HBA-DMD H.B. 190 76(R) BILL ANALYSIS Office of House Bill AnalysisH.B. 190 By: Longoria Insurance 2/5/1999 Introduced BACKGROUND AND PURPOSE Currently, health care practitioners who refer patients for additional diagnosis or treatment by a specialist or for using their own best judgment in prescribing certain medications, treatments, or devices, have had deductions from their bonuses for doing so. H.B. 190 prohibits a health benefit plan from including a contract that would prohibit a health care practitioner from referring patients for additional diagnosis or treatment or for using their own best judgment in prescribing medication or treatment, and subjects any entity violating that prohibition to an administrative penalty. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that this bill does not expressly delegate any additional rulemaking authority to a state officer, department, agency, or institution. SECTION BY SECTION ANALYSIS SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding Article 21.52L, as follows: Article 21.52L. RESTRICTIONS BY INSURERS ON PERFORMANCE OF CERTAIN PROFESSIONAL HEALTH CARE SERVICES PROHIBITED Sec. 1. DEFINITIONS. Defines "enrollee," "health benefit plan," and "health care practitioner." Sec. 2. SCOPE OF ARTICLE. (a) Specifies that this article applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including: (1) an individual, group, blanket, or franchise insurance policy or insurance agreement, group hospital service contract, or an individual or group evidence of coverage that is offered by: an insurance company; a group hospital service corporation operating under Chapter 20 (Group Hospital Service) of this code; a fraternal benefit society operating under Chapter 10 (Fraternal Benefit Societies) of this code; a stipulated premium insurance company operating under Chapter 22 (Stipulated Premium Insurance Companies) of this code; a health maintenance organization operating under the Texas Health Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance Code); or (2) to a health benefit plan that is offered by either a multiple employer welfare arrangement as defined by Section 3, Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1002), or an analogous benefit arrangement, to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.). Establishes that this article also applies to a health benefit plan that is offered by an approved nonprofit health corporation certified under Section 5.01(a), Medical Practice Act (Article 4495b, V.T.C.S.), holding a certificate of authority issued by the Commissioner of Insurance (commissioner) under Article 21.52F (Certification of Certain Nonprofit Health Corporations) of this code, or to a health benefit plan that is offered by any other entity not licensed under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, which includes an entity that contracts for health care services on a capitation basis. (b) Establishes that this article applies to a health benefit plan that provides coverage only for a specific disease or condition or for hospitalization. (c) Specifies that this article applies to health and accident coverage provided by a risk pool created under Chapter 172 Local Government Code (Texas Political Subdivisions Uniform Group Benefits Program), despite Section 172.014 Local Government Code (Application of Certain Laws), or any other law. (d) Establishes that this article does not apply to a plan that provides coverage solely for accidental death or dismemberment, or for wages or payment in place of wages for a period when an employee is absent from work because of sickness or injury, or to a plan that provides coverage as a supplement to liability insurance. Specifies that this article does not apply to a small-employer plan written under Chapter 26 (Health Insurance Availability) of this code, a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss), workers' compensation insurance coverage, medical payment insurance issued as part of a motor vehicle insurance policy, or a long-term care 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 Subsection (a) of this section. Sec. 3. RESTRICTIONS PROHIBITED. Prohibits a health benefit plan from including provisions that penalize a health care practitioner for referring an enrollee to a specialist for additional diagnosis or treatment, or for using the practitioner's best professional judgment in prescribing a particular medication, treatment, or device for use by an enrollee. Establishes that this section does not preclude a health benefit plan from using a utilization review consistent with Article 21.58A of this code (Health Care Utilization Review Agents). Sec. 4. ADMINISTRATIVE PENALTY. Provides that an insurance company, health maintenance organization, or other entity that operates a health benefit plan in violation of this article is subject to an administrative penalty as provided by Article 1.10E (Administrative Penalties) of this code. SECTION 2. Effective date: September 1, 1999. Makes application of this Act prospective from January 1, 2000. SECTION 3. Emergency clause.