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.