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A BILL TO BE ENTITLED
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AN ACT
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relating to the operation of certain managed care plans with |
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respect to certain physicians and health care providers; amending |
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provisions subject to a criminal penalty. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter A, Chapter 843, Insurance Code, is |
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amended by adding Section 843.010 to read as follows: |
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Sec. 843.010. APPLICABILITY OF CERTAIN PROVISIONS TO |
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GOVERNMENTAL HEALTH BENEFIT PLANS. Sections 843.306(f) and |
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843.363(a)(4) do not apply to coverage under: |
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(1) the child health plan program under Chapter 62, |
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Health and Safety Code, or the health benefits plan for children |
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under Chapter 63, Health and Safety Code; or |
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(2) a Medicaid program, including a Medicaid managed |
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care program operated under Chapter 533, Government Code. |
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SECTION 2. Section 843.306, Insurance Code, is amended by |
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adding Subsection (f) to read as follows: |
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(f) A health maintenance organization may not terminate |
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participation of a physician or provider solely because the |
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physician or provider informs an enrollee of the full range of |
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physicians and providers available to the enrollee, including |
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out-of-network providers. |
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SECTION 3. Section 843.363, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsection (a-1) to read as |
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follows: |
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(a) A health maintenance organization may not, as a |
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condition of a contract with a physician, dentist, or provider, or |
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in any other manner, prohibit, attempt to prohibit, or discourage a |
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physician, dentist, or provider from discussing with or |
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communicating in good faith with a current, prospective, or former |
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patient, or a person designated by a patient, with respect to: |
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(1) information or opinions regarding the patient's |
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health care, including the patient's medical condition or treatment |
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options; |
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(2) information or opinions regarding the terms, |
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requirements, or services of the health care plan as they relate to |
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the medical needs of the patient; [or] |
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(3) the termination of the physician's, dentist's, or |
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provider's contract with the health care plan or the fact that the |
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physician, dentist, or provider will otherwise no longer be |
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providing medical care, dental care, or health care services under |
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the health care plan; or |
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(4) information regarding the availability of |
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facilities, both in-network and out-of-network, for the treatment |
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of the patient's medical condition. |
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(a-1) A health maintenance organization may not, as a |
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condition of payment with a physician, dentist, or provider, or in |
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any other manner, require a physician, dentist, or provider to |
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provide a notification form stating that the physician, dentist, or |
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provider is an out-of-network provider to a current, prospective, |
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or former patient, or a person designated by the patient, if the |
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form contains additional information that is intended, or is |
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otherwise required to be presented in a manner that is intended, to |
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intimidate the patient. |
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SECTION 4. Section 1301.001, Insurance Code, is amended by |
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adding Subdivision (5-a) to read as follows: |
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(5-a) "Out-of-network provider" means a physician or |
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health care provider who is not a preferred provider. |
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SECTION 5. Subchapter A, Chapter 1301, Insurance Code, is |
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amended by adding Sections 1301.0057 and 1301.0058 to read as |
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follows: |
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Sec. 1301.0057. ACCESS TO OUT-OF-NETWORK PROVIDERS. An |
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insurer may not terminate, or threaten to terminate, an insured's |
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participation in a preferred provider benefit plan solely because |
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the insured uses an out-of-network provider. |
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Sec. 1301.0058. PROTECTED COMMUNICATIONS BY PREFERRED |
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PROVIDERS. (a) An insurer may not in any manner prohibit, attempt |
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to prohibit, penalize, terminate, or otherwise restrict a preferred |
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provider from communicating with an insured about the availability |
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of out-of-network providers for the provision of the insured's |
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medical or health care services. |
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(b) An insurer may not terminate the contract of or |
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otherwise penalize a preferred provider solely because the |
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provider's patients use out-of-network providers for medical or |
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health care services. |
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(c) An insurer's contract with a preferred provider may |
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require that, except in a case of a medical emergency as determined |
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by the preferred provider, before the provider may make an |
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out-of-network referral for an insured, the preferred provider |
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inform the insured: |
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(1) that: |
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(A) the insured may choose a preferred provider |
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or an out-of-network provider; and |
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(B) if the insured chooses the out-of-network |
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provider the insured may incur higher out-of-pocket expenses; and |
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(2) whether the preferred provider has a financial |
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interest in the out-of-network provider. |
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SECTION 6. Section 1301.057(d), Insurance Code, is amended |
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to read as follows: |
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(d) On request, an insurer shall provide [make an expedited
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review available] to a practitioner whose participation in a |
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preferred provider benefit plan is being terminated: |
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(1) an [. The] expedited review conducted in |
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accordance with a process that complies [must comply] with rules |
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established by the commissioner; and |
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(2) all information on which the insurer wholly or |
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partly based the termination, including the economic profile of the |
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preferred provider, the standards by which the provider is |
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measured, and the statistics underlying the profile and standards. |
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SECTION 7. Section 1301.067, Insurance Code, is amended by |
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adding Subsection (a-1) to read as follows: |
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(a-1) An insurer may not, as a condition of payment with a |
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physician or health care provider or in any other manner, require a |
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physician or health care provider to provide a notification form |
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stating that the physician or health care provider is an |
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out-of-network provider to a current, prospective, or former |
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patient, or a person designated by the patient, if the form contains |
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additional information that is intended, or is otherwise required |
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to be presented in a manner that is intended, to intimidate the |
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patient. |
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SECTION 8. (a) Except as provided by this section, the |
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changes in law made by this Act apply only to an insurance policy, |
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insurance or health maintenance organization contract, or evidence |
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of coverage delivered, issued for delivery, or renewed on or after |
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January 1, 2016. A policy, contract, or evidence of coverage |
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delivered, issued for delivery, or renewed before that date is |
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governed by the law in effect immediately before the effective date |
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of this Act, and that law is continued in effect for that purpose. |
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(b) Sections 843.306, 843.363, and 1301.057(d), Insurance |
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Code, as amended by this Act, and Section 1301.0058, Insurance |
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Code, as added by this Act, apply only to a contract between a |
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health maintenance organization or insurer and a physician or |
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health care provider that is entered into or renewed on or after the |
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effective date of this Act. A contract entered into or renewed |
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before the effective date of this Act is governed by the law as it |
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existed immediately before the effective date of this Act, and that |
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law is continued in effect for that purpose. |
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SECTION 9. This Act takes effect September 1, 2015. |
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