82R7383 TRH-F
By: Taylor of Galveston H.B. No. 1772
A BILL TO BE ENTITLED
AN ACT
relating to the regulation of certain exclusive provider benefit
plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1273.001(4), Insurance Code, is amended
to read as follows:
(4) "Point-of-service plan" means an arrangement
under which:
(A) an enrollee chooses to obtain benefits or
services through:
(i) a health maintenance organization
delivery network, including a limited provider network; or
(ii) a non-network delivery system outside
the health maintenance organization delivery network, including an
exclusive provider benefit plan under Chapter 1301 or a limited
provider network, that is administered under an indemnity benefit
arrangement for the cost of health care services; or
(B) indemnity benefits for the cost of health
care services are provided by an insurer or group hospital service
corporation in conjunction with network benefits arranged or
provided by a health maintenance organization.
SECTION 2. Section 1301.001, Insurance Code, is amended by
amending Subdivision (1) and adding Subdivision (1-a) to read as
follows:
(1) "Exclusive provider benefit plan" means a benefit
plan in which an insurer excludes benefits to an insured for some or
all services, other than emergency care services required under
Section 1301.155, provided by a physician or health care provider
who is not a preferred provider.
(1-a) "Health care provider" means a practitioner,
institutional provider, or other person or organization that
furnishes health care services and that is licensed or otherwise
authorized to practice in this state. The term does not include a
physician.
SECTION 3. Section 1301.003, Insurance Code, is amended to
read as follows:
Sec. 1301.003. PREFERRED PROVIDER BENEFIT PLANS AND
EXCLUSIVE PROVIDER BENEFIT PLANS PERMITTED. A preferred provider
benefit plan or an exclusive provider benefit plan [health
insurance policy that provides different benefits from the basic
level of coverage for the use of preferred providers and] that meets
the requirements of this chapter is not:
(1) unjust under Chapter 1701;
(2) unfair discrimination under Subchapter A or B,
Chapter 544; or
(3) a violation of Subchapter B or C, Chapter 1451.
SECTION 4. Section 1301.0041, Insurance Code, is amended to
read as follows:
Sec. 1301.0041. APPLICABILITY. (a) Except as otherwise
specifically provided by this chapter, this [This] chapter applies
to each [any] preferred provider benefit plan in which an insurer
provides, through the insurer's health insurance policy, for the
payment of a level of coverage that is different from the basic
level of coverage provided by the health insurance policy if the
insured uses a preferred provider.
(b) Unless otherwise specified, an exclusive provider
benefit plan is subject to this chapter in the same manner as a
preferred provider benefit plan.
SECTION 5. Subchapter A, Chapter 1301, Insurance Code, is
amended by adding Section 1301.0042 to read follows:
Sec. 1301.0042. APPLICABILITY OF INSURANCE LAW. A
provision of this code or another insurance law of this state that
applies to a preferred provider benefit plan applies to an
exclusive provider benefit plan to the extent that the commissioner
determines the provision to be consistent with the function and
purpose of an exclusive provider benefit plan.
SECTION 6. Section 1301.0045, Insurance Code, is amended to
read as follows:
Sec. 1301.0045. CONSTRUCTION OF CHAPTER. (a) Except as
provided by Section 1301.0046, this chapter may not be construed to
limit the level of reimbursement or the level of coverage,
including deductibles, copayments, coinsurance, or other
cost-sharing provisions, that are applicable to preferred
providers or, for plans other than exclusive provider benefit
plans, nonpreferred providers.
(b) Except as provided by Section 1301.155, this chapter may
not be construed to require an exclusive provider benefit plan to
compensate a nonpreferred provider for services provided to an
insured.
SECTION 7. Section 1301.0046, Insurance Code, is amended to
read as follows:
Sec. 1301.0046. COINSURANCE REQUIREMENTS FOR SERVICES OF
NONPREFERRED PROVIDERS. The insured's coinsurance applicable to
payment to nonpreferred providers may not exceed 50 percent of the
total covered amount applicable to the medical or health care
services. This section does not apply to an exclusive provider
benefit plan.
SECTION 8. Section 1301.005, Insurance Code, is amended by
adding Subsection (d) to read as follows:
(d) This section does not apply to an exclusive provider
benefit plan.
SECTION 9. The change in law made by this Act applies only
to an exclusive provider benefit plan that is delivered, issued for
delivery, or renewed on or after January 1, 2012. An exclusive
provider benefit plan that is delivered, issued for delivery, or
renewed before January 1, 2012, is governed by the law as it existed
immediately before the effective date of this Act, and that law is
continued in effect for that purpose.
SECTION 10. This Act takes effect September 1, 2011.