Bill Text: TX HB3124 | 2017-2018 | 85th Legislature | Comm Sub
Bill Title: Relating to certain physician-specific comparison data compiled by a health benefit plan issuer, including the release of that data to physicians participating in certain physician-led organizations.
Spectrum: Partisan Bill (Republican 2-0)
Status: (Engrossed - Dead) 2017-05-26 - Returned to the Senate for further action [HB3124 Detail]
Download: Texas-2017-HB3124-Comm_Sub.html
By: Gooden (Senate Sponsor - Creighton) | H.B. No. 3124 | |
(In the Senate - Received from the House May 8, 2017; | ||
May 9, 2017, read first time and referred to Committee on Business & | ||
Commerce; May 17, 2017, reported favorably by the following vote: | ||
Yeas 8, Nays 0; May 17, 2017, sent to printer.) | ||
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relating to certain physician-specific comparison data compiled by | ||
a health benefit plan issuer, including the release of that data to | ||
physicians participating in certain physician-led organizations. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. The heading to Chapter 1460, Insurance Code, is | ||
amended to read as follows: | ||
CHAPTER 1460. [ |
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RANKINGS AND COST COMPARISONS BY HEALTH BENEFIT PLANS | ||
SECTION 2. Chapter 1460, Insurance Code, is amended by | ||
designating Sections 1460.001 and 1460.002 as Subchapter A and | ||
adding a subchapter heading to read as follows: | ||
SUBCHAPTER A. GENERAL PROVISIONS | ||
SECTION 3. Section 1460.001, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1460.001. DEFINITIONS. In this chapter: | ||
(1) "Accountable care organization" means an entity: | ||
(A) that is composed of physicians or physicians | ||
and other health care providers; | ||
(B) that is owned and controlled by one or more | ||
physicians licensed in this state and engaged in active clinical | ||
practice in this state; | ||
(C) that contracts with a health benefit plan | ||
issuer to provide medical or health care services to a defined | ||
population; | ||
(D) that uses a payment structure that takes into | ||
account the total costs and quality of the care provided to the | ||
defined population served by the entity; and | ||
(E) through which physicians and health care | ||
providers, if any: | ||
(i) share in savings created by improvement | ||
of the quality of, and reduction of cost increases for, care | ||
delivered to the defined population served by the entity; or | ||
(ii) are compensated through another | ||
payment methodology intended to reduce the total cost of care | ||
delivered to the defined population served by the entity. | ||
(2) "Cost comparison data" means information compiled | ||
by a health benefit plan issuer to show the health care costs | ||
associated with a physician or other health care provider relative | ||
to another physician or health care provider. | ||
(3) "Designated entity" means a limited liability | ||
company in which a majority ownership interest is held by an | ||
incorporated association whose purpose includes uniting in one | ||
organization all physicians licensed to practice medicine in this | ||
state and that has been in continued existence for at least 15 | ||
years. | ||
(4) "Health benefit plan issuer" means an entity | ||
authorized under this code or another insurance law of this state | ||
that provides health insurance or health benefits in this state, | ||
including: | ||
(A) an insurance company; | ||
(B) a group hospital service corporation | ||
operating under Chapter 842; | ||
(C) a health maintenance organization operating | ||
under Chapter 843; and | ||
(D) a stipulated premium company operating under | ||
Chapter 884. | ||
(5) "Participating physician" means a physician who | ||
participates in an accountable care organization. | ||
(6) [ |
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practice medicine in this state or another state of the United | ||
States. | ||
SECTION 4. Chapter 1460, Insurance Code, is amended by | ||
designating Sections 1460.003 through 1460.007 as Subchapter B and | ||
adding a subchapter heading to read as follows: | ||
SUBCHAPTER B. PHYSICIAN RANKINGS | ||
SECTION 5. Section 1460.003(a), Insurance Code, is amended | ||
to read as follows: | ||
(a) Except as provided by Subchapter C, a [ |
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benefit plan issuer, including a subsidiary or affiliate, may not | ||
rank physicians, classify physicians into tiers based on | ||
performance, or publish physician-specific information that | ||
includes rankings, tiers, ratings, or other comparisons of a | ||
physician's performance against standards, measures, or other | ||
physicians, unless: | ||
(1) the standards used by the health benefit plan | ||
issuer conform to nationally recognized standards and guidelines as | ||
required by rules adopted under Section 1460.005; | ||
(2) the standards and measurements to be used by the | ||
health benefit plan issuer are disclosed to each affected physician | ||
before any evaluation period used by the health benefit plan | ||
issuer; and | ||
(3) each affected physician is afforded, before any | ||
publication or other public dissemination, an opportunity to | ||
dispute the ranking or classification through a process that, at a | ||
minimum, includes due process protections that conform to the | ||
following protections: | ||
(A) the health benefit plan issuer provides at | ||
least 45 days' written notice to the physician of the proposed | ||
rating, ranking, tiering, or comparison, including the | ||
methodologies, data, and all other information utilized by the | ||
health benefit plan issuer in its rating, tiering, ranking, or | ||
comparison decision; | ||
(B) in addition to any written fair | ||
reconsideration process, the health benefit plan issuer, upon a | ||
request for review that is made within 30 days of receiving the | ||
notice under Paragraph (A), provides a fair reconsideration | ||
proceeding, at the physician's option: | ||
(i) by teleconference, at an agreed upon | ||
time; or | ||
(ii) in person, at an agreed upon time or | ||
between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday; | ||
(C) the physician has the right to provide | ||
information at a requested fair reconsideration proceeding for | ||
determination by a decision-maker, have a representative | ||
participate in the fair reconsideration proceeding, and submit a | ||
written statement at the conclusion of the fair reconsideration | ||
proceeding; and | ||
(D) the health benefit plan issuer provides a | ||
written communication of the outcome of a fair reconsideration | ||
proceeding prior to any publication or dissemination of the rating, | ||
ranking, tiering, or comparison. The written communication must | ||
include the specific reasons for the final decision. | ||
SECTION 6. Section 1460.005(a), Insurance Code, is amended | ||
to read as follows: | ||
(a) The commissioner shall adopt rules as necessary to | ||
implement this subchapter [ |
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SECTION 7. Sections 1460.006 and 1460.007, Insurance Code, | ||
are amended to read as follows: | ||
Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A | ||
health benefit plan issuer shall ensure that: | ||
(1) physicians currently in clinical practice are | ||
actively involved in the development of the standards used under | ||
this subchapter [ |
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(2) the measures and methodology used in the | ||
comparison programs described by Section 1460.003 are transparent | ||
and valid. | ||
Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A | ||
health benefit plan issuer that violates this subchapter [ |
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or a rule adopted under this subchapter [ |
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sanctions and disciplinary actions under Chapters 82 and 84. | ||
(b) A violation of this subchapter [ |
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constitutes grounds for disciplinary action by the Texas Medical | ||
Board, including imposition of an administrative penalty. | ||
SECTION 8. Chapter 1460, Insurance Code, is amended by | ||
adding Subchapter C to read as follows: | ||
SUBCHAPTER C. COST COMPARISON DATA | ||
Sec. 1460.051. PROVISION OF COST COMPARISON DATA | ||
AUTHORIZED. Notwithstanding Section 1460.003, a health benefit | ||
plan issuer may provide cost comparison data to a participating | ||
physician or a designated entity. | ||
Sec. 1460.052. PROVISION OF CERTAIN COST COMPARISON DATA | ||
REQUIRED. If cost comparison data associated with health care | ||
providers other than physicians is available to a health benefit | ||
plan issuer that provides cost comparison data under Section | ||
1460.051, the plan issuer shall provide the cost comparison data | ||
associated with the other health care providers. | ||
Sec. 1460.053. REQUIRED DISCLOSURES. Not later than the | ||
15th business day after the date that a health benefit plan issuer | ||
receives a request from a participating physician, the health | ||
benefit plan issuer shall disclose to the physician: | ||
(1) the cost comparison data associated with the | ||
physician; | ||
(2) the measures and methodology used to compare | ||
costs; and | ||
(3) any other information considered in making the | ||
cost comparison. | ||
Sec. 1460.054. RIGHT TO DISPUTE. (a) A health benefit plan | ||
issuer shall give a physician, regardless of whether the physician | ||
is a participating physician, a fair opportunity to dispute the | ||
cost comparison data associated with the physician at least once | ||
each calendar quarter and when the health benefit plan issuer | ||
changes the measures and methodology described by Section 1460.053. | ||
(b) A physician may initiate a dispute by sending to the | ||
health benefit plan issuer a written statement of the dispute. | ||
Sec. 1460.055. DISPUTE PROCEEDING. (a) Not later than the | ||
15th business day after the date a health benefit plan issuer | ||
receives a statement of the dispute under Section 1460.054, the | ||
plan issuer shall provide the cost comparison data associated with | ||
the physician, the measures and methodology used to compare costs, | ||
and any other information considered in making the cost comparison, | ||
unless the information was already provided under Section 1460.052. | ||
(b) In addition to any written fair reconsideration | ||
process, the health benefit plan issuer shall provide a cost | ||
comparison data dispute proceeding, at the physician's option: | ||
(1) by teleconference, at an agreed upon time; or | ||
(2) in person, at an agreed upon time. | ||
(c) At the proceeding described by Subsection (b), the | ||
physician has the right to: | ||
(1) provide information to a decision-maker; | ||
(2) have a representative participate in the | ||
proceeding; and | ||
(3) submit a written statement at the conclusion of | ||
the proceeding. | ||
(d) The health benefit plan issuer shall provide to the | ||
physician who initiated the dispute process under Section 1460.054 | ||
a written communication of the outcome of the proceeding not later | ||
than the 60th day after the date the physician initiated the dispute | ||
process. The written communication must include the specific | ||
reasons for the final decision. | ||
Sec. 1460.056. CORRECTIONS REQUIRED. If in a dispute | ||
process initiated under Section 1460.054 the health benefit plan | ||
issuer determines that the physician's cost comparison data is | ||
inaccurate or the measures and methodology used to compare costs | ||
are invalid, the health benefit plan issuer shall promptly correct | ||
the data or update the measures and methodology and associated | ||
data, as applicable. | ||
Sec. 1460.057. MEASURES AND METHODOLOGY. The measures and | ||
methodology used to compare costs under this subchapter must use | ||
risk and severity adjustments to account for health status | ||
differences among different patient populations. | ||
Sec. 1460.058. NOTICE REQUIRED. A health benefit plan | ||
issuer shall provide written notice to a physician who contracts | ||
with the plan issuer that: | ||
(1) explains the plan issuer's compilation and use of | ||
cost comparison data, the purpose and scope of the plan issuer's | ||
release of cost comparison data under this subchapter, and the | ||
requirements of this subchapter regarding cost comparison data; and | ||
(2) informs the physician of the physician's rights | ||
and duties under this subchapter. | ||
Sec. 1460.059. CONFIDENTIALITY. A physician who receives | ||
cost comparison data about another physician under this subchapter | ||
may not disclose the data to any other person, except for the | ||
purpose of: | ||
(1) managing an accountable care organization; | ||
(2) managing the receiving physician's practice or | ||
referrals; | ||
(3) evaluating or disputing the cost comparison data | ||
associated with the receiving physician; | ||
(4) obtaining professional advice related to a legal | ||
claim; or | ||
(5) reporting, complaining, or responding to a | ||
governmental agency. | ||
Sec. 1460.060. CONSTRUCTION OF SUBCHAPTER. Nothing in this | ||
subchapter may be construed to authorize: | ||
(1) the disclosure of a contract rate; or | ||
(2) the publication of cost comparison data to a | ||
person other than a participating physician or a designated | ||
entity. | ||
Sec. 1460.061. RULES. The commissioner shall adopt rules | ||
as necessary to implement this subchapter. | ||
Sec. 1460.062. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A | ||
health benefit plan issuer shall ensure that: | ||
(1) physicians currently in clinical practice are | ||
actively involved in the development of the standards used under | ||
this subchapter; and | ||
(2) the measures and methodology used in the | ||
development of cost comparison data described by this subchapter | ||
are transparent and valid. | ||
Sec. 1460.063. SANCTIONS; DISCIPLINARY ACTIONS. (a) A | ||
health benefit plan issuer that violates this subchapter or a rule | ||
adopted under this subchapter is subject to sanctions and | ||
disciplinary actions under Chapters 82 and 84. | ||
(b) A violation of this subchapter by a physician | ||
constitutes grounds for disciplinary action by the Texas Medical | ||
Board, including imposition of an administrative penalty. | ||
SECTION 9. The change in law made by this Act applies only | ||
to a contract between a physician and a health benefit plan issuer | ||
entered into or renewed on or after September 1, 2017. A contract | ||
between a physician and health benefit plan issuer entered into or | ||
renewed before September 1, 2017, is governed by the law as it | ||
existed immediately before that date, and that law is continued in | ||
effect for that purpose. | ||
SECTION 10. This Act takes effect September 1, 2017. | ||
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