| |
| |
|
|
A BILL TO BE ENTITLED
|
|
|
AN ACT
|
|
|
relating to specialist referrals by primary care providers for |
|
|
certain managed care health benefit plans. |
|
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
|
SECTION 1. Subtitle C, Title 8, Insurance Code, is amended |
|
|
by adding Chapter 1276 to read as follows: |
|
|
CHAPTER 1276. REFERRAL REQUIREMENTS |
|
|
Sec. 1276.001. APPLICABILITY OF CHAPTER. (a) This chapter |
|
|
applies only to a health benefit plan, including a plan provided by |
|
|
a health maintenance organization operating under Chapter 843, that |
|
|
requires a primary care physician or other participating health |
|
|
care provider to provide a referral to an enrollee as a condition of |
|
|
payment or for the enrollee to receive a network benefit. |
|
|
(b) Notwithstanding any other law, this chapter applies to: |
|
|
(1) a basic coverage plan under Chapter 1551; |
|
|
(2) a basic plan under Chapter 1575; and |
|
|
(3) a primary care coverage plan under Chapter 1579. |
|
|
Sec. 1276.002. EXCEPTION. This chapter does not apply to a |
|
|
Medicaid managed care program operated under Chapter 540, |
|
|
Government Code. |
|
|
Sec. 1276.003. SPECIALIST REFERRALS. (a) An issuer or |
|
|
administrator of a managed care plan that requires an enrollee to |
|
|
obtain a referral from a primary care provider before receiving |
|
|
health care services from a specialist shall accept a referral from |
|
|
the provider for the plan if: |
|
|
(1) the enrollee has had at least one visit with the |
|
|
provider before the provider made the referral; and |
|
|
(2) the referral is for treatment of a chronic or |
|
|
ongoing condition. |
|
|
(b) Notwithstanding Subsection (a), a managed care plan |
|
|
issuer or administrator may refuse to accept a referral from a |
|
|
primary care provider for specialist services if: |
|
|
(1) more than three years have passed since the |
|
|
provider made the referral; |
|
|
(2) the provider has withdrawn the referral; |
|
|
(3) the enrollee's primary care provider has changed |
|
|
since the referral was made; or |
|
|
(4) the enrollee's managed care plan issuer or |
|
|
administrator has changed since the referral was made. |
|
|
SECTION 2. The changes in law made by this Act apply only to |
|
|
a health benefit plan that is delivered, issued for delivery, or |
|
|
renewed on or after January 1, 2026. |
|
|
SECTION 3. This Act takes effect September 1, 2025. |