HB 115 — Managed care plan coverage of a health care service that

90R3693 RDS-F By: Oliverson H.B. No. 115 relating to managed care plan coverage of a health care service that was referred by certain primary care providers; creating an administrative penalty.

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.