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A BILL TO BE ENTITLED
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AN ACT
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relating to required procedures regarding the ranking of physicians |
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by health benefit plan issuers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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by adding Chapter 1460 to read as follows: |
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CHAPTER 1460. PHYSICIAN RANKING BY HEALTH BENEFIT PLANS |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1460.001. DEFINITIONS. In this chapter: |
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(1) "Hearing panel" means the physician panel |
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described by Section 1460.056(a). |
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(2) "Physician" means an individual licensed to |
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practice medicine in this state under Subtitle B, Title 3, |
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Occupations Code. |
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Sec. 1460.002. APPLICABILITY. This chapter applies to any |
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health benefit plan that: |
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(1) provides benefits for medical or surgical expenses |
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incurred as a result of a health condition, accident, or sickness, |
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including an individual, group, blanket, or franchise insurance |
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policy or insurance agreement, a group hospital service contract, |
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or an individual or group evidence of coverage that is offered by: |
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(A) an insurance company; |
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(B) a group hospital service corporation |
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operating under Chapter 842; |
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(C) a fraternal benefit society operating under |
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Chapter 885; |
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(D) a stipulated premium company operating under |
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Chapter 884; |
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(E) a health maintenance organization operating |
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under Chapter 843; |
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(F) a multiple employer welfare arrangement that |
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holds a certificate of authority under Chapter 846; |
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(G) an approved nonprofit health corporation |
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that holds a certificate of authority under Chapter 844; or |
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(H) an entity not authorized under this code or |
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another insurance law of this state that contracts directly for |
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health care services on a risk-sharing basis, including a |
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capitation basis; or |
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(2) provides health and accident coverage through a |
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risk pool created under Chapter 172, Local Government Code, |
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notwithstanding Section 172.014, Local Government Code, or any |
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other law. |
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[Sections 1460.003-1460.050 reserved for expansion] |
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SUBCHAPTER B. RESTRICTIONS ON PHYSICIAN RANKING |
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Sec. 1460.051. PHYSICIAN RANKING. A health benefit plan |
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issuer, including a subsidiary or an affiliate of the health |
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benefit plan issuer, may not, in any manner, disseminate |
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information to the public that compares, rates, tiers, classifies, |
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measures, or ranks a physician's performance, efficiency, or |
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quality of practice against objective standards or the practice of |
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other physicians unless: |
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(1) the objective standards or comparison criteria |
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used by the health benefit plan issuer are disclosed to the |
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physician prior to the evaluation period; |
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(2) the data used to establish satisfaction of the |
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objective criteria or to make the comparison are available to the |
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physician for verification before any dissemination of information |
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to the public; and |
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(3) the health benefit plan issuer provides due |
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process to the physician as provided by this chapter. |
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Sec. 1460.052. INJUNCTIVE RELIEF. (a) A writ of injunction |
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may be granted by any district court if a health benefit plan issuer |
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disseminates, or intends to disseminate, information that |
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compares, rates, tiers, classifies, measures, or ranks physician |
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performance, efficiency, or quality without meeting the criteria |
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required under Section 1460.051. |
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(b) An action under Subsection (a) may be brought by any |
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affected physician or on the behalf of affected physicians. |
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(c) Subchapter B, Chapter 26, Civil Practice and Remedies |
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Code, does not apply to an action brought under this chapter. |
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Sec. 1460.053. DUE PROCESS; NOTICE OF INTENT. (a) Before a |
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health benefit plan issuer declines to invite a physician into a |
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preferred tier, classifies a physician into a particular tier, or |
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otherwise differentiates a physician from the physician's peers |
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based on performance, efficiency, or quality, the issuer must |
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notify the affected physician of its intent in a written notice |
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that meets the requirements of this section. |
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(b) A notice of intent issued under Subsection (a) must |
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include: |
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(1) a statement describing the proposed action of the |
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health benefit plan issuer and the reasons for that proposed |
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action; |
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(2) a statement that the affected physician has the |
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right to request a hearing on the proposed action as provided by |
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this chapter; |
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(3) any time limit within which the physician must |
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request a hearing under this chapter, which may not be less than 60 |
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days from the date on which the notice of intent is issued; and |
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(4) a summary of the physician's rights under Section |
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1460.055. |
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Sec. 1460.054. NOTICE OF HEARING. If a hearing is requested |
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by a physician who receives a notice of intent under Section |
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1460.053, not later than the 30th day after the date on which the |
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physician requests the hearing the physician must be given a |
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written notice of the hearing that includes: |
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(1) a statement of the place, time, and date of the |
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hearing, which must be conducted: |
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(A) not less than 60 days after the date the |
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notice of the hearing is received by the physician; and |
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(B) not more than 90 days after the date the |
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notice of the hearing is received by the physician; and |
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(2) a list of the witnesses, if any, expected to |
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testify at the hearing on behalf of the health benefit plan issuer. |
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Sec. 1460.055. PHYSICIAN RIGHTS. A physician who requests |
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a hearing under this chapter has the following rights at the |
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hearing: |
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(1) the right to be represented by counsel; |
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(2) the right to have a record made of the proceedings |
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and to obtain a copy of the record for a reasonable charge; |
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(3) the right to call, examine, and cross-examine |
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witnesses; |
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(4) the right to present evidence; |
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(5) the right to submit a written statement to the |
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hearing panel at the close of the hearing; and |
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(6) the right to receive, following the hearing, the |
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written decision of the hearing panel, including a statement of the |
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basis for any recommendations by the panel. |
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Sec. 1460.056. HEARING PANEL; CONDUCT OF HEARING. (a) A |
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hearing requested under Section 1460.054 must be held before a |
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panel of three physicians who practice the same medical specialty |
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as the affected physician or a similar medical specialty. |
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(b) The order of presentation in the hearing shall be as |
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follows: |
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(1) opening statements by the health benefit plan |
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issuer followed by the physician or the physician's counsel; |
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(2) presentation of the case by the health benefit |
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plan issuer followed by presentation of the case by the physician or |
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the physician's counsel; |
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(3) rebuttal by the health benefit plan issuer |
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followed by the physician or the physician's counsel; and |
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(4) closing statements by the health benefit plan |
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issuer followed by the physician or the physician's counsel. |
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Sec. 1460.057. EFFECT OF NONAPPEARANCE; WAIVER. (a) The |
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hearing panel is not precluded from proceeding with a hearing |
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conducted under this chapter by the failure to appear at all or any |
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part of the hearing of: |
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(1) the affected physician or the physician's legal |
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counsel, if any; or |
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(2) any witness. |
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(b) Failure of a physician not represented by counsel or |
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failure of both a physician and the physician's counsel to appear |
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at the hearing is deemed a waiver of all procedural rights under |
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this chapter that could have been exercised by, or on behalf of, the |
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affected physician at the hearing. |
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Sec. 1460.058. EXAMINATION OF WITNESSES. Each of the |
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following persons present at a hearing conducted under this chapter |
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may examine or cross-examine any witness testifying at the hearing |
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in person, telephonically, or electronically through the Internet |
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or otherwise: |
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(1) the physician or, at the physician's option, the |
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physician's counsel, but not both; |
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(2) the representative of the health benefit plan |
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issuer, as designated by the issuer; and |
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(3) the members of the hearing panel. |
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Sec. 1460.059. BURDEN OF PROOF; DECISION. (a) The health |
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benefit plan issuer must prove, by a preponderance of evidence, |
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that: |
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(1) in the case of a methodology using objective |
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standards, the affected physician's performance, efficiency, or |
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quality and the effectiveness of the medical care delivered by the |
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physician has not met the standards disclosed under Section |
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1460.051; or |
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(2) in the case of a methodology using relative |
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comparison criteria, the data is accurate and correctly portrays |
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the affected physician's performance, efficiency, or quality |
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relative to other physicians in the same or similar medical |
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specialty with comparable patient populations. |
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(b) The decision of the hearing panel is binding. |
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(c) If the hearing panel's decision is that the health |
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benefit plan issuer has met its burden of proof, the health benefit |
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plan issuer may publish the comparison, rating, tier, |
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classification, measurement, or ranking. |
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(d) If the hearing panel's decision is that the health |
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benefit plan issuer has not met its burden of proof, the panel shall |
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instruct the health benefit plan issuer to appropriately modify the |
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comparison, rating, tier, classification, measurement, or ranking |
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before publication. |
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Sec. 1460.060. EFFECT OF CONTINUED DISAGREEMENT. (a) On |
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written notice that the affected physician disagrees with the |
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health benefit plan issuer's comparison, rating, tier, |
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classification, measurement, or ranking or the decision of the |
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hearing panel, the health benefit plan issuer shall prominently |
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display a symbol indicating the physician disputes the comparison, |
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rating, tier, classification, measurement, or ranking next to any |
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comparison, rating, tier, classification, measurement, or ranking |
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information for that physician. |
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(b) Each Internet web page displaying comparison, rating, |
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tier, classification, measurement, or ranking information must |
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contain a key explaining the meaning of the symbol required by |
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Subsection (a). |
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SECTION 2. This Act takes effect immediately if it receives |
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a vote of two-thirds of all the members elected to each house, as |
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provided by Section 39, Article III, Texas Constitution. If this |
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Act does not receive the vote necessary for immediate effect, this |
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Act takes effect September 1, 2009. |