This bulletin provides information regarding HB 574, enacted by the 84th Legislature, Regular Session (2015). HB 574 expands statutory prohibitions on Health Maintenance Organizations (HMOs) and issuers of preferred provider (PPO) and exclusive provider (EPO) benefit plans against discouraging the discussion of patient health care options. HB 574 provides that carriers may not: (1) terminate a network provider solely because the provider informed the insured of out-of-network options; or (2) prohibit, discourage, or penalize a provider for discussing the availability of out-of-network facilities with the insured. The bill also amends Insurance Code §843.363(a-1) and §1301.067(a-1) to prohibit carriers from requiring a physician or provider to give a notification form stating that the physician or provider is an out-of-network provider if the form contains additional information intended to intimidate the patient.
Specifically as to PPO/EPO plans, HB 574 adds Sections 1301.0057 and 1301.0058 to the Insurance Code, as follows:
Sec. 1301.0057. ACCESS TO OUT-OF-NETWORK PROVIDERS. An insurer may not terminate, or threaten to terminate, an insured's participation in a preferred provider benefit plan solely because the insured uses an out-of-network provider.
Sec. 1301.0058. PROTECTED COMMUNICATIONS BY PREFERRED PROVIDERS.
(a) An insurer may not in any manner prohibit, attempt to prohibit, penalize, terminate, or otherwise restrict a preferred provider from communicating with an insured about the availability of out-of-network providers for the provision of the insured's medical or health care services.
(b) An insurer may not terminate the contract of or otherwise penalize a preferred provider solely because the provider's patients use out-of-network providers for medical or health care services.
(c) An insurer's contract with a preferred provider may require that, except in a case of a medical emergency as determined by the preferred provider, before the provider may make an out-of-network referral for an insured, the preferred provider inform the insured:
(A) the insured may choose a preferred provider or an out-of-network provider; and
(B) if the insured chooses the out-of-network provider the insured may incur higher out-of-pocket expenses; and
(2) whether the preferred provider has a financial interest in the out-of-network provider.
With its list of permitted contract provisions, §1301.0058 creates a limited set of disclosures that a carrier may require its preferred providers to give to patients. That list does not include warnings regarding the legality or propriety of provider conduct. Carrier-required notices should not vary from or exceed the list in §1301.0058.
David C. Mattax
Commissioner of Insurance