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 business day [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 physician's or health care
provider's contract with the health benefit plan 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 with the health benefit plan
issuer.
(d-2) Except as provided
by Subsection (d-3), if the termination of the physician's or health care
provider's contract with the health benefit plan issuer 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 received under this section or otherwise
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 Texas Department of
Insurance operating account.
(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.
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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 five 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 three
business days after the effective date of the physician's or health care
provider's contract with the health benefit plan issuer; or
(2) remove a physician or
health care provider not later than three
business days after the effective date of the termination of the
physician's or health care provider's contract with the health benefit plan
issuer.
(d-2) Except as provided
by Subsection (d-3), if the termination of the physician's or health care
provider's contract with the health benefit plan issuer 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 three
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 third 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 received under this section or otherwise
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 described by
Section 401.156(a).
(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.
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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 total number of mediation requests under this
chapter 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
Texas Department of Insurance operating account.
(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) the year in which the
insurer had the highest or second highest total number of mediation
requests under this chapter.
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 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.
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No
equivalent provision.
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