HBA-NMO H.B. 96 76(R) BILL ANALYSIS
Office of House Bill AnalysisH.B. 96
By: Reyna, Arthur
Insurance
2/8/1999
Introduced
BACKGROUND AND PURPOSE
Currently, health benefit plans may require an enrollee to receive a
referral from the enrollee's primary care physician in order to see a
specialist physician. This type of system may extend the time to increase
treatment and the expense of treatment. H.B. 96 authorizes enrollees in
certain health benefit plans to have direct access to a specialist
physician.
RULEMAKING AUTHORITY
It is the opinion of the Office of House Bill Analysis that rulemaking
authority is expressly delegated to the Commissioner of Insurance in
SECTION 1 (Section 6, Article 21.53Y, Insurance Code) of this bill.
SECTION BY SECTION ANALYSIS
SECTION 1. Amends Subchapter E, Chapter 21, Insurance Code, by adding
Article 21.53Y, as follows:
Article 21.53Y. ACCESS TO SPECIALTY HEALTH CARE SERVICES
Sec. 1. DEFINITIONS. Defines "enrollee," "health benefit plan," and
"physician."
Sec. 2. SCOPE OF ARTICLE. (a) Sets forth that this article applies to a
health benefit plan (plan) that:
(1) is an insurance policy or agreement, a group hospital service contract,
or individual or group evidence of coverage offered by an insurance
company, a group hospital service corporation (Chapter 20, Insurance Code),
a fraternal benefit society (Chapter 10, Insurance Code), a stipulated
premium insurance company (Chapter 22, Insurance Code), a health
maintenance organization (Chapter 20A, Insurance Code); and to the extent
permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C.
Section 1001 et seq.), a plan that is offered by a multiple employer
welfare arrangement or another similar benefit arrangement;
(2) is offered by an approved nonprofit health corporation that is
certified under Section 5.01(a), Medical Practice Act (Article 4495b,
V.T.C.S., Certification of Certain Organizations), and that holds a
certificate of authority issued by the Commissioner of Insurance
(commissioner) under Article 21.52F, Insurance Code (Certification of
Certain Nonprofit Health Corporations); or
(3) is offered by any other non-licensed entity that contracts directly for
health care services on a risk-sharing basis, including an entity that
contracts for health care services on a capitation basis.
(b) Sets forth that this article applies to health and accident coverage by
a risk pool created under Chapter 172, Local Government Code (Texas
Political Subdivisions Uniform Group Benefits Program), notwithstanding
Section 172.014, Local Government Code. Section 172.014 states that a risk
pool created under Chapter 172 is not insurance or an insurer under the
laws of this state.
(c) Provides that this article does not apply to:
(1) a plan that provides coverage only for a specified disease; only for
accidental death or dismemberment; for lost wages due to sickness or
injury; or as a supplement to liability insurance;
(2) a plan written under Chapter 26, Insurance Code (Health Insurance
Availability);
(3) a Medicare supplement policy as defined by Section 1882(g)(1), Social
Security Act (42 U.S.C. Section 1395ss, Certification of medicare
supplemental health insurance policies);
(4) workers' compensation insurance coverage;
(5) medical payment insurance issued as a part of a motor vehicle insurance
policy; or
(6) 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).
Sec. 3. ACCESS OF ENROLLEE TO SPECIALTY HEALTH CARE SERVICES. (a)
Authorizes an enrollee, who has received a diagnosis from a physician of a
disease or condition the treatment of which falls within the scope of a
professional specialty practice, to select, in addition to a primary care
physician, a properly credentialed specialist physician (specialist) to
provide services under the health benefit plan within the scope of that
specialty. Provides that this section does not preclude an enrollee from
selecting a family, internal medicine, or other qualified physician to
provide that care.
(b) Provides that a plan that does not include a specialist who is
participating in the plan and within whose specialty an enrollee's disease
or condition falls must permit the enrollee to select a specialist who is
not a participating physician under the plan and provide benefits for the
services of that specialist at the same level as would be provided for the
services of a participating physician.
Sec. 4. DIRECT ACCESS TO SPECIALITY HEALTH CARE SERVICES. (a) Provides
that a plan must permit an enrollee who selects a specialist under Section
3 direct access to the services of the specialist without referral by the
enrollee's primary care physician or prior authorization or
precertification from the plan.
(b) Provides that access to health care service required under this article
includes diagnosis, treatment, and referral for any disease or condition
within the scope of a physician's specialty practice.
(c) Prohibits a plan from imposing a copayment or deductible for direct
access to the services of a specialist under this article unless an
additional cost is imposed for access to other health care services
provided under the plan.
(d) Provides that this section does not affect the authority of a plan to
require the selected specialist to forward information concerning the
medical care of the patient to the primary care physician. Prohibits the
plan from imposing any financial or other penalty on the specialist or the
enrollee because the specialist fails to provide this information if the
specialist has made a reasonable and good faith effort to provide the
information to the primary care physician.
(e) Prohibits a plan from sanctioning or terminating a primary care
physician as a result of enrollee's access to specialists under this
article.
Sec. 5. NOTICE. Requires a person operating a plan to provide each
enrollee a timely written notice in clear and accurate language of the
direct access requirements of this article.
Sec. 6. RULES. Requires the commissioner to adopt rules as necessary to
implement this article.
Sec. 7. ADMINISTRATIVE PENALTY. Provides that a person who operates a
plan in violation of this article is subject to an administrative penalty
under Article 1.10E, Insurance Code (Administrative Penalties).
SECTION 2. Effective date: September 1, 1999.
Makes application of this Act prospective beginning
January 1, 2000.
SECTION 3. Emergency clause.