82R4095 PMO-F
By: Hancock H.B. No. 1393
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 1301.0051 and 1301.0052 to read as
follows:
Sec. 1301.0051. 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. 1301.0052. 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, 2012. A policy, contract, or evidence of coverage issued
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 1301.0052, 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, 2011.