Contracts with insurers must keep certain care and payment protections in place when a provider leaves a preferred provider plan, except for medical competence or professional behavior reasons.
Sec. 1301.153. CONTINUITY OF CARE. (a) In this section: (1) "Life-threatening" means a disease or condition for which the likelihood of death is probable unless the course of the disease or condition is interrupted. (2) "Special circumstances" means a condition regarding which the treating physician or health care provider reasonably believes that discontinuing care by the treating physician or provider could cause harm to the insured. Examples of an insured who has a special circumstance include an insured with a disability, acute condition, or life-threatening illness or an insured who is past the 24th week of pregnancy. (b) Each contract between an insurer and a physician or health care provider must provide that the termination of the physician's or provider's participation in a preferred provider benefit plan, except for reason of medical competence or professional behavior, does not: (1) release the physician or health care provider from the generally recognized obligation to: (A) treat an insured whom the physician or provider is currently treating; and (B) cooperate in arranging for appropriate referrals; or (2) release the insurer from the obligation to reimburse the physician or health care provider or, if applicable, the insured, at the same preferred provider rate if, at the time a physician's or provider's participation is terminated, an insured whom the physician or provider is currently treating has special circumstances in accordance with the dictates of medical prudence. (c) The treating physician or health care provider shall identify a special circumstance. The treating physician or health care provider shall: (1) request that the insured be permitted to continue treatment under the physician's or provider's care; and (2) agree not to seek payment from the insured of any amount for which the insured would not be responsible if the physician or provider were still a preferred provider. Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.