|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
|
relating to standards required for certain rankings of physicians |
|
by health benefit plans. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
|
by adding Chapter 1460 to read as follows: |
|
CHAPTER 1460. STANDARDS REQUIRED REGARDING CERTAIN PHYSICIAN |
|
RANKINGS BY HEALTH BENEFIT PLANS |
|
Sec. 1460.001. DEFINITIONS. In this chapter: |
|
(1) "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. |
|
(2) "Physician" means an individual licensed to |
|
practice medicine in this state or another state of the United |
|
States. |
|
Sec. 1460.002. EXEMPTION. This chapter does not apply to: |
|
(1) a Medicaid managed care program operated under |
|
Chapter 533, Government Code; |
|
(2) a Medicaid program operated under Chapter 32, |
|
Human Resources Code; |
|
(3) the child health plan program under Chapter 62, |
|
Health and Safety Code, or the health benefits plan for children |
|
under Chapter 63, Health and Safety Code; or |
|
(4) a Medicare supplement benefit plan, as defined by |
|
Chapter 1652. |
|
Sec. 1460.003. PHYSICIAN RANKING REQUIREMENTS. (a) A |
|
health 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. |
|
(b) This section does not apply to the publication of a list |
|
of network physicians and providers if ratings or comparisons are |
|
not made and the list is not a product of nor reflects the tiering or |
|
classification of physicians or providers. |
|
Sec. 1460.004. DUTIES OF PHYSICIANS. A physician may not |
|
require or request that a patient of the physician enter into an |
|
agreement under which the patient agrees not to: |
|
(1) rank or otherwise evaluate the physician; |
|
(2) participate in surveys regarding the physician; or |
|
(3) in any way comment on the patient's opinion of the |
|
physician. |
|
Sec. 1460.005. RULES; STANDARDS. (a) The commissioner |
|
shall adopt rules in the manner prescribed by Subchapter A, Chapter |
|
36, as necessary to implement this chapter.as necessary to implement this chapter. |
|
(b) The commissioner shall adopt rules as necessary to |
|
ensure that a health benefit plan issuer that uses a physician |
|
ranking system complies with the standards and guidelines described |
|
by Subsection (c). |
|
(c) In adopting rules under this section, the commissioner |
|
shall consider the standards, guidelines and measures prescribed by |
|
nationally recognized organizations that establish or promote |
|
guidelines and performance measures emphasizing quality of health |
|
care, including the National Quality Forum and the AQA Alliance. If |
|
neither the National Quality Forum nor the AQA Alliance has |
|
established standards or guidelines regarding an issue, the |
|
commissioner shall consider the standards, guidelines, and |
|
measures prescribed by the National Committee on Quality Assurance |
|
and other similar national organizations. If the National Quality |
|
Forum, nor the AQA Alliance nor other national organizations have |
|
established standards or guidelines regarding an issue, the |
|
commissioner shall consider standards, guidelines and measures |
|
based on other bona-fide nationally recognized guidelines, |
|
expert-based physician consensus quality standards, or leading |
|
objective clinical evidence and scholarship. |
|
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 chapter; and |
|
(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 chapter or a rule |
|
adopted under this chapter is subject to sanctions and disciplinary |
|
actions under Chapters 82 and 84. |
|
(b) A violation of this chapter by a physician constitutes |
|
grounds for disciplinary action by the Texas Medical Board, |
|
including imposition of an administrative penalty. |
|
SECTION 2. (a) A health benefit plan issuer shall comply |
|
with Chapter 1460, Insurance Code, as added by this Act, not later |
|
than December 31, 2009. |
|
(b) A health benefit plan issuer is not subject to sanctions |
|
or disciplinary actions under Section 1460.007, Insurance Code, as |
|
added by this Act, before January 1, 2010. |
|
(c) A physician is not subject to sanctions or disciplinary |
|
actions under Section 1460.007, Insurance Code, as added by this |
|
Act, before January 1, 2010. |
|
SECTION 3. This Act takes effect September 1, 2009. |
|
|
|
* * * * * |