Law:Title 8. Health Insurance And Other Health Coverages. Subtitle F. Physicians And Health Care Providers (Texas)

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Subtitle F. Physicians And Health Care Providers

Contents

Chapter 1451. Access To Certain Practitioners And Facilities

Subchapter A. General Provisions

Section  1451.001.  Definitions; Health Care Practitioners.

In this chapter:

(1)  "Acupuncturist" means an individual licensed to practice acupuncture by the Texas State Board of Medical Examiners.

(2)  "Advanced practice nurse" means an individual licensed by the Texas Board of Nursing as a registered nurse and recognized by that board as an advanced practice nurse.

(3)  "Audiologist" means an individual licensed to practice audiology by the State Board of Examiners for Speech-Language Pathology and Audiology.

(4)  "Chemical dependency counselor" means an individual licensed by the Texas Commission on Alcohol and Drug Abuse.

(5)  "Chiropractor" means an individual licensed by the Texas Board of Chiropractic Examiners.

(6)  "Dentist" means an individual licensed to practice dentistry by the State Board of Dental Examiners.

(7)  "Dietitian" means an individual licensed by the Texas State Board of Examiners of Dietitians.

(8)  "Hearing instrument fitter and dispenser" means an individual licensed by the State Committee of Examiners in the Fitting and Dispensing of Hearing Instruments.

(9)  "Licensed clinical social worker" means an individual licensed by the Texas State Board of Social Worker Examiners as a licensed clinical social worker.

(10)  "Licensed professional counselor" means an individual licensed by the Texas State Board of Examiners of Professional Counselors.

(11)  "Marriage and family therapist" means an individual licensed by the Texas State Board of Examiners of Marriage and Family Therapists.

(12)  "Occupational therapist" means an individual licensed as an occupational therapist by the Texas Board of Occupational Therapy Examiners.

(13)  "Optometrist" means an individual licensed to practice optometry by the Texas Optometry Board.

(14)  "Physical therapist" means an individual licensed as a physical therapist by the Texas Board of Physical Therapy Examiners.

(15)  "Physician" means an individual licensed to practice medicine by the Texas State Board of Medical Examiners. The term includes a doctor of osteopathic medicine.

(16)  "Physician assistant" means an individual licensed by the Texas State Board of Physician Assistant Examiners.

(17)  "Podiatrist" means an individual licensed to practice podiatry by the Texas State Board of Podiatric Medical Examiners.

(18)  "Psychological associate" means an individual licensed as a psychological associate by the Texas State Board of Examiners of Psychologists who practices solely under the supervision of a licensed psychologist.

(19)  "Psychologist" means an individual licensed as a psychologist by the Texas State Board of Examiners of Psychologists.

(20)  "Speech-language pathologist" means an individual licensed to practice speech-language pathology by the State Board of Examiners for Speech-Language Pathology and Audiology.

(21)  "Surgical assistant" means an individual licensed as a surgical assistant by the Texas State Board of Medical Examiners.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2005, 79th Leg., Ch. 728, Sec. 11.041(a), eff. September 1, 2005.

Acts 2007, 80th Leg., R.S., Ch. 889, Sec. 71, eff. September 1, 2007.



Subchapter B. Designation Of Practitioners Under Accident And Health Insurance Policy

Section  1451.051. 

 APPLICABILITY OF

Subchapter

. (a) This subchapter applies to an accident and health insurance policy, including an individual, blanket, or group policy.

(b)  This subchapter applies to an accident and health insurance policy issued by a stipulated premium company subject to Chapter 884.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.052.  Applicability Of General Provisions Of Other Law.

The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, the construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.053.  Practitioner Designation.

(a) An accident and health insurance policy may not make a benefit contingent on treatment or examination by one or more particular health care practitioners listed in Section 1451.001 unless the policy contains a provision that designates the practitioners whom the insurer will and will not recognize.

(b)  The insurer may include the provision anywhere in the policy or in an endorsement attached to the policy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.054.  Terms Used To Designate Health Care Practitioners.

A provision of an accident and health insurance policy that designates the health care practitioners whom the insurer will and will not recognize must use the terms defined by Section 1451.001 with the meanings assigned by that section.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter C. Selection Of Practitioners

Section  1451.101.  Definitions.

In this subchapter:

(1)  "Health insurance policy" means a policy, contract, or agreement described by Section 1451.102.

(2)  "Insured" means an individual who is issued, is a party to, or is a beneficiary under a health insurance policy.

(3)  "Insurer" means an insurer, association, or organization described by Section 1451.102.

(4)  "Nurse first assistant" has the meaning assigned by Section 301.1525, Occupations Code.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.102.

  APPLICABILITY OF

Subchapter

. Except as provided by this subchapter, this subchapter applies only to an individual, group, blanket, or franchise insurance policy, insurance agreement, or group hospital service contract that provides health benefits, accident benefits, or health and accident benefits for medical or surgical expenses incurred as a result of an accident or sickness and that is delivered, issued for delivery, or renewed in this state by any incorporated or unincorporated insurance company, association, or organization, including:

(1)  a fraternal benefit society operating under Chapter 885;

(2)  a general casualty company operating under Chapter 861;

(3)  a life, health, and accident insurance company operating under Chapter 841 or 982;

(4)  a Lloyd's plan operating under Chapter 941;

(5)  a local mutual aid association operating under Chapter 886;

(6)  a mutual insurance company writing insurance other than life insurance operating under Chapter 883;

(7)  a mutual life insurance company operating under Chapter 882;

(8)  a reciprocal exchange operating under Chapter 942;

(9)  a statewide mutual assessment company, mutual assessment company, or mutual assessment life, health, and accident association operating under Chapter 881 or 887; and

(10)  a stipulated premium company operating under Chapter 884.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.103.  Conflicting Provisions Void.

(a) A provision of a health insurance policy that conflicts with this subchapter is void to the extent of the conflict.

(b)  The presence in a health insurance policy of a provision void under Subsection (a) does not affect the validity of other policy provisions.

(c)  An insurer shall bring each approved policy form that contains a provision that conflicts with this subchapter into compliance with this subchapter by use of:

(1)  a rider or endorsement approved by the commissioner; or

(2)  a new or revised policy form approved by the commissioner.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.104.  Nondiscriminatory Payment Or Reimbursement; Exception.

(a) An insurer may not classify, differentiate, or discriminate between scheduled services or procedures provided by a health care practitioner selected under this subchapter and performed in the scope of that practitioner's license and the same services or procedures provided by another type of health care practitioner whose services or procedures are covered by a health insurance policy, in regard to:

(1)  the payment schedule or payment provisions of the policy; or

(2)  the amount or manner of payment or reimbursement under the policy.

(b)  An insurer may not deny payment or reimbursement for services or procedures in accordance with the policy payment schedule or payment provisions solely because the services or procedures were performed by a health care practitioner selected under this subchapter.

(c)  Notwithstanding Subsection (a), a health insurance policy may provide for a different amount of payment or reimbursement for scheduled services or procedures performed by an advanced practice nurse, nurse first assistant, licensed surgical assistant, or physician assistant if the methodology used to compute the amount is the same as the methodology used to compute the amount of payment or reimbursement when the services or procedures are provided by a physician.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.105.  Selection Of Acupuncturist.

An insured may select an acupuncturist to provide the services or procedures scheduled in the health insurance policy that are within the scope of the acupuncturist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.106.  Selection Of Advanced Practice Nurse.

An insured may select an advanced practice nurse to provide the services scheduled in the health insurance policy that are within the scope of the nurse's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.107.  Selection Of Audiologist.

An insured may select an audiologist to measure hearing to determine the presence or extent of the insured's hearing loss or provide aural rehabilitation services to the insured if the insured has a hearing loss and the services or procedures are scheduled in the health insurance policy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.108.  Selection Of Chemical Dependency Counselor.

An insured may select a chemical dependency counselor to provide services or procedures scheduled in the health insurance policy that are within the scope of the counselor's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.109.  Selection Of Chiropractor.

An insured may select a chiropractor to provide the medical or surgical services or procedures scheduled in the health insurance policy that are within the scope of the chiropractor's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.110.  Selection Of Dentist.

An insured may select a dentist to provide the medical or surgical services or procedures scheduled in the health insurance policy that are within the scope of the dentist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.111.  Selection Of Dietitian.

An insured may select a licensed dietitian or a provisionally licensed dietitian acting under the supervision of a licensed dietitian to provide the services scheduled in the health insurance policy that are within the scope of the dietitian's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.112.  Selection Of Hearing Instrument Fitter And Dispenser.

An insured may select a hearing instrument fitter and dispenser to provide the services or procedures scheduled in the health insurance policy that are within the scope of the license of the fitter and dispenser.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section 1451.113.  Selection Of Licensed Clinical Social Worker.

An insured may select a licensed clinical social worker to provide the services or procedures scheduled in the health insurance policy that:

(1)  are within the scope of the social worker's license, including the provision of direct, diagnostic, preventive, or clinical services to individuals, families, and groups whose functioning is threatened or affected by social or psychological stress or health impairment; and

(2)  are specified as services under the terms of the health insurance policy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2005, 79th Leg., Ch. 728, Sec. 11.042(a), eff. September 1, 2005.



Section 1451.114.  Selection Of Licensed Professional Counselor.

An insured may select a licensed professional counselor to provide the services scheduled in the health insurance policy that are within the scope of the counselor's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 221, Sec. 1, eff. September 1, 2009.



Section  1451.115.  Selection Of Surgical Assistant.

An insured may select a surgical assistant to provide the services or procedures scheduled in the health insurance policy that are within the scope of the assistant's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section 1451.116.  Selection Of Marriage And Family Therapist.

An insured may select a marriage and family therapist to provide the services scheduled in the health insurance policy that are within the scope of the therapist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2009, 81st Leg., R.S., Ch. 221, Sec. 2, eff. September 1, 2009.



Section  1451.117.  Selection Of Nurse First Assistant.

An insured may select a nurse first assistant to provide the services scheduled in the health insurance policy that:

(1)  are within the scope of the nurse's license; and

(2)  are requested by the physician whom the nurse is assisting.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.118.  Selection Of Occupational Therapist.

An insured may select an occupational therapist to provide the services scheduled in the health insurance policy that are within the scope of the therapist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.119.  Selection Of Optometrist.

An insured may select an optometrist to provide the services or procedures scheduled in the health insurance policy that are within the scope of the optometrist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.120.  Selection Of Physical Therapist.

An insured may select a physical therapist to provide the services scheduled in the health insurance policy that are within the scope of the therapist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.121.  Selection Of Physician Assistant.

An insured may select a physician assistant to provide the services scheduled in the health insurance policy that are within the scope of the assistant's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.122.  Selection Of Podiatrist.

An insured may select a podiatrist to provide the medical or surgical services or procedures scheduled in the health insurance policy that are within the scope of the podiatrist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.123.  Selection Of Psychological Associate.

An insured may select a psychological associate to provide the services scheduled in the health insurance policy that are within the scope of the associate's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.124.  Selection Of Psychologist.

An insured may select a psychologist to provide the services or procedures scheduled in the health insurance policy that are within the scope of the psychologist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.125.  Selection Of Speech-language Pathologist.

An insured may select a speech-language pathologist to evaluate speech or language, provide habilitative or rehabilitative services to restore speech or language loss, or correct a speech or language impairment if the services or procedures are scheduled in the health insurance policy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.126.  Reimbursement For Physical Modalities And Procedures By Health Insurer, Administrator, Health Maintenance Organization, Or Preferred Provider Benefit Plan Issuer.

(a) A health insurer or licensed third-party administrator may not deny reimbursement to a health care practitioner for the provision of covered services of physical modalities and procedures that are within the scope of the practitioner's practice if the services are performed in strict compliance with:

(1)  laws and rules related to that practitioner's license; and

(2)  the terms of the insurance policy or other coverage agreement.

(b)  A health maintenance organization or preferred provider benefit plan issuer may not deny reimbursement to a participating health care practitioner for services provided under a coverage agreement solely because of the type of practitioner providing the services if the services are performed in strict compliance with:

(1)  laws and rules related to that practitioner's license; and

(2)  the terms of the insurance policy or other coverage agreement.

(c)  This section may not be construed to circumvent any contractual provider network agreement between a health insurer or third-party administrator and a licensed health care practitioner.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.127.  Duty Of Person Arranging Provider Contracts For Health Insurer Or Health Maintenance Organization.

(a) A person who arranges contracts with providers on behalf of a health maintenance organization or health insurer shall comply with laws related to the duties of the organization or insurer to notify and consider providers for those contracts.

(b)  A violation of this section:

(1)  is an unlawful practice under Section 15.05, Business & Commerce Code; and

(2)  constitutes restraint of trade.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter D. Access To Optometrists And Ophthalmologists Used Under Managed Care Plan

Section  1451.151.  Definitions.

In this subchapter:

(1)  "Managed care plan" means a plan under which a health maintenance organization, preferred provider benefit plan issuer, or other organization provides or arranges for health care benefits to plan participants and requires or encourages plan participants to use health care practitioners the plan designates.

(2)  "Ophthalmologist" means a physician who specializes in ophthalmology.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.152. 

 APPLICABILITY AND CONSTRUCTION OF

Subchapter

. (a) This subchapter applies only to a managed care plan that provides or arranges for benefits for vision or medical eye care services or procedures that are within the scope of an optometrist's or therapeutic optometrist's license.

(b)  This subchapter does not require a managed care plan to provide vision or medical eye care services or procedures.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.153.  Use Of Optometrist, Therapeutic Optometrist, Or Ophthalmologist.

(a) A managed care plan may not:

(1)  discriminate against a health care practitioner because the practitioner is an optometrist, therapeutic optometrist, or ophthalmologist;

(2)  restrict or discourage a plan participant from obtaining covered vision or medical eye care services or procedures from a participating optometrist, therapeutic optometrist, or ophthalmologist solely because the practitioner is an optometrist, therapeutic optometrist, or ophthalmologist;

(3)  exclude an optometrist, therapeutic optometrist, or ophthalmologist as a participating practitioner in the plan because the optometrist, therapeutic optometrist, or ophthalmologist does not have medical staff privileges at a hospital or at a particular hospital; or

(4)  exclude an optometrist, therapeutic optometrist, or ophthalmologist as a participating practitioner in the plan because the services or procedures provided by the optometrist, therapeutic optometrist, or ophthalmologist may be provided by another type of health care practitioner.

(b)  A managed care plan shall:

(1)  include optometrists, therapeutic optometrists, and ophthalmologists as participating health care practitioners in the plan; and

(2)  include the name of a participating optometrist, therapeutic optometrist, or ophthalmologist in any list of participating health care practitioners and give equal prominence to each name.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.

Amended by:

Acts 2005, 79th Leg., Ch. 728, Sec. 11.043, eff. September 1, 2005.



Section 1451.154.  Participation Of Therapeutic Optometrist.

(a) In this section:

(1)  "Medical panel" means the health care practitioners who are listed as participating providers in a managed care plan or who a patient seeking diagnosis or treatment of a medical disease, disorder, or condition is encouraged or required to use under a managed care plan.

(2)  "Vision panel" means the optometrists, therapeutic optometrists, and ophthalmologists who are listed as participating providers for routine eye examinations under a managed care plan or who a patient seeking a routine eye examination is encouraged or required to use under a managed care plan.

(b)  A managed care plan must allow a therapeutic optometrist who is on one or more of the plan's vision panels to be a fully participating provider on the plan's medical panels to the full extent of the therapeutic optometrist's license to practice therapeutic optometry.

(c)  A therapeutic optometrist who is included in a managed care plan's medical panels under Subsection (b) must:

(1)  abide by the terms and conditions of the managed care plan;

(2)  satisfy the managed care plan's credentialing standards for therapeutic optometrists;

(3)  provide proof that the Texas Optometry Board considers the therapeutic optometrist's license to practice therapeutic optometry to be in good standing; and

(4)  comply with the requirements of the Controlled Substances Registration Program operated by the Department of Public Safety.

(d)  A managed care plan may charge a participating therapeutic optometrist:

(1)  any reasonable credentialing costs associated with the therapeutic optometrist's being included in the managed care plan's medical panel; and

(2)  a one-time administrative fee not to exceed $200 for expenses incurred in adding the therapeutic optometrist to the managed care plan's medical panel.

Added by Acts 2005, 79th Leg., Ch. 728, Sec. 11.044(a), eff. September 1, 2005.



Subchapter E. Dental Care Benefits In Health Insurance Policies Or Employee Benefit Plans

Section  1451.201.  Definitions.

In this subchapter:

(1)  "Dental care service" means a service provided to a person to prevent, alleviate, cure, or heal a human dental illness or injury.

(2)  "Employee benefit plan" means a plan, fund, or program established or maintained by an employer or employee organization.

(3)  "Health insurance policy" means any individual, group, blanket, or franchise insurance policy, insurance agreement, or group hospital service contract.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.202.

  APPLICABILITY AND CONSTRUCTION OF

Subchapter

. (a) This subchapter applies only to an employee benefit plan or health insurance policy delivered, issued for delivery, renewed, or contracted for in this state to the extent that:

(1)  the employee benefit plan is established or maintained to provide dental care services, through insurance or otherwise, for the plan's participants or the beneficiaries of the plan's participants; or

(2)  the health insurance policy provides benefits for dental care services.

(b)  This subchapter does not apply to a health maintenance organization governed by Chapter 843.

(c)  The exemptions and exceptions of Sections 881.002 and 881.004 and Article 21.41 do not apply to this subchapter.

(d)  This subchapter does not require an employee benefit plan or health insurance policy to provide any type of benefits for dental care expenses.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.203.  Conflicting Provisions.

A provision of an employee benefit plan or health insurance policy that conflicts with this subchapter is void to the extent of the conflict.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.204.  Certain Conduct Permitted.

(a) Notwithstanding any other provision of this subchapter, a dentist may contract directly with a patient to provide dental care services to the patient as authorized by law.

(b)  Notwithstanding any other provision of this subchapter, a person providing a health insurance policy or employee benefit plan or an employer or an employee organization may:

(1)  make information available to its insureds, beneficiaries, participants, employees, or members regarding dental care services through the distribution of factually accurate information about dental care services and the rates, fees, locations, and hours for the services if the information is distributed on the request of a dentist;

(2)  establish an administrative mechanism to facilitate payments for dental care services from an insured, beneficiary, participant, employee, or member to a dentist chosen by the insured, beneficiary, participant, employee, or member; or

(3)  nondiscriminatorily pay or reimburse its insured, beneficiary, participant, employee, or member for the cost of dental care services provided by a dentist chosen by the insured, beneficiary, participant, employee, or member.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.205.  Disclosure Of Benefit Terms.

An employee benefit plan or health insurance policy shall:

(1)  if applicable, disclose that the benefit for dental care services offered is limited to the least costly treatment; and

(2)  specify in dollars and cents the amount of the payment or reimbursement to be provided for dental care services or define and explain the standard on which payment of benefits or reimbursement for the cost of dental care services is based, such as:

(A)  "usual and customary" fees;

(B)  "reasonable and customary" fees;

(C)  "usual, customary, and reasonable" fees; or

(D)  words of similar meaning.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.206.  Payment Or Reimbursement Of Dentist.

(a) The employee benefit plan or health insurance policy shall provide:

(1)  that payment or reimbursement for a noncontracting provider dentist shall be the same as payment or reimbursement for a contracting provider dentist; and

(2)  that the party to or beneficiary of the plan or policy may assign the right to payment or reimbursement to the dentist who provides the dental care services.

(b)  Notwithstanding Subsection (a)(1), the employee benefit plan or health insurance policy is not required to make payment or reimbursement in an amount greater than:

(1)  the amount specified in the plan or policy; or

(2)  the fee the providing dentist charges for the dental care services provided.

(c)  If the right to payment or reimbursement is assigned as provided by Subsection (a)(2):

(1)  payment or reimbursement shall be made directly to the designated dentist; and

(2)  direct payment to the designated dentist discharges the payor's obligation.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.207.  Prohibited Conduct.

(a) An employee benefit plan or health insurance policy may not:

(1)  interfere with or prevent an individual who is a party to or beneficiary of the plan or policy from selecting a dentist of the individual's choice to provide a dental care service the plan or policy offers if the dentist selected is licensed in this state to provide the service;

(2)  deny a dentist the right to participate as a contracting provider under the plan or policy if the dentist is licensed to provide the dental care services the plan or policy offers;

(3)  authorize a person to regulate, interfere with, or intervene in the provision of dental care services a dentist provides a patient, including diagnosis, if the dentist practices within the scope of the dentist's license; or

(4)  require a dentist to make or obtain a dental x-ray or other diagnostic aid in providing dental care services.

(b)  Subsection (a)(4) does not prohibit a request for an existing dental x-ray or other existing diagnostic aid for a determination of benefits payable under an employee benefit plan or health insurance policy.

(c)  This section does not prohibit the predetermination of benefits for dental care expenses before the attending dentist provides treatment.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter F. Access To Obstetrical Or Gynecological Care

Section  1451.251.  Definition.

In this subchapter, "enrollee" means an individual enrolled in a health benefit plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.252.

  APPLICABILITY OF

Subchapter

. This subchapter applies only to a health benefit plan that requires an enrollee to obtain certain specialty health care services through a referral made by a primary care physician or other gatekeeper and that:

(1)  provides benefits for medical or surgical expenses incurred as a result of a health condition, accident, or sickness, including:

(A)  an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by:

(i)  an insurance company;

(ii)  a group hospital service corporation operating under Chapter 842;

(iii)  a fraternal benefit society operating under Chapter 885;

(iv)  a stipulated premium company operating under Chapter 884; or

(v)  a health maintenance organization operating under Chapter 843; and

(B)  to the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health benefit plan that is offered by:

(i)  a multiple employer welfare arrangement as defined by Section 3 of that Act; or

(ii)  another analogous benefit arrangement;

(2)  is offered by:

(A)  an approved nonprofit health corporation that holds a certificate of authority under Chapter 844; or

(B)  an entity that is not authorized under this code or another insurance law of this state that contracts directly for health care services on a risk-sharing basis, including a capitation basis; or

(3)  provides health and accident coverage through a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.253.  Exception.

This subchapter does not apply to:

(1)  a plan that provides coverage:

(A)  only for a specified disease;

(B)  only for accidental death or dismemberment;

(C)  for wages or payments instead of wages for a period during which an employee is absent from work because of sickness or injury; or

(D)  as a supplement to a liability insurance policy;

(2)  a small employer health benefit plan written under Chapter 1501;

(3)  a Medicare supplemental policy as defined by Section 1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);

(4)  a workers' compensation insurance policy;

(5)  medical payment insurance coverage provided under a motor vehicle insurance policy;

(6)  a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1451.252; or

(7)  any health benefit plan that does not provide:

(A)  benefits related to pregnancy; or

(B)  well-woman care benefits.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.254.  Rules.

The commissioner shall adopt rules necessary to implement this subchapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.255.  Right Of Female Enrollee To Select Obstetrician Or Gynecologist.

(a) Except as provided by Subsection (b), a health benefit plan shall permit a female enrollee to select, in addition to a primary care physician, an obstetrician or gynecologist to provide the enrollee with health care services that are within the scope of the professional specialty practice of a properly credentialed obstetrician or gynecologist.

(b)  A health benefit plan may limit an enrollee's self-referral under Subsection (a) to only one participating obstetrician or gynecologist to provide both gynecological and obstetrical care to the enrollee. This subsection does not affect the right of an enrollee to select the physician who provides that care.

(c)  This section does not preclude an enrollee from selecting a qualified physician, including a family physician or internal medicine physician, to provide the enrollee with health care services described by Subsection (a).

(d)  This section does not affect the authority of a health benefit plan issuer to establish selection criteria regarding other physicians who provide services under the plan.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.256.  Direct Access To Services Of Obstetrician Or Gynecologist.

(a) In this section, "health care services" includes:

(1)  one well-woman examination each year;

(2)  care related to pregnancy;

(3)  care for any active gynecological condition; and

(4)  diagnosis, treatment, and referral for any disease or condition that is within the scope of the professional specialty practice of a properly credentialed obstetrician or gynecologist.

(b)  In addition to other benefits authorized under the health benefit plan, a health benefit plan shall permit an enrollee who selects an obstetrician or gynecologist under Section 1451.255 to have direct access to the health care services of that selected physician without:

(1)  a referral from the enrollee's primary care physician; or

(2)  prior authorization or precertification from the plan issuer.

(c)  A health benefit plan may not impose a copayment or deductible for direct access to health care services as required by this section unless the same copayment or deductible is imposed for access to other health care services provided under the plan.

(d)  This section does not affect the authority of a health benefit plan issuer to require an obstetrician or gynecologist selected by an enrollee under Section 1451.255 to forward information concerning the medical care of the enrollee to the enrollee's primary care physician.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.257.  Availability Of Providers.

To ensure access to services that are within the scope of the professional specialty practice of a properly credentialed obstetrician or gynecologist, a health benefit plan shall include in the classification of persons authorized to provide medical services under the plan a sufficient number of properly credentialed obstetricians and gynecologists.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.258.  Notice Of Available Providers.

(a) A health benefit plan issuer shall provide to each person covered under the plan a timely written notice of the choices of the types of physician providers available for the direct access required under this subchapter.

(b)  The notice must be stated in clear and accurate language.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.259.  Limits On Physician Sanctions.

(a) A health benefit plan may not sanction or terminate a primary care physician because of female enrollees' access to participating obstetricians and gynecologists under this subchapter.

(b)  A health benefit plan may not impose a financial or other penalty on an obstetrician or gynecologist selected under Section 1451.255, or on the enrollee who selected the physician, because the selected physician failed to provide to the enrollee's primary care physician information concerning the medical care of the enrollee if the selected physician made a reasonable good faith effort to forward the information.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.260.  Administrative Penalty.

An entity that operates a health benefit plan in violation of this subchapter is subject to an administrative penalty as provided by Chapter 84.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter G. Access To Dietitian Services

Section  1451.301.  Applicability Of General Provisions Of Other Law.

The provisions of Chapter 1201, including provisions relating to the applicability, purpose, and enforcement of that chapter, the construction of policies under that chapter, rulemaking under that chapter, and definitions of terms applicable in that chapter, apply to this subchapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.302.  Dietitian Services.

An individual or group accident and health insurance policy delivered or issued for delivery in this state may not:

(1)  exclude or deny coverage for services performed by:

(A)  a dietitian; or

(B)  a provisionally licensed dietitian acting under the supervision of a dietitian; or

(2)  refuse payment or reimbursement for charges for services described by Subdivision (1) if the services:

(A)  are in the scope of the dietitian's license;

(B)  are related to an injury or illness the policy covers if the services are scheduled in the policy; and

(C)  are provided under a professional recommendation of a physician whose treatment or examination for the injury or illness would be covered by the policy and would be payable or reimbursable under the policy.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter H. Disability Certified By Podiatrist

Section  1451.351.  Loss Of Income Benefits For Disability Treatable By Podiatrist.

(a) This section applies only to an insurance policy delivered, issued for delivery, or renewed in this state that provides benefits covering loss of income as a result of an acute temporary disability caused by sickness or injury.

(b)  An insurance policy may not deny payment of benefits described by Subsection (a) solely because the disability is certified or attested to by a podiatrist if the disability is caused by a sickness or injury that may be treated within the scope of the podiatrist's license.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Subchapter I. Use Of Osteopathic Hospital

Section  1451.401.  Contract With Osteopathic Hospital.

A health maintenance organization or preferred provider benefit plan issuer that contracts with a hospital to provide services to covered individuals may not refuse to contract with an osteopathic hospital solely because the hospital is an osteopathic hospital.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.402.  Services At Osteopathic Hospital.

A health maintenance organization or preferred provider benefit plan issuer that provides benefits for inpatient or outpatient services provided by an allopathic hospital shall seek to provide benefits for similar services provided by an osteopathic hospital if there is an osteopathic hospital within the service area of the health maintenance organization or preferred provider benefit plan issuer that will provide the services at a substantially similar cost.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.403.  Request For Action Of Commissioner.

An aggrieved party may request that the commissioner conduct an investigation, review, hearing, or other proceeding to determine compliance with this subchapter.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.



Section  1451.404.  Enforcement.

The commissioner shall take all reasonable actions to ensure compliance with this subchapter, including issuing orders and assessing penalties.

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.


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