CHAPTER 1451. ACCESS TO CERTAIN PRACTITIONERS AND FACILITIES

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1451-access-to-certain-practitioners-and-facilities

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1451. ACCESS TO CERTAIN PRACTITIONERS AND FACILITIES

SUBCHAPTER A. GENERAL PROVISIONS

Sec. 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

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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

Sec. 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.

Sec. 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.

Sec. 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.

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.

Sec. 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.

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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

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.

Sec. 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

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

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

Sec. 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.

Sec. 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.

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.

Sec. 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.

Sec. 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.

Sec. 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;

(D) words of similar meaning.

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

2005.

Sec. 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.

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.

Sec. 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.

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

Sec. 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.

Sec. 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;

(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.

Sec. 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;

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;

(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.

Sec. 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.

Sec. 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.

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.

Sec. 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.

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.

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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

Sec. 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.

Sec. 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

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

Sec. 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

Sec. 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.

Sec. 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.

Sec. 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.

Sec. 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.

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

State Codes and Statutes

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