Bill Text: TX SB1765 | 2023-2024 | 88th Legislature | Introduced

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Bill Title: Relating to network adequacy standards and other requirements for preferred provider benefit plans.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2023-03-20 - Referred to Health & Human Services [SB1765 Detail]

Download: Texas-2023-SB1765-Introduced.html

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2023S0261-T 03/07/23
By: Schwertner S.B. No. 1765

A BILL TO BE ENTITLED
AN ACT
relating to network adequacy standards and other requirements for
preferred provider benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1301.001, Insurance Code, is amended by
adding Subdivision (6-a) to read as follows:
(6-a) "Post-emergency stabilization care" means health care
services that are furnished by an out-of-network provider,
including an out-of-network hospital, freestanding emergency
medical care facility or comparable emergency facility,
(regardless of the department of the hospital in which such
services or supplies are furnished) after the insured is stabilized
and as part of outpatient observation or an inpatient or outpatient
stay with respect to the visit in which the services defined by
Section 1301.155(a) are furnished.
SECTION 2. Section 1301.0046, Insurance Code, is amended to
read as follows:
Sec. 1301.0046. COST-SHARING [COINSURANCE] REQUIREMENTS
FOR SERVICES OF NONPREFERRED PROVIDERS. (a) The insured's
coinsurance applicable to payment to nonpreferred providers may not
exceed 50 percent of the total covered amount applicable to the
medical or health care services.
(b) An insurer shall credit a cost-sharing payment,
including any copayment, coinsurance, or deductible, paid by or on
behalf of an insured for services furnished by an out-of-network
provider to any out-of-pocket maximum that applies to the insured.
The cost-sharing payment must be applied to the out-of-pocket
maximum in the same manner as if it were made with respect to
services furnished by a preferred provider.
(c) An insurer may not have separate out-of-pocket maximums
for in-network and out-of-network services.
(d) The commissioner by rule shall set a reasonable cap on
an out-of-pocket maximum under this section.
(e) This section does not apply to an exclusive provider
benefit plan.
SECTION 3. The heading to Section 1301.005, Insurance Code,
is amended to read as follows:
Sec. 1301.005. AVAILABILITY OF PREFERRED PROVIDERS;
SERVICE AREA LIMITATIONS.
SECTION 4. Section 1301.005, Insurance Code, is amended by
amending Subsections (a) and adding Subsection (d) to read as
follows:
(a) An insurer offering a preferred provider benefit plan
shall ensure that both preferred provider benefits and basic level
benefits, including benefits for emergency care, as defined by
Section 1301.155 and post-emergency stabilization care, are
reasonably available to all insureds within the designated service
area. This subsection does not apply to an exclusive provider
benefit plan.
(d) A service area, other than a statewide service area, may
include noncontiguous geographic areas but:
(1) may not divide a county; and
(2) must include at least one trauma service area in
its entirety.
SECTION 5. 1301.0053, Insurance Code, is amended by
amending Subsections (a) and (b) and adding Subsections (d) and (e)
to read as follows:
(a) If an out-of-network provider provides emergency care,
as defined by Section 1301.155 or post-emergency stabilization care
to an enrollee in an exclusive provider benefit plan, the issuer of
the plan shall reimburse the out-of-network provider at the usual
and customary rate or at a rate agreed to by the issuer and the
out-of-network provider for the provision of the services and any
supply related to those services. The insurers shall make a payment
required by this subsection directly to the provider not later
than, as applicable:
(1) the 30th day after the date the insurer receives an
electronic clean claim as defined by Section 1301.101 for those
services that includes all information necessary for the insurer to
pay the claim; or
(2) the 45th day after the date the insurer receives a
nonelectronic clean claim as defined by Section 1301.101 for those
services that includes all information necessary for the insurer to
pay the claim;
(b) For emergency care or post-emergency stabilization care
subject to this section or a supply related to that care, an
out-of-network provider or a person asserting a claim as an agent or
assignee of the provider may not bill an insured in, and the insured
does not have financial responsibility for, an amount greater than
an applicable copayment, coinsurance, and deductible under the
insured's exclusive provider benefit plan that:
(1) is based on:
(A) the amount initially determined payable by
the insurer; or
(B) if applicable, a modified amount as
determined under the insured's internal appeal process; and
(2) is not based on any additional amount determined
to be owed to the provider under Chapter 1467.
(d) Post-emergency stabilization care that is subject to
this section and a supply related to that care are subject to
Chapter 1467 in the same manner as if they were emergency care, as
defined by Section 1301.155.
(e) This section does not apply to claims for post-emergency
stabilization care if each of the conditions described under 42 USC §
300gg-111(a)(3)(C)(ii)(II) are met.
SECTION 6. Section 1301.0055, Insurance Code, is amended to
read as follows:
Sec. 1301.0055. NETWORK ADEQUACY STANDARDS. (a) The
commissioner shall by rule adopt network adequacy standards that:
(1) require an insurer offering a preferred provider
benefit plan to monitor compliance with network adequacy standards,
including provisions of this chapter relating to network adequacy,
on an ongoing basis, reporting any material deviation from network
adequacy standards to the department within 30 days and promptly
taking any correction action required to ensure the network is
compliant; [adapted to local markets in which the insurer offering
a preferred provider benefit plan operates];
(2) ensure availability of, and accessibility to, a
full range of contracted physicians and health care providers to
provide current and projected utilization of health care services
for adult and minor insureds; [and]
(3) [on good cause shown,] may allow a waiver for a
departure from [local market] network adequacy standards for a
period not to exceed one year if the commissioner determines after
receiving testimony at a public hearing under Section 1301.00565
that good cause is shown and posts on the department's Internet
website the name of the preferred provider benefit plan, the
insurer offering the plan, each affected county, and the specific
network adequacy standards waived;
(4) require disclosure by the insurer of the
information described by Subdivision (3) in all promotion and
advertisement of the preferred provider benefit plan for which a
waiver is allowed under that subdivision; and
(5) limit a waiver from being issued to a preferred
provider benefit plan:
(A) more than twice consecutively for the same
network adequacy standard in the same county unless the insurer
demonstrates, in addition to the good cause described in
Subdivision (4), multiple good faith attempts to bring the plan
into compliance with the network adequacy standard during each of
the prior consecutive waiver periods; or
(B) more than a total of four times within a
21-year period for each county in a service area for issues that may
be remedied through good faith efforts [and the affected local
market].
(b) The standards described by Subsection (a)(2) must
include factors regarding time, distance and appointment
availability. The factors must:
(1) require that all insureds are able to receive an
appointment with a preferred provider within the maximum travel
times and distances established under Sections 1301.00553 and
1301.00554;
(2) require that at all insureds are able to receive an
appointment with a preferred provider within the maximum
appointment wait times established under Section 1301.0055;
(3) require a preferred provider benefit plan to
ensure sufficient choice, access, and quality of physicians and
health care providers, in number, size, and geographic
distribution, to be capable of providing the health care services
covered by the plan from preferred providers to all insureds within
the insurer's designated service area, taking into account the
insureds' characteristics, medical conditions, and health care
needs, including:
(A) the current utilization of covered health
care services within the counties of the service area; and
(B) an actuarial projection of utilization of
covered health care services, physicians, and health care providers
needed within the counties of the service area to meet the needs of
the number of projected insureds.
(4) require a sufficient number of preferred providers
of emergency medicine, anesthesiology, pathology, radiology,
neonatology, surgery, hospitalist, intensivist and diagnostic
services, including radiology and laboratory services at each
preferred hospital, ambulatory surgical center or freestanding
emergency medical care facility with credentials for these
specialties to ensure all insureds are able to receive covered
benefits at that preferred location;
(5) require that all insureds have the ability to
access a preferred institutional provider listed in Section
1301.00553 within the maximum travel times and distances for the
corresponding county classification;
(6) require that insureds have the option of
facilities, if available, of pediatric, for-profit, nonprofit, and
tax-supported institutions, with special consideration to
contracting with teaching hospitals that provide indigent care or
care for uninsured individual as a significant percentage of their
overall patient load;
(7) require that there is an adequate number of
preferred provider physicians who have admitting privileges at one
or more preferred provider hospitals located within the insurer's
designated service area to make any necessary hospital admissions;
(8) provide for necessary hospital services by
requiring contracting with general, pediatric, specialty, and
psychiatric hospitals on a preferred benefit basis within the
insurer's designated service area, as applicable;
(9) ensure that emergency care, as defined by Section
1301.155, is available and accessible 24 hours a day, seven days a
week, by preferred providers;
(10) ensure that covered urgent care is available and
accessible from preferred providers within the insurer's
designated service area within 24 hours for medical and behavioral
health conditions;
(11) require an adequate number of preferred providers
available and accessible to insureds 24 hours a day, seven days a
week, within the insurer's designated service area; and
(12) require sufficient numbers and classes of
preferred providers to ensure choice, access, and quality of care
across the insurer's designated service area.
SECTION 7. Subchapter A, Chapter 1301, Insurance Code, is
amended by adding Sections 1301.00553, 1301.00554, and 1301.00555
to read as follows:
Sec. 1301.00553. MAXIMUM TRAVEL TIME AND DISTANCE STANDARDS
BY PREFERRED PROVIDER TYPE. (a) For purposes of this section, each
county in this state is classified as a large metro, metro, micro,
or rural county, or a county with extreme access considerations as
determined by the federal Centers for Medicare and Medicaid
Services by population and density thresholds as of March 1, 2023.
(b) Maximum travel time in minutes and maximum distance in
miles for preferred provider benefit plans by preferred provider
type for each large metro county are:
(1) For physicians:
(A) Designated by physician specialty. The
preferred provider benefit plan's network must comply with the time
and distance standards for the following physician specialties:
Time Distance
Allergy and Immunology 30 15
Anesthesiology 20 10
Cardiology 20 10
Cardiothoracic Surgery 30 15
Dermatology 20 10
Emergency Medicine 20 10
Endocrinology 30 15
Ear, Nose, and Throat/Otolaryngology 30 15
Gastroenterology 20 10
General Surgery 20 10
Gynecology and Obstetrics 10 5
Infectious Diseases 30 15
Nephrology 30 15
Neurology 20 10
Neurosurgery 30 15
Oncology: Medical, Surgical 20 10
Oncology: Radiation 30 15
Ophthalmology 20 10
Orthopedic Surgery 20 10
Physical Medicine and Rehabilitation 30 15
Plastic Surgery 30 15
Primary Care: Adults 10 5
Primary Care: Pediatric 10 5
Psychiatry 20 10
Pulmonology 20 10
Rheumatology 30 15
Urology 20 10
Vascular Surgery 30 15
(2) For health care providers:
(A) Designated by the kind of practitioner or
institutional provider furnishing the health care service.
(i) The preferred provider benefit plan's
network must comply with the time and distance standards for
practitioners licensed to provide health care services in this
state, in the following disciplines:
Time Distance
Chiropractic 30 15
Occupational Therapy 20 10
Physical Therapy 20 10
Podiatry 20 10
Speech Therapy 20 10
(ii) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following kinds of institutional providers:
Time Distance
Acute Inpatient Hospitals (Emergency
Services Available 24/7) 20 10
Cardiac Catheterization Services 30 15
Cardiac Surgery Program 30 15
Critical Care Services: Intensive Care Units 20 10
Diagnostic Radiology (Freestanding;
Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 20 10
Inpatient or Residential Behavioral
Health Facility Services 30 15
Mammography 20 10
Outpatient Infusion/Chemotherapy 20 10
Skilled Nursing Facilities 20 10
Surgical Services (Outpatient or Ambulatory Surgical Center) 20 10
(3) For other settings:
(A) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following settings:
Time Distance
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 10 5
Urgent Care 20 10
(c) Maximum travel time in minutes and maximum distance in
miles for preferred provider benefit plans by preferred provider
type for each metro county are:
(1) For physicians:
(A) Designated by physician specialty. The
preferred provider benefit plan's network must comply with the time
and distance standards for the following physician specialties:
Time Distance
Allergy and Immunology 45 30
Anesthesiology 30 20
Cardiology 30 20
Cardiothoracic Surgery 60 40
Dermatology 45 30
Emergency Medicine 45 30
Endocrinology 60 40
Ear, Nose, and Throat/Otolaryngology 45 30
Gastroenterology 45 30
General Surgery 30 20
Gynecology and Obstetrics 15 10
Infectious Diseases 60 40
Nephrology 45 30
Neurology 45 30
Neurosurgery 60 40
Oncology: Medical, Surgical 45 30
Oncology: Radiation 60 40
Ophthalmology 30 20
Orthopedic Surgery 30 20
Physical Medicine and Rehabilitation 45 30
Plastic Surgery 60 40
Primary Care: Adults 15 10
Primary Care: Pediatric 15 10
Psychiatry 45 30
Pulmonology 45 30
Rheumatology 60 40
Urology 45 30
Vascular Surgery 60 40
(2) For health care providers:
(A) Designated by the kind of practitioner or
institutional provider furnishing the health care service.
(i) The preferred provider benefit plan's
network must comply with the time and distance standards for
practitioners licensed to provide health care services in this
state, in the following disciplines:
Time Distance
Chiropractic 45 30
Occupational Therapy 45 30
Physical Therapy 45 30
Podiatry 45 30
Speech Therapy 45 30
(ii) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following kinds of institutional providers:
Time Distance
Acute Inpatient Hospitals (Emergency Services Available 24/7) 45 30
Cardiac Catheterization Services 60 40
Cardiac Surgery Program 60 40
Critical Care Services: Intensive Care Units 45 30
Diagnostic Radiology (Freestanding;
Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 45 30
Inpatient or Residential
Behavioral Health Facility Services 70 45
Mammography 45 30
Outpatient Infusion/Chemotherapy 45 30
Skilled Nursing Facilities 45 30
Surgical Services (Outpatient or Ambulatory Surgical Center) 45 30
(3) For other settings:
(A) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following settings:
Time Distance
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 15 10
Urgent Care 45 30
(d) Maximum travel time in minutes and maximum distance in
miles for preferred provider benefit plans by preferred provider
type for each micro county are:
(1) For physicians:
(A) Designated by physician specialty. The
preferred provider benefit plan's network must comply with the time
and distance standards for the following physician specialties:
Time Distance
Allergy and Immunology 80 60
Anesthesiology 50 35
Cardiology 50 35
Cardiothoracic Surgery 100 75
Dermatology 60 45
Emergency Medicine 80 60
Endocrinology 100 75
Ear, Nose, and Throat/Otolaryngology 80 60
Gastroenterology 80 60
General Surgery 50 35
Gynecology and Obstetrics 30 20
Infectious Diseases 100 75
Nephrology 80 60
Neurology 60 45
Neurosurgery 100 75
Oncology: Medical, Surgical 60 45
Oncology: Radiation 100 75
Ophthalmology 50 35
Orthopedic Surgery 50 35
Physical Medicine and Rehabilitation 80 60
Plastic Surgery 100 75
Primary Care: Adults 30 20
Primary Care: Pediatric 30 20
Psychiatry 60 45
Pulmonology 60 45
Rheumatology 100 75
Urology 60 45
Vascular Surgery 100 75
(2) For health care providers:
(A) Designated by the kind of practitioner or
institutional provider furnishing the health care service.
(i) The preferred provider benefit plan's
network must comply with the time and distance standards for
practitioners licensed to provide health care services in this
state, in the following disciplines:
Time Distance
Chiropractic 80 60
Occupational Therapy 80 60
Physical Therapy 80 60
Podiatry 60 45
Speech Therapy 80 60
(ii) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following kinds of institutional providers:
Time Distance
Acute Inpatient Hospitals (Emergency Services Available 24/7) 80 60
Cardiac Catheterization Services 160 120
Cardiac Surgery Program 160 120
Critical Care Services: Intensive Care Units 160 120
Diagnostic Radiology (Freestanding;
Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 80 60
Inpatient or Residential
Behavioral Health Facility Services 100 75
Mammography 80 60
Outpatient Infusion/Chemotherapy 80 60
Skilled Nursing Facilities 80 60
Surgical Services (Outpatient or Ambulatory Surgical Center) 80 60
(3) For other care and settings:
(A) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following care and settings:
Time Distance
Outpatient Clinical Behavioral Health (Texas Licensed, Accredited, or Certified) 30 20
Urgent Care 80 60
(e) Maximum travel time in minutes and maximum distance in
miles for preferred provider benefit plans by preferred provider
type for each rural county are:
(1) For physicians:
(A) Designated by physician specialty. The
preferred provider benefit plan's network must comply with the time
and distance standards for the following physician specialties:
Time Distance
Allergy and Immunology 90 75
Anesthesiology 75 60
Cardiology 75 60
Cardiothoracic Surgery 110 90
Dermatology 75 60
Emergency Medicine 75 60
Endocrinology 110 90
Ear, Nose, and Throat/Otolaryngology 90 75
Gastroenterology 75 60
General Surgery 75 60
Gynecology and Obstetrics 40 30
Infectious Diseases 110 90
Nephrology 90 75
Neurology 75 60
Neurosurgery 110 90
Oncology: Medical, Surgical 75 60
Oncology: Radiation 110 90
Ophthalmology 75 60
Orthopedic Surgery 75 60
Physical Medicine and Rehabilitation 90 75
Plastic Surgery 110 90
Primary Care: Adults 40 30
Primary Care: Pediatric 40 30
Psychiatry 75 60
Pulmonology 75 60
Rheumatology 110 90
Urology 75 60
Vascular Surgery 110 90
(2) For health care providers:
(A) Designated by the kind of practitioner or
institutional provider furnishing the health care service.
(i) The preferred provider benefit plan's
network must comply with the time and distance standards for
practitioners licensed to provide health care services in this
state, in the following disciplines:
Time Distance
Chiropractic 90 75
Occupational Therapy 75 60
Physical Therapy 75 60
Podiatry 75 60
Speech Therapy 75 60
(ii) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following kinds of institutional providers:
Time Distance
Acute Inpatient Hospitals (Emergency Services Available 24/7) 75 60
Cardiac Catheterization Services 145 120
Cardiac Surgery Program 145 120
Critical Care Services: Intensive Care Units 145 120
Diagnostic Radiology (Freestanding;
Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 75 60
Inpatient or Residential
Behavioral Health Facility Services 90 75
Mammography 75 60
Outpatient Infusion/Chemotherapy 75 60
Skilled Nursing Facilities 75 60
Surgical Services (Outpatient or Ambulatory Surgical Center) 75 60
(3) For other settings:
(A) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following settings:
Time Distance
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 40 30
Urgent Care 75 60
(f) Maximum travel time in minutes and maximum distance in
miles for preferred provider benefit plans by preferred provider
type for each county with extreme access considerations are:
(1) For physicians:
(A) Designated by physician specialty. The
preferred provider benefit plan's network must comply with the time
and distance standards for the following physician specialties:
Time Distance
Allergy and Immunology 125 110
Anesthesiology 95 85
Cardiology 95 85
Cardiothoracic Surgery 145 130
Dermatology 110 100
Emergency Medicine 110 100
Endocrinology 145 130
Ear, Nose, and Throat/Otolaryngology 125 110
Gastroenterology 110 100
General Surgery 95 85
Gynecology and Obstetrics 70 60
Infectious Diseases 145 130
Nephrology 125 110
Neurology 110 100
Neurosurgery 145 130
Oncology: Medical, Surgical 110 100
Oncology: Radiation 145 130
Ophthalmology 95 85
Orthopedic Surgery 95 85
Physical Medicine and Rehabilitation 125 110
Plastic Surgery 145 130
Primary Care: Adults 70 60
Primary Care: Pediatric 70 60
Psychiatry 110 100
Pulmonology 110 100
Rheumatology 145 130
Urology 110 100
Vascular Surgery 145 130
(2) For health care providers:
(A) Designated by the kind of practitioner or
institutional provider furnishing the health care service.
(i) The preferred provider benefit plan's
network must comply with the time and distance standards for
practitioners licensed to provide health care services in this
state, in the following disciplines:
Time Distance
Chiropractic 125 110
Occupational Therapy 110 100
Physical Therapy 110 100
Podiatry 110 100
Speech Therapy 110 100
(ii) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following kinds of institutional providers:
Time Distance
Acute Inpatient Hospitals (Emergency Services Available 24/7) 110 100
Cardiac Catheterization Services 155 140
Cardiac Surgery Program 155 140
Critical Care Services: Intensive Care Units 155 140
Diagnostic Radiology (Freestanding;
Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 110 100
Inpatient or Residential Behavioral
Health Facility Services 155 140
Mammography 110 100
Outpatient Infusion/Chemotherapy 110 100
Skilled Nursing Facilities 95 85
Surgical Services (Outpatient or Ambulatory Surgical Center) 110 100
(3) For other settings:
(A) The preferred provider benefit plan's
network must comply with the time and distance standards for the
following settings:
Time Distance
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 70 60
Urgent Care 110 100
Sec. 1301.00554. OTHER MAXIMUM DISTANCE STANDARD
REQUIREMENTS. (a) For any physician specialty not specifically
listed in Section 1301.00553, the maximum distance, in any county
classification, is 75 miles.
(b) When necessary due to utilization or supply patterns,
the commissioner may by rule decrease the base maximum time and
distance standards listed in this Section or Section 1301.00553 for
specific counties.
Sec. 1301.00555. MAXIMUM APPOINTMENT WAIT TIME STANDARDS.
An insurer must ensure that:
(1) routine care is available and accessible from
preferred providers:
(A) within three weeks for medical conditions;
and
(B) within two weeks for behavioral health
conditions; and
(2) preventive health care services are available and
accessible from preferred providers:
(A) within two months for a child, or earlier if
necessary for compliance with recommendations for specific
preventive health care services; and
(B) within three months for an adult.
SECTION 8. Section 1301.0056, Insurance Code, is amended by
amending Subsection (a) and adding Subsections (a-1) and (e) to
read as follows:
(a) The commissioner shall by rule adopt a process for the
commissioner to examine a preferred provider benefit plan before an
insurer offers for delivery the plan to insureds to determine
whether the plan meets the quality of care and network adequacy
standards of this chapter. An insurer may not offer [used by] a
preferred provider benefit plan before [or an exclusive provider
benefit plan offered by] the commissioner determines that the
network meets the quality of care and network adequacy standards of
[insurer under] this chapter.
(a-1) An insurer is subject to a qualifying examination of
the insurer's preferred provider benefit plans [and exclusive
provider benefit plans] and subsequent quality of care and network
adequacy examinations by the commissioner at least once every three
years, in connection with a public hearing under Section 1301.00565
concerning a material deviation from network adequacy standards by
a previously authorized plan or a request for a waiver of a network
adequacy standard, and whenever the commissioner considers an
examination necessary. Documentation provided to the commissioner
during an examination conducted under this section is confidential
and is not subject to disclosure as public information under
Chapter 552, Government Code.
(e) Rules adopted under this section must require insurers
to provide access to or submit data necessary for the commissioner
to evaluate and make a determination of compliance with quality of
care and network adequacy standards. The rules must require
insurers to submit data that includes:
(1) a searchable and sortable database of network
physicians and health care providers by national provider
identifier, county, physician specialty, hospital privileges and
credentials, and kind of health care provider or licensure type, as
applicable;
(2) actuarial data of current and projected number of
insureds by county; and
(3) actuarial data of current and projected
utilization of each preferred provider type listed in Sections
1301.00553 and 1301.00554(a) by county; and
(4) any other data or information considered necessary
by the commissioner to make a determination to authorize the use of
the preferred provider benefit plan in the most efficient and
effective manner possible.
SECTION 9. Subchapter A, Chapter 1301, Insurance Code, is
amended by adding Section 1301.00565 to read as follows:
Sec. 1301.00565. PUBLIC HEARING ON NETWORK ADEQUACY
STANDARDS WAIVERS. (a) On the earlier of a request from an insurer
to receive a waiver from any network adequacy standard or receipt of
notice under Section 1301.0055 of a material deviation from the
network adequacy standards of this chapter, the commissioner shall
set a public hearing for a determination of whether there is good
cause for a waiver.
(b) The commissioner shall notify affected physicians and
health care providers that may be the subject of a discussion of
good faith efforts on behalf of the insurer to meet network adequacy
standards and provide the physicians and health care providers with
an opportunity to submit evidence, including written testimony, and
to attend the public hearing and offer testimony either in person or
virtually. A physician, including a physician group referenced in
the insurer's waiver request or notice of material deviation, may
not be identified by name at the hearing unless the physician
consents to be identified in advance of the hearing.
(c) At the hearing, the commissioner shall consider all
written and oral testimony and evidence submitted by the insurer
and the public pertinent to the requested waiver, including:
(1) the total number of physicians or health care
providers in each preferred provider type listed in Section
1301.00553 within the county and service area being submitted for
the waiver and whether the insurer made a good faith effort to
contract with those required preferred provider types to meet
network adequacy standards of this chapter;
(2) the total number of facilities, and availability
of pediatric, for-profit, nonprofit, tax-supported, and teaching
facilities, within the county and service area being submitted for
a waiver and whether the insurer made a good faith effort to
contract with these facilities and facility-based physicians and
health care providers to meet network adequacy standards of this
chapter;
(3) population, density, and geographical information
to determine the possibility and travel time and distance
requirements within the county and service area being submitted for
a waiver; and
(4) availability of services, population, and density
within a county and service area being submitted for a waiver.
(d) The commissioner may not consider a prohibition on
balance billing in determining whether to grant a waiver from
network adequacy standards.
(e) The commissioner may not grant a waiver without a public
hearing.
(f) Except as provided by this subsection, any evidence
submitted to the commissioner as evidence for the public hearing
that is proprietary in nature is confidential and not subject to
disclosure as public information under Chapter 552, Government
Code. Information related to provider directories, credentials,
and privileges, estimates of patient populations, and actuarial
estimates of needed providers to meet the estimated patient
population is not protected under this subsection.
(g) A policyholder is entitled to seek judicial review of
the commissioner's decision to grant a waiver under this section in
Travis County district court. Review by the district court under
this subsection is de novo.
SECTION 10. Section 1301.009(b), Insurance Code, is amended
to read as follows:
(b) The report shall:
(1) be verified by at least two principal officers;
(2) be in a form prescribed by the commissioner; and
(3) include:
(A) a financial statement of the insurer,
including its balance sheet and receipts and disbursements for the
preceding calendar year, certified by an independent public
accountant;
(B) the number of individuals enrolled during the
preceding calendar year, the number of enrollees as of the end of
that year, and the number of enrollments terminated during that
year; and
(C) a statement of:
(i) an evaluation of enrollee satisfaction;
(ii) an evaluation of quality of care;
(iii) coverage areas;
(iv) accreditation status;
(v) premium costs;
(vi) plan costs;
(vii) premium increases;
(viii) the range of benefits provided;
(ix) copayments and deductibles;
(x) the accuracy and speed of claims
payment by the insurer for the plan;
(xi) the credentials of physicians who are
preferred providers;
(xii) the number of preferred providers;
[and]
(xiii) any waiver requests made and waivers
of network adequacy standards granted under Section 1301.00565; and
(xiv) any material deviation from network
adequacy standards reported to the department under Section
1301.0055; and
(xv) any corrective actions, sanctions or
penalties assessed against the insurer by the department for
deficiencies related to the preferred provider benefit plan.
SECTION 11. Subchapter B, Chapter 1301, Insurance Code is
amended by adding Section 1301.0642 to read as follows:
Sec. 1301.0642. CONTRACT PROVISIONS ALLOWING CERTAIN
CHANGE PROHIBITED. (a) In this section, "adverse material change"
means a change to a preferred provider contract that would decrease
the preferred provider's payment or compensation; change the
preferred provider's tier to a less preferred tier; or change the
administrative procedures in a way that may reasonably be expected
to significantly increase the provider's administrative expenses.
Adverse material change does not include:
(1) a decrease in payment or compensation resulting
soley from a change in a published fee schedule upon which the
payment or compensation is based and the date of applicability is
clearly identified in the contract;
(2) a decrease in payment or compensation that was
anticipated under the terms of the contract, if the amount and date
of applicability of the decrease is clearly identified in the
contract;
(3) An administrative change that may significantly
increase the preferred provider's administrative expense, the
specific applicability of which is clearly identified in the
contract; or
(4) A change that is required by the operation of state
or federal law.
(b) An adverse material change to a preferred provider
contract may only be made during the term of the preferred provider
contract with the mutual agreement of the parties. A provision in a
preferred provider contract that allows the insurer to unilaterally
make an adverse material change during the term of the contract is
void and unenforceable.
(c) Any adverse material change to the preferred provider
contract may not go into effect until 120 days after physician or
health care provider affirmatively agrees to the adverse material
change in writing.
(d) A proposed amendment by an insurer seeking an adverse
material change to a preferred provider contract must include a
notice that clearly and conspicuously identifies such amendment as
proposing an adverse material change to the contract. The notice
must also clearly and conspicuously state that a physician or
health care provider may choose not to agree to the amendment and
that such a decision not to agree to the amendment may not affect
the terms of the physician or health care provider's existing
contract with the insurer or the preferred provider's participation
in other health plans or products.
(e) A physician or health care provider's failure to agree
to an adverse material change to a preferred provider contract
shall not affect:
(1) the terms of the physician or health care
provider's existing contract or other contracts with the insurer;
or
(2) the preferred provider's participation in other
health care products or plans.
(f) An insurer's failure to include the notice described by
Subsection (d) with the proposed amendment shall make an otherwise
agreed-to adverse material change void and unenforceable.
SECTION 12. The changes in law made by this Act apply only
to an insurance policy that is delivered, issued, for delivery, or
renewed on or after January 1, 2024. A policy delivered, issued for
delivery, or renewed before January 1, 2024, is governed by the law
as it existed immediately before the effective date of this Act, and
the law is continued in effect for that purpose.
SECTION 13. This Act takes effect September 1, 2023.