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.