HBA-ATS H.B. 1720 76(R)    BILL ANALYSIS


Office of House Bill AnalysisH.B. 1720
By: Edwards
Insurance
4/17/1999
Introduced



BACKGROUND AND PURPOSE 

Under H.B. 1720, an enrollee is authorized, on referral by a primary care
physician, to select, in addition to a primary care physician, a properly
credentialed specialist physician to provide under the health care plan
medically necessary covered services that fall within the scope of a
professional specialty practice.  To be selected, the specialist physician
must be member of a health maintenance organization's (HMO) delivery
network or have contracted with a managed care organization's provider
network. The HMO or the managed care organizations may restrict the choice
of specialist physicians to those who are in the same limited provider
network as the enrollee's primary care physician, but the HMO or managed
care organization is prohibited from restricting the enrollee's choice of a
specialist physician within that limited provider network. 

RULEMAKING AUTHORITY

It is the opinion of the Office of House Bill Analysis that this bill does
not expressly delegate any additional rulemaking authority to a state
officer, department, agency, or institution. 

SECTION BY SECTION ANALYSIS

SECTION 1.  Amends Chapter 20A, Insurance Code (Texas Health Maintenance
Organization Act), by adding Section 9B, as follows: 

Sec. 9B.  ACCESS OF ENROLLEE TO SPECIALTY HEALTH CARE SERVICES.  (a)
Authorizes an enrollee, on referral by a primary care physician, to select,
in addition to a primary care physician, a properly credentialed specialist
physician to provide under the health care plan medically necessary covered
services that fall within the scope of a professional specialty practice. 

(b) Authorizes an enrollee to select any specialist physician who is a
member of the health maintenance organization delivery network to provide
health care services.  Authorizes a health maintenance organization (HMO)
to restrict an enrollee's right to choose a specialist physician under this
section to specialist physicians who are in the same limited provider
network as the enrollee's primary care physician.  Prohibits an HMO from
restricting the enrollee's choice of a specialist physician within that
limited provider network. 

SECTION 2.  Amends Subchapter A, Chapter 533, Government Code, by adding
Section 533.0056, as follows: 

Sec. 533.0056.  ACCESS TO SPECIALTY HEALTH CARE SERVICES.  (a) Authorizes a
recipient, on referral by a primary care physician, to select, in addition
to a primary care physician, a properly credentialed specialist physician
to provide under the managed care plan medically necessary covered services
that fall within the scope of a professional specialty practice. 

(b) Authorizes a recipient to select any specialist physician who has
contracted with the managed care organization's provider network to provide
health care services.  Authorizes a managed care organization to restrict a
recipient's right to choose a specialist physician  under this section to
specialist physicians who are in the same limited provider network as the
recipient's primary care physician.  Prohibits a managed care organization
from restricting the enrollee's choice of a specialist physician within
that limited provider network. 

SECTION 3.  Makes application of Section 9B, Chapter 20A, Insurance Code
(Texas Health Maintenance Organization Act), prospective for an evidence of
coverage delivered, issued for delivery, or renewed on or after January 1,
2000. 

SECTION 4.  Makes application of Section 533.0056, Government Code,
prospective for a managed care plan provided under a contract that is
entered into or renewed on or after January 1, 2000. 

SECTION 5.  Requires the Health and Human Services Commission to request a
waiver or authorization from a federal agency if necessary to implement any
provision of Section 533.0056, Government Code.  Authorizes the Health and
Human Services Commission to delay implementing any provision of Section
533.0056, Government Code, until a waiver or authorization is granted. 

SECTION 6.  Effective date: September 1, 1999.

SECTION 7.  Emergency clause.