89R9289 SCR-D
By: Guerra H.B. No. 2320
A BILL TO BE ENTITLED
AN ACT
relating to specialist referrals by primary care providers for
certain managed care health benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle C, Title 8, Insurance Code, is amended
by adding Chapter 1276 to read as follows:
CHAPTER 1276. REFERRAL REQUIREMENTS
Sec. 1276.001. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including a plan provided by
a health maintenance organization operating under Chapter 843, that
requires a primary care physician or other participating health
care provider to provide a referral to an enrollee as a condition of
payment or for the enrollee to receive a network benefit.
(b) Notwithstanding any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575; and
(3) a primary care coverage plan under Chapter 1579.
Sec. 1276.002. EXCEPTION. This chapter does not apply to a
Medicaid managed care program operated under Chapter 540,
Government Code.
Sec. 1276.003. SPECIALIST REFERRALS. (a) An issuer or
administrator of a managed care plan that requires an enrollee to
obtain a referral from a primary care provider before receiving
health care services from a specialist shall accept a referral from
the provider for the plan if:
(1) the enrollee has had at least one visit with the
provider before the provider made the referral; and
(2) the referral is for treatment of a chronic or
ongoing condition.
(b) Notwithstanding Subsection (a), a managed care plan
issuer or administrator may refuse to accept a referral from a
primary care provider for specialist services if:
(1) more than three years have passed since the
provider made the referral;
(2) the provider has withdrawn the referral;
(3) the enrollee's primary care provider has changed
since the referral was made; or
(4) the enrollee's managed care plan issuer or
administrator has changed since the referral was made.
SECTION 2. The changes in law made by this Act apply only to
a health benefit plan that is delivered, issued for delivery, or
renewed on or after January 1, 2026.
SECTION 3. This Act takes effect September 1, 2025.