| 1 | 1 | | 89R9289 SCR-D |
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| 2 | 2 | | By: Guerra H.B. No. 2320 |
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| 3 | 3 | | |
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| 4 | 4 | | |
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| 5 | 5 | | |
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| 6 | 6 | | |
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| 7 | 7 | | A BILL TO BE ENTITLED |
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| 8 | 8 | | AN ACT |
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| 9 | 9 | | relating to specialist referrals by primary care providers for |
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| 10 | 10 | | certain managed care health benefit plans. |
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| 11 | 11 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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| 12 | 12 | | SECTION 1. Subtitle C, Title 8, Insurance Code, is amended |
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| 13 | 13 | | by adding Chapter 1276 to read as follows: |
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| 14 | 14 | | CHAPTER 1276. REFERRAL REQUIREMENTS |
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| 15 | 15 | | Sec. 1276.001. APPLICABILITY OF CHAPTER. (a) This chapter |
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| 16 | 16 | | applies only to a health benefit plan, including a plan provided by |
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| 17 | 17 | | a health maintenance organization operating under Chapter 843, that |
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| 18 | 18 | | requires a primary care physician or other participating health |
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| 19 | 19 | | care provider to provide a referral to an enrollee as a condition of |
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| 20 | 20 | | payment or for the enrollee to receive a network benefit. |
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| 21 | 21 | | (b) Notwithstanding any other law, this chapter applies to: |
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| 22 | 22 | | (1) a basic coverage plan under Chapter 1551; |
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| 23 | 23 | | (2) a basic plan under Chapter 1575; and |
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| 24 | 24 | | (3) a primary care coverage plan under Chapter 1579. |
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| 25 | 25 | | Sec. 1276.002. EXCEPTION. This chapter does not apply to a |
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| 26 | 26 | | Medicaid managed care program operated under Chapter 540, |
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| 27 | 27 | | Government Code. |
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| 28 | 28 | | Sec. 1276.003. SPECIALIST REFERRALS. (a) An issuer or |
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| 29 | 29 | | administrator of a managed care plan that requires an enrollee to |
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| 30 | 30 | | obtain a referral from a primary care provider before receiving |
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| 31 | 31 | | health care services from a specialist shall accept a referral from |
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| 32 | 32 | | the provider for the plan if: |
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| 33 | 33 | | (1) the enrollee has had at least one visit with the |
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| 34 | 34 | | provider before the provider made the referral; and |
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| 35 | 35 | | (2) the referral is for treatment of a chronic or |
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| 36 | 36 | | ongoing condition. |
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| 37 | 37 | | (b) Notwithstanding Subsection (a), a managed care plan |
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| 38 | 38 | | issuer or administrator may refuse to accept a referral from a |
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| 39 | 39 | | primary care provider for specialist services if: |
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| 40 | 40 | | (1) more than three years have passed since the |
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| 41 | 41 | | provider made the referral; |
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| 42 | 42 | | (2) the provider has withdrawn the referral; |
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| 43 | 43 | | (3) the enrollee's primary care provider has changed |
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| 44 | 44 | | since the referral was made; or |
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| 45 | 45 | | (4) the enrollee's managed care plan issuer or |
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| 46 | 46 | | administrator has changed since the referral was made. |
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| 47 | 47 | | SECTION 2. The changes in law made by this Act apply only to |
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| 48 | 48 | | a health benefit plan that is delivered, issued for delivery, or |
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| 49 | 49 | | renewed on or after January 1, 2026. |
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| 50 | 50 | | SECTION 3. This Act takes effect September 1, 2025. |
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