Bill Text: TX SB1188 | 2019-2020 | 86th Legislature | Introduced


Bill Title: Relating to health benefit plan provider networks; providing an administrative penalty; authorizing an assessment.

Spectrum: Slight Partisan Bill (Republican 3-1)

Status: (Introduced - Dead) 2019-03-07 - Referred to Business & Commerce [SB1188 Detail]

Download: Texas-2019-SB1188-Introduced.html
  86R4498 SMT-F
 
  By: Buckingham, et al. S.B. No. 1188
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to health benefit plan provider networks; providing an
  administrative penalty; authorizing an assessment.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 842.261, Insurance Code, is amended by
  adding Subsection (a-1) and amending Subsection (c) to read as
  follows:
         (a-1)  The listing required by Subsection (a) must meet the
  requirements of a provider directory under Sections 1451.504 and
  1451.505.  Notwithstanding Subsection (b), the group hospital
  service corporation is subject to the requirements of Sections
  1451.504 and 1451.505, including the time limits for directory
  corrections and updates, with respect to the listing.
         (c)  The commissioner may adopt rules as necessary to
  implement this section. The rules may govern the form and content
  of the information required to be provided under this section
  [Subsection (a)].
         SECTION 2.  Section 843.2015, Insurance Code, is amended by
  adding Subsection (a-1) and amending Subsection (c) to read as
  follows:
         (a-1)  The listing required by Subsection (a) must meet the
  requirements of a provider directory under Sections 1451.504 and
  1451.505.  Notwithstanding Subsection (b), the health maintenance
  organization is subject to the requirements of Sections 1451.504
  and 1451.505, including the time limits for directory corrections
  and updates, with respect to the listing.
         (c)  The commissioner may adopt rules as necessary to
  implement this section. The rules may govern the form and content
  of the information required to be provided under this section
  [Subsection (a)].
         SECTION 3.  Sections 1301.0056(a) and (d), Insurance Code,
  are amended to read as follows:
         (a)  The commissioner shall [may] examine an insurer to
  determine the quality and adequacy of a network used by a preferred
  provider benefit plan [an exclusive provider benefit plan] offered
  by the insurer under this chapter.  An insurer is subject to a
  qualifying examination of the insurer's preferred provider benefit
  plans [exclusive provider benefit plans] and subsequent quality of
  care and network adequacy examinations by the commissioner at least
  once every two [five] years 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.
         (d)  The department shall deposit an assessment collected
  under this section to the credit of the [Texas Department of
  Insurance operating] account with the Texas Treasury Safekeeping
  Trust Company described by Section 401.156.  Money deposited under
  this subsection shall be used to pay the salaries and expenses of
  examiners and all other expenses relating to the examination of
  insurers under this section.
         SECTION 4.  Section 1301.1591, Insurance Code, is amended by
  adding Subsection (a-1) and amending Subsection (c) to read as
  follows:
         (a-1)  The listing required by Subsection (a) must meet the
  requirements of a provider directory under Sections 1451.504 and
  1451.505.  Notwithstanding Subsection (b), the insurer is subject
  to the requirements of Sections 1451.504 and 1451.505, including
  the time limits for directory corrections and updates, with respect
  to the listing.
         (c)  The commissioner may adopt rules as necessary to
  implement this section.  The rules may govern the form and content
  of the information required to be provided under this section
  [Subsection (a)].
         SECTION 5.  Section 1451.504(b), Insurance Code, is amended
  to read as follows:
         (b)  The directory must include the name, specialty, if any,
  street address, and telephone number of each physician and health
  care provider described by Subsection (a) and indicate whether the
  physician or provider is accepting new patients.
         SECTION 6.  The heading to Section 1451.505, Insurance Code,
  is amended to read as follows:
         Sec. 1451.505.  ACCESSIBILITY AND ACCURACY OF PHYSICIAN AND
  HEALTH CARE PROVIDER DIRECTORY [ON INTERNET WEBSITE].
         SECTION 7.  Section 1451.505, Insurance Code, is amended by
  amending Subsections (c), (d), and (e) and adding Subsections
  (d-1), (d-2), (d-3), and (f) through (p) to read as follows:
         (c)  The directory must be:
               (1)  electronically searchable by physician or health
  care provider name, specialty, if any, and location; and
               (2)  publicly accessible without necessity of
  providing a password, a user name, or personally identifiable
  information.
         (d)  The health benefit plan issuer shall conduct an ongoing
  review of the directory and correct or update the information as
  necessary. Except as provided by Subsections (d-1), (d-2), (d-3),
  and (f) [Subsection (e)], corrections and updates, if any, must be
  made not less than once every two business days [each month].
         (d-1)  Except as provided by Subsection (d-2), the health
  benefit plan issuer shall update the directory to:
               (1)  list a physician or health care provider not later
  than two business days after the effective date of the contract that
  establishes the physician's or other health care provider's
  participation in a network for a health benefit plan offered by the
  issuer; or
               (2)  remove a physician or health care provider not
  later than two business days after the effective date of the
  termination of the physician's or health care provider's contract
  if the termination is at the request of the physician or health care
  provider.
         (d-2)  Except as provided by Subsection (d-3), if the
  termination of the physician's or health care provider's contract
  was not at the request of the physician or health care provider and
  the health benefit plan issuer is subject to Section 843.308 or
  1301.160, the health benefit plan issuer shall remove the physician
  or health care provider from the directory not later than two
  business days after the later of:
               (1)  the date of a formal recommendation under Section
  843.306 or 1301.057, as applicable; or
               (2)  the effective date of the termination.
         (d-3)  If the termination was related to imminent harm, the
  health benefit plan issuer shall remove the physician or health
  care provider from the directory in the time provided by Subsection
  (d-1)(2).
         (e)  The health benefit plan issuer shall conspicuously
  display in at least 10-point boldfaced font in the directory
  required by Section 1451.504 a notice that an individual may report
  an inaccuracy in the directory to the health benefit plan issuer or
  the department.  The health benefit plan issuer shall include in the
  notice: 
               (1)  an e-mail address and a toll-free telephone number
  to which any individual may report any inaccuracy in the directory
  to the health benefit plan issuer; and
               (2)  an e-mail address and Internet website address or
  link for the appropriate complaint division of the department.
         (f)  Notwithstanding any other law, if [If] the health
  benefit plan issuer receives an oral or written [a] report from any
  person that specifically identified directory information may be
  inaccurate, the issuer shall:
               (1)  immediately:
                     (A)  inform the individual of the individual's
  right to report inaccurate directory information to the department;
  and
                     (B)  provide the individual with an e-mail address
  and Internet website address or link for the appropriate complaint
  division of the department;
               (2)  investigate the report and correct the
  information, as necessary, not later than:
                     (A)  the second business [seventh] day after the
  date the report is received if the report concerns the health
  benefit plan issuer's representation of the network participation
  status of the physician or health care provider; or
                     (B)  the fifth day after the date the report is
  received if the report concerns any other type of information in the
  directory; and
               (3)  promptly enter the report in the log required
  under Subsection (h).
         (g)  A health benefit plan issuer that receives an oral
  report that specifically identified directory information may be
  inaccurate may not require the individual making the oral report to
  file a written report to trigger the time limits and requirements of
  this section.
         (h)  The health benefit plan issuer shall create and maintain
  for inspection by the department a log that records all reports
  regarding inaccurate network directories or listings.  The log
  required under this subsection must include supporting information
  as required by the commissioner by rule, including:
               (1)  the name of the person, if known, who reported the
  inaccuracy and whether the person is an insured, enrollee,
  physician, health care provider, or other individual;
               (2)  the alleged inaccuracy that was reported;
               (3)  the date of the report;
               (4)  steps taken by the health benefit plan issuer to
  investigate the report, including the date each of the steps was
  taken;
               (5)  the findings of the investigation of the report;
               (6)  a copy of the health benefit plan issuer's
  correction or update, if any, made to the network directory as a
  result of the investigation, including the date of the correction
  or update;
               (7)  proof that the health benefit plan issuer made the
  disclosure required by Subsection (f)(1); and 
               (8)  the total number of reports received each month
  for each network offered by the health benefit plan issuer.
         (i)  A health benefit plan issuer shall submit the log
  required by Subsection (h) at least once annually on a date
  specified by the commissioner by rule and as otherwise required by
  Subsection (l).
         (j)  A health benefit plan issuer shall retain the log for
  three years after the last entry date unless the commissioner by
  rule requires a longer retention period. 
         (k)  The following elements of a log provided to the
  department under this section are confidential and are not subject
  to disclosure as public information under Chapter 552, Government
  Code:
               (1)  personally identifiable information or medical
  information about the individual making the report; and
               (2)  personally identifiable information about a
  physician or health care provider.
         (l)  If, in any 30-day period, the health benefit plan issuer
  receives three or more reports that allege the health benefit plan
  issuer's directory inaccurately represents a physician's or a
  health care provider's network participation status and that are
  confirmed by the health benefit plan issuer's investigation, the
  health benefit plan issuer shall immediately report that occurrence
  to the commissioner and provide to the department a copy of the log
  required by Subsection (h).
         (m)  The department shall review a log submitted by a health
  benefit plan issuer under Subsection (i) or (l). If the department
  determines that the health benefit plan issuer appears to have
  engaged in a pattern of maintaining an inaccurate network
  directory, the commissioner shall investigate the health benefit
  plan issuer's compliance with Subsections (d-1) and (d-2).
         (n)  A health benefit plan issuer investigated under this
  section shall pay the cost of the investigation in an amount
  determined by the commissioner.
         (o)  The department shall collect an assessment in an amount
  determined by the commissioner from the health benefit plan issuer
  at the time of the investigation to cover all expenses attributable
  directly to the investigation, including the salaries and expenses
  of department employees and all reasonable expenses of the
  department necessary for the administration of this section.  The
  department shall deposit an assessment collected under this section
  to the credit of the account with the Texas Treasury Safekeeping
  Trust Company described by Section 401.156.
         (p)  Money deposited under this section shall be used to pay
  the salaries and expenses of investigators and all other expenses
  related to the investigation of a health benefit plan issuer under
  this section.
         SECTION 8.  The heading to Chapter 1467, Insurance Code, is
  amended to read as follows:
  CHAPTER 1467.  OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION; NETWORK
  ADEQUACY
         SECTION 9.  The heading to Subchapter D, Chapter 1467,
  Insurance Code, is amended to read as follows:
  SUBCHAPTER D. COMPLAINTS; CONSUMER PROTECTION; NETWORK ADEQUACY
         SECTION 10.  Subchapter D, Chapter 1467, Insurance Code, is
  amended by adding Sections 1467.152 and 1467.153 to read as
  follows:
         Sec. 1467.152.  NETWORK ADEQUACY EXAMINATIONS AND FEES. (a)
  At the beginning of each calendar year, the department shall review
  mediation request information collected by the department for the
  preceding calendar year to identify the two insurers with the
  highest percentage of claims that are subject to mediation requests
  under this chapter in comparison to other insurers offering health
  benefit plans subject to mediation for the reviewed year.
         (b)  Not later than May 1 of each year, the department shall
  examine any insurer identified under Subsection (a) to determine
  the quality and adequacy of networks offered by the insurer.
         (c)  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. 
         (d)  An insurer examined under this section shall pay the
  cost of the examination in an amount determined by the
  commissioner.
         (e)  The department shall collect an assessment in an amount
  determined by the commissioner from the insurer at the time of the
  examination to cover all expenses attributable directly to the
  examination, including the salaries and expenses of department
  employees and all reasonable expenses of the department necessary
  for the administration of this section.  The department shall
  deposit an assessment collected under this section to the credit of
  the account with the Texas Treasury Safekeeping Trust Company
  described by Section 401.156.
         (f)  Money deposited under this section shall be used to pay
  the salaries and expenses of examiners and all other expenses
  related to the examination of an insurer under this section.
         (g)  An examination conducted by the department under this
  section is in addition to any examination of an insurer required by
  other law, including Section 1301.0056.
         (h)  The commissioner shall publish and make available on the
  department's Internet website for at least 10 years after the date
  of the examination information regarding an examination under this
  section, including:
               (1)  the name of an insurer and health benefit plan
  whose networks were examined under this section; and
               (2)  each year in which the insurer was subject to an
  examination under this section.
         Sec. 1467.153.  TERMINATION WITHOUT CAUSE. (a) In this
  section, "termination without cause" means the termination of the
  provider network or preferred provider contract between a
  physician, practitioner, health care provider, or facility and an
  insurer for a reason other than:
               (1)  at the request of the physician, practitioner,
  health care provider, or facility; or
               (2)  fraud or a material breach of contract.
         (b)  An insurer shall notify the department on the 15th day
  of each month of the total number of terminations without cause made
  by the insurer during the preceding month with respect to a health
  benefit plan that is subject to this chapter.  The notification
  shall include information identifying:
               (1)  the type and number of physicians, practitioners,
  health care providers, or facilities that were terminated; 
               (2)  the location of the physician, practitioner,
  health care provider, or facility that was terminated; and
               (3)  each health benefit plan offered by the insurer
  that is affected by the termination.
         (c)  The department may investigate any insurer notifying
  the department of a significant number of terminations without
  cause with respect to a health benefit plan subject to this chapter.  
  The investigation must emphasize terminations without cause that:
               (1)  may impact the quality or adequacy of a health
  benefit plan's network; or
               (2)  occur within the first three months after an open
  enrollment period closes. 
         (d)  Except for good cause shown, the department shall impose
  an administrative penalty in accordance with Chapter 84 on an
  insurer if the department makes a determination that the
  terminations without cause made by an insurer caused, wholly or
  partly, an inadequate network to be used by a health benefit plan
  that is offered by the insurer.  The department may not grant a
  waiver from any related network adequacy requirements to an insurer
  offering a health benefit plan with an inadequate network caused,
  wholly or partly, by terminations without cause made by the
  insurer.
         (e)  Personally identifiable information regarding a
  physician or practitioner included in documentation provided to or
  collected by the department under this section is confidential and
  is not subject to disclosure as public information under Chapter
  552, Government Code.
         SECTION 11.  This Act takes effect September 1, 2019.
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