  participation of a physician or provider solely because the
  physician or provider informs an enrollee of the full range of
  physicians and providers available to the enrollee, including
  out-of-network providers.
         SECTION 2.  Section 843.363(a), Insurance Code, is amended
  to read as follows:
         (a)  A health maintenance organization may not, as a
  condition of a contract with a physician, dentist, or provider, or
  in any other manner, prohibit, attempt to prohibit, or discourage a
  physician, dentist, or provider from discussing with or
  communicating in good faith with a current, prospective, or former
  patient, or a person designated by a patient, with respect to:
               (1)  information or opinions regarding the patient's
  health care, including the patient's medical condition or treatment
  options;
               (2)  information or opinions regarding the terms,
  requirements, or services of the health care plan as they relate to
  the medical needs of the patient; [or]
               (3)  the termination of the physician's, dentist's, or
  provider's contract with the health care plan or the fact that the
  physician, dentist, or provider will otherwise no longer be
  providing medical care, dental care, or health care services under
  the health care plan; or
               (4)  information regarding the availability of
  facilities, both in-network and out-of-network, for the treatment
  of the patient's medical condition.
         SECTION 3.  Section 1301.001, Insurance Code, is amended by
  adding Subdivision (5-a) to read as follows:
               (5-a)  "Out-of-network provider" means a physician or
  health care provider who is not a preferred provider.
         SECTION 4.  Subchapter A, Chapter 1301, Insurance Code, is
  amended by adding Sections 1301.0057 and 1301.0058 to read as
  follows:
         Sec. 1301.0057.  ACCESS TO OUT-OF-NETWORK PROVIDERS. An
  insurer may not terminate, or threaten to terminate, an insured's
  participation in a preferred provider benefit plan solely because
  the insured uses an out-of-network provider.
         Sec. 1301.0058.  PROTECTED COMMUNICATIONS BY PREFERRED
  PROVIDERS. (a)  An insurer may not in any manner prohibit, attempt
  to prohibit, penalize, terminate, or otherwise restrict a preferred
  provider from communicating with an insured about the availability
  of out-of-network providers for the provision of the insured's
  medical or health care services.
         (b)  An insurer may not terminate the contract of or
  otherwise penalize a preferred provider solely because the
  provider's patients use out-of-network providers for medical or
  health care services.
         (c)  An insurer's contract with a preferred provider may
  require that, except in a case of a medical emergency as determined
  by the preferred provider, before the provider may make an
  out-of-network referral for an insured, the preferred provider
  inform the insured:
               (1)  that:
                     (A)  the insured may choose a preferred provider
  or an out-of-network provider; and
                     (B)  if the insured chooses the out-of-network
  provider the insured may incur higher out-of-pocket expenses; and
               (2)  whether the preferred provider has a financial
  interest in the out-of-network provider.
         SECTION 5.  Section 1301.057(d), Insurance Code, is amended
  to read as follows:
         (d)  On request, an insurer shall provide [make an expedited
  review available] to a practitioner whose participation in a
  preferred provider benefit plan is being terminated:
               (1)  an [. The] expedited review conducted in
  accordance with a process that complies [must comply] with rules
  established by the commissioner; and
               (2)  all information on which the insurer wholly or
  partly based the termination, including the economic profile of the
  preferred provider, the standards by which the provider is
  measured, and the statistics underlying the profile and standards.
         SECTION 6.  (a)  Except as provided by this section, the
  changes in law made by this Act apply only to an insurance policy,
  insurance or health maintenance organization contract, or evidence
  of coverage delivered, issued for delivery, or renewed on or after
  January 1, 2014. A policy, contract, or evidence of coverage
  delivered, issued for delivery, or renewed 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)  Sections 843.306, 843.363, and 1301.057(d), Insurance
  Code, as amended by this Act, and Section 1301.0058, Insurance
  Code, as added by this Act, apply only to a contract between a
  health maintenance organization or preferred provider benefit plan
  issuer and a physician or health care provider that is entered into
  or renewed 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 the effective date
  of this Act, and that law is continued in effect for that purpose.
         SECTION 7.  This Act takes effect September 1, 2013.