bill making health plans honor specialist referrals

The text as introduced · 370 words

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(2) the provider has withdrawn the referral;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.