Bill Text: TX SB744 | 2019-2020 | 86th Legislature | Introduced
Bill Title: Relating to the relationship between physicians or health care providers and health maintenance organizations or preferred provider benefit plans.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2019-03-01 - Referred to Business & Commerce [SB744 Detail]
Download: Texas-2019-SB744-Introduced.html
86R2897 SMT-F | ||
By: Perry | S.B. No. 744 |
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relating to the relationship between physicians or health care | ||
providers and health maintenance organizations or preferred | ||
provider benefit plans. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 843.306, Insurance Code, is amended by | ||
amending Subsections (a), (b), and (e) and adding Subsections | ||
(a-1), (a-2), (b-1), (b-2), (b-3), and (g) to read as follows: | ||
(a) Before terminating a contract with a physician or | ||
provider, a health maintenance organization shall provide to the | ||
physician or provider: | ||
(1) written notice of: | ||
(A) the health maintenance organization's intent | ||
to terminate the physician's or provider's contract; | ||
(B) the physician's or provider's right to | ||
request a review under Subsection (b); and | ||
(C) the physician's or provider's right to | ||
request the review be expedited under Section 843.307; and | ||
(2) a written explanation of the reasons for | ||
termination. | ||
(a-1) In a case involving fraud or malfeasance by a | ||
provider, the written notice required by Subsection (a) must | ||
include notice of the health maintenance organization's right to | ||
suspend the provider's participation in the health maintenance | ||
organization network during the review process as provided by | ||
Subsection (b-1). | ||
(a-2) If a health maintenance organization terminates a | ||
contract with a physician or provider, the health maintenance | ||
organization shall provide to the physician or provider a written | ||
copy of all information on which the health maintenance | ||
organization wholly or partly based the termination, including the | ||
economic profile of the physician or provider, the standards by | ||
which the physician or provider is measured, and the statistics | ||
underlying the profile and standards. | ||
(b) On request, before the effective date of the termination | ||
and within a period not to exceed 60 days, a physician or provider | ||
is entitled to a review by an advisory review panel of the health | ||
maintenance organization's proposed termination, except in a case | ||
involving: | ||
(1) imminent harm to patient health; | ||
(2) an action by a state medical or dental board, | ||
another medical or dental licensing board, or another licensing | ||
board or government agency that effectively impairs the physician's | ||
or provider's ability to practice medicine, dentistry, or another | ||
profession; or | ||
(3) fraud or malfeasance by a physician. | ||
(b-1) If a provider requests a review under Subsection (b) | ||
in a case involving fraud or malfeasance by the provider, the health | ||
maintenance organization may suspend the provider's participation | ||
in the health maintenance organization network: | ||
(1) beginning not earlier than the date notice is | ||
provided under Subsection (a); and | ||
(2) ending on the earlier of: | ||
(A) the 60th day after the date the provider | ||
requests the review; | ||
(B) the 30th day after the date the provider | ||
requests the review be expedited under Section 843.307, if | ||
applicable; or | ||
(C) the date the health maintenance organization | ||
makes a final determination under Subsection (b-2). | ||
(b-2) If a health maintenance organization suspends a | ||
provider's participation in the health maintenance organization | ||
network under Subsection (b-1), the health maintenance | ||
organization shall make a final determination to terminate or | ||
resume the provider's participation not later than three business | ||
days after the date the health maintenance organization receives | ||
the recommendation of the advisory review panel. The health | ||
maintenance organization shall immediately notify the provider of | ||
the determination. | ||
(b-3) Review under Subsection (b) must provide an | ||
opportunity for the physician or provider to present evidence to | ||
the advisory review panel before the panel makes a recommendation. | ||
(e) The health maintenance organization [ |
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provide to the affected physician or provider a copy of the | ||
recommendation of the advisory review panel and the health | ||
maintenance organization's determination. | ||
(g) A health maintenance organization may not terminate a | ||
provider's contract without cause. | ||
SECTION 2. Section 843.308, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 843.308. NOTIFICATION OF PATIENTS OF DESELECTED OR | ||
TERMINATED PHYSICIAN OR PROVIDER. (a) Except as provided by | ||
Subsection (b), if a physician or provider is deselected or | ||
terminated for a reason other than the request of the physician or | ||
provider, a health maintenance organization may not notify patients | ||
of the deselection or termination until the later of the effective | ||
date of the deselection or termination, or, if a review is | ||
requested, the date the advisory review panel makes a formal | ||
recommendation. | ||
(b) If the contract of a physician or provider is deselected | ||
or terminated for a reason related to imminent harm, a health | ||
maintenance organization may notify patients immediately. | ||
SECTION 3. Section 843.309, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 843.309. CONTRACTS WITH PHYSICIANS OR PROVIDERS: | ||
NOTICE TO CERTAIN ENROLLEES OF TERMINATION OF PHYSICIAN OR PROVIDER | ||
PARTICIPATION IN PLAN. Subject to Section 843.308, a [ |
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between a health maintenance organization and a physician or | ||
provider must provide that reasonable advance notice shall be given | ||
to an enrollee of the impending termination from the plan of a | ||
physician or provider who is currently treating the enrollee. | ||
SECTION 4. Subchapter I, Chapter 843, Insurance Code, is | ||
amended by adding Section 843.3095 to read as follows: | ||
Sec. 843.3095. WAIVER OF CERTAIN PROVISIONS PROHIBITED. | ||
The provisions of this subchapter related to deselection or | ||
termination of a contract with a physician or provider may not be | ||
waived, voided, or nullified by contract. | ||
SECTION 5. Section 1301.053, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1301.053. APPEAL RELATING TO DESIGNATION AS PREFERRED | ||
PROVIDER. (a) An insurer that does not designate a physician or | ||
health care provider [ |
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provide a reasonable mechanism for reviewing that action. The | ||
review mechanism must incorporate, in an advisory role only, a | ||
review panel. | ||
(b) A review panel must be composed of at least three | ||
individuals selected by the insurer from a list of participating | ||
physicians or health care providers [ |
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include one member who is a physician or health care provider | ||
[ |
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physician or health care provider [ |
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The physicians or health care providers [ |
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contracting with the insurer in the applicable service area shall | ||
provide the list of physicians or health care providers | ||
[ |
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(c) On request, the insurer shall provide to the affected | ||
physician or health care provider [ |
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(1) the panel's recommendation, if any; and | ||
(2) a written explanation of the insurer's | ||
determination, if that determination is contrary to the panel's | ||
recommendation. | ||
SECTION 6. Section 1301.057, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED | ||
REVIEW PROCESS. (a) Before terminating a contract with a preferred | ||
provider, an insurer shall: | ||
(1) provide written notice of: | ||
(A) the insurer's intent to terminate the | ||
preferred provider's contract; | ||
(B) the preferred provider's right to request a | ||
review under this section; and | ||
(C) the preferred provider's right to request the | ||
review be expedited under Subsection (d); | ||
(2) provide written reasons for the termination; and | ||
(3) [ |
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provide, on request, a reasonable review mechanism, except in a | ||
case involving: | ||
(A) imminent harm to a patient's health; | ||
(B) an action by a state medical or other | ||
physician licensing board or other government agency that | ||
effectively impairs the physician's or health care provider's | ||
[ |
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another profession; or | ||
(C) fraud or malfeasance by a physician. | ||
(a-1) In a case involving fraud or malfeasance by a health | ||
care provider, the written notice required by Subsection (a) must | ||
include notice of the insurer's right to suspend the health care | ||
provider's participation in the preferred provider benefit plan | ||
during the review process as provided by Subsection (a-3). | ||
(a-2) An insurer may not terminate a health care provider's | ||
contract without cause. | ||
(a-3) If a health care provider requests a review under | ||
Subsection (a) in a case involving fraud or malfeasance by the | ||
health care provider, the insurer may suspend the health care | ||
provider's participation in the preferred provider benefit plan: | ||
(1) beginning not earlier than the date notice is | ||
provided under Subsection (a); and | ||
(2) ending on the earlier of: | ||
(A) the 60th day after the date the health care | ||
provider requests the review; | ||
(B) the 30th day after the date the health care | ||
provider requests the review be expedited, if applicable; or | ||
(C) the date the insurer makes a final | ||
determination under Subsection (a-4). | ||
(a-4) If an insurer suspends a health care provider's | ||
participation in the preferred provider benefit plan under | ||
Subsection (a-3), the insurer shall make a final determination to | ||
terminate or resume the health care provider's participation not | ||
later than three business days after the date the insurer receives | ||
the recommendation of the review panel described by Subsection (b). | ||
The insurer shall immediately notify the health care provider of | ||
the insurer's determination. | ||
(b) The review mechanism described by Subsection (a)(3) | ||
[ |
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selected in the manner described by Section 1301.053(b) and must be | ||
completed within a period not to exceed 60 days. | ||
(b-1) Review under Subsection (a)(3) must provide an | ||
opportunity for the affected physician or health care provider to | ||
present evidence to the review panel before the panel makes a | ||
recommendation. | ||
(c) The insurer shall provide to the affected physician or | ||
health care provider [ |
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(1) the review panel's recommendation, if any; and | ||
(2) [ |
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insurer's determination, if that determination is contrary to the | ||
panel's recommendation. | ||
(d) On request, an insurer shall provide to a physician or | ||
health care provider [ |
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preferred provider benefit plan is being terminated: | ||
(1) an expedited review conducted in accordance with a | ||
process that complies with rules established by the commissioner; | ||
and | ||
(2) all information on which the insurer wholly or | ||
partly based the termination, including the economic profile of the | ||
preferred provider, the standards by which the physician or health | ||
care provider is measured, and the statistics underlying the | ||
profile and standards. | ||
(e) The provisions of this section may not be waived, | ||
voided, or nullified by contract. | ||
SECTION 7. Section 1301.160, Insurance Code, is amended by | ||
amending Subsections (a) and (c) and adding Subsection (d) to read | ||
as follows: | ||
(a) If a physician's or health care provider's | ||
[ |
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plan is terminated for a reason other than at the physician's or | ||
health care provider's [ |
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notify insureds of the termination until the later of: | ||
(1) the effective date of the termination; or | ||
(2) if a review is requested, the time at which a | ||
review panel makes a formal recommendation regarding the | ||
termination. | ||
(c) If a physician's or health care provider's | ||
[ |
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plan is terminated for reasons related to imminent harm, an insurer | ||
may notify insureds immediately. | ||
(d) The provisions of this section may not be waived, | ||
voided, or nullified by contract. | ||
SECTION 8. The changes in law made by this Act apply only to | ||
a contract entered into, amended, or renewed on or after the | ||
effective date of this Act. A contract entered into, amended, or | ||
renewed before the effective date of this Act is governed by the law | ||
as it existed immediately before the effective date of this Act, and | ||
that law is continued in effect for that purpose. | ||
SECTION 9. This Act takes effect September 1, 2019. |