Oliverson Bill Bars Plans From Rejecting Out-Of-Network Primary Care Referrals

The text as introduced · 856 words

90R3693 RDS-F

By: Oliverson
H.B. No. 115

A BILL TO BE ENTITLED

AN ACT

relating to managed care plan coverage of a health care service that

was referred by certain primary care providers; creating an

administrative penalty.

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. HEALTH CARE SERVICES REQUIRING REFERRAL

Sec. 1276.001. DEFINITIONS. In this chapter:

(1) "Advanced practice registered nurse" means an

individual licensed by the Texas Board of Nursing as a registered

nurse and recognized by that board as an advanced practice

registered nurse.

(2) "Direct patient care" and "direct patient care

agreement" have the meanings assigned by Section 117.001,

Occupations Code.

(3) "Health benefit plan" means a plan that provides

benefits for medical or surgical expenses incurred as a result of a

health condition, accident, or sickness, including an individual,

group, blanket, or franchise insurance policy.

(4) "Health care service" has the meaning assigned by

Section 117.001, Occupations Code.

(5) "Managed care plan" means a health benefit plan

under which health care services or supplies are provided to

enrollees through contracts with health care providers and that

requires enrollees to use contracting providers or that provides a

different level of coverage for enrollees who use contracting

providers.

(6) "Physician" and "physician assistant" have the

meanings assigned by Section 1451.001.

(7) "Primary care provider" means a physician,

advanced practice registered nurse, or physician assistant who is

trained to serve as the first point of contact with a patient and to

provide continuous comprehensive health care services to a patient.

The term includes a physician who practices family medicine,

general practice, internal medicine, obstetrics, gynecology, or

pediatrics.

Sec. 1276.002. APPLICABILITY OF CHAPTER. (a) This chapter

applies to a managed care plan issued by a health maintenance

organization operating under Chapter 843 or an insurer offering a

preferred provider benefit plan under Chapter 1301.

(b) Notwithstanding any other law, this chapter applies to:

(1) a basic coverage plan under Chapter 1551;

(2) a basic plan under Chapter 1575;

(3) a primary care coverage plan under Chapter 1579;

and

(4) a plan providing basic coverage under Chapter

1601.

Sec. 1276.003. EXCLUSIONS. This chapter does not apply to:

(1) a managed care plan that provides coverage only

for:

(A) a specified disease;

(B) accidental death or dismemberment; or

(C) lost wages for a period during which an

employee is absent from work due to sickness or injury;

(2) credit insurance;

(3) dental or vision benefits;

(4) benefits for long-term care, home health care,

community-based care, or benefits for a combination of the types of

care described by this subdivision; or

(5) a Medicare supplemental policy as defined by

Section 1882(g)(1), Social Security Act (42 U.S.C. Section

1395ss(g)(1)).

Sec. 1276.004. PROHIBITED PRACTICES RELATED TO REFERRAL BY

PRIMARY CARE PROVIDER. (a) A managed care plan issuer or

administrator may not, solely on the basis that the referral for a

covered health care service was made by an out-of-network primary

care provider:

(1) deny coverage;

(2) apply a deductible, coinsurance, copayment, or

other cost-sharing requirement that exceeds the deductible,

coinsurance, copayment, or other cost-sharing requirement

applicable to the service if the referral had been made by a

participating provider;

(3) assess a facility or administrative fee; or

(4) assess any other penalty.

(b) A managed care plan issuer or administrator may not

refuse to recognize a referral for a covered health care service on

the basis that the referral was made by a primary care provider

that:

(1) is an out-of-network provider;

(2) provides direct patient care under a direct

patient care agreement; or

(3) is not credentialed by the issuer or administrator

if the provider is authorized to provide primary care services in

this state and is acting within the scope of the provider's license,

certificate, or other authorization.

Sec. 1276.005. ENFORCEMENT. (a) In addition to other

enforcement authority under Subtitle B, Title 2, the commissioner

may impose an additional administrative penalty in an amount not to

exceed $5,000 against a managed care plan issuer or administrator

that violates this chapter. The commissioner shall impose the

additional administrative penalty in accordance with Chapter 84.

(b) A violation of Section 1276.004(a)(3) or (4) is an

unfair method of competition or an unfair or deceptive act or

practice in the business of insurance under Chapter 541 and is

subject to enforcement under that chapter.

(c) For purposes of enforcing this chapter:

(1) each denial of coverage, application of an

additional deductible, coinsurance, copayment, or other

cost-sharing requirement, or assessment of an additional facility

or administrative fee or other penalty in violation of this chapter

is considered a separate violation; and

(2) each day a violation described by Subdivision (1)

continues is considered a separate violation.

Sec. 1276.006. RULES. The commissioner may adopt rules

necessary to implement this chapter.

SECTION 2. The changes in law made by this Act apply only to

a managed care plan delivered, issued for delivery, or renewed on or

after the effective date of this Act.

SECTION 3. This Act takes effect September 1, 2027.