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A BILL TO BE ENTITLED
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AN ACT
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relating to certain physician-specific comparison data compiled by |
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a health benefit plan issuer, including the release of that data to |
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physicians participating in certain physician-led organizations. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. The heading to Chapter 1460, Insurance Code, is |
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amended to read as follows: |
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CHAPTER 1460. [STANDARDS REQUIRED REGARDING] CERTAIN PHYSICIAN |
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RANKINGS AND COST COMPARISONS BY HEALTH BENEFIT PLANS |
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SECTION 2. Chapter 1460, Insurance Code, is amended by |
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designating Sections 1460.001 and 1460.002 as Subchapter A and |
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adding a subchapter heading to read as follows: |
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SUBCHAPTER A. GENERAL PROVISIONS |
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SECTION 3. Section 1460.001, Insurance Code, is amended to |
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read as follows: |
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Sec. 1460.001. DEFINITIONS. In this chapter: |
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(1) "Accountable care organization" means an entity: |
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(A) that is composed of physicians or physicians |
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and other health care providers; |
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(B) that is owned and controlled by one or more |
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physicians licensed in this state and engaged in active clinical |
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practice in this state; |
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(C) that contracts with a health benefit plan |
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issuer to provide medical or health care services to a defined |
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population; |
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(D) that uses a payment structure that takes into |
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account the total costs and quality of the care provided to the |
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defined population served by the entity; and |
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(E) through which physicians and health care |
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providers, if any: |
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(i) share in savings created by improvement |
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of the quality of, and reduction of cost increases for, care |
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delivered to the defined population served by the entity; or |
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(ii) are compensated through another |
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payment methodology intended to reduce the total cost of care |
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delivered to the defined population served by the entity. |
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(2) "Cost comparison data" means information compiled |
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by a health benefit plan issuer to show the health care costs |
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associated with a physician or other health care provider relative |
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to another physician or health care provider. |
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(3) "Designated entity" means a limited liability |
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company in which a majority ownership interest is held by an |
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incorporated association whose purpose includes uniting in one |
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organization all physicians licensed to practice medicine in this |
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state and that has been in continued existence for at least 15 |
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years. |
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(4) "Health benefit plan issuer" means an entity |
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authorized under this code or another insurance law of this state |
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that provides health insurance or health benefits in this state, |
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including: |
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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 health maintenance organization operating |
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under Chapter 843; and |
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(D) a stipulated premium company operating under |
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Chapter 884. |
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(5) "Participating physician" means a physician who |
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participates in an accountable care organization. |
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(6) [(2)] "Physician" means an individual licensed to |
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practice medicine in this state or another state of the United |
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States. |
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SECTION 4. Chapter 1460, Insurance Code, is amended by |
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designating Sections 1460.003 through 1460.007 as Subchapter B and |
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adding a subchapter heading to read as follows: |
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SUBCHAPTER B. PHYSICIAN RANKINGS |
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SECTION 5. Section 1460.003(a), Insurance Code, is amended |
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to read as follows: |
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(a) Except as provided by Subchapter C, a [A] health |
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benefit plan issuer, including a subsidiary or affiliate, may not |
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rank physicians, classify physicians into tiers based on |
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performance, or publish physician-specific information that |
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includes rankings, tiers, ratings, or other comparisons of a |
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physician's performance against standards, measures, or other |
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physicians, unless: |
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(1) the standards used by the health benefit plan |
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issuer conform to nationally recognized standards and guidelines as |
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required by rules adopted under Section 1460.005; |
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(2) the standards and measurements to be used by the |
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health benefit plan issuer are disclosed to each affected physician |
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before any evaluation period used by the health benefit plan |
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issuer; and |
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(3) each affected physician is afforded, before any |
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publication or other public dissemination, an opportunity to |
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dispute the ranking or classification through a process that, at a |
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minimum, includes due process protections that conform to the |
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following protections: |
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(A) the health benefit plan issuer provides at |
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least 45 days' written notice to the physician of the proposed |
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rating, ranking, tiering, or comparison, including the |
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methodologies, data, and all other information utilized by the |
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health benefit plan issuer in its rating, tiering, ranking, or |
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comparison decision; |
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(B) in addition to any written fair |
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reconsideration process, the health benefit plan issuer, upon a |
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request for review that is made within 30 days of receiving the |
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notice under Paragraph (A), provides a fair reconsideration |
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proceeding, at the physician's option: |
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(i) by teleconference, at an agreed upon |
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time; or |
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(ii) in person, at an agreed upon time or |
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between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday; |
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(C) the physician has the right to provide |
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information at a requested fair reconsideration proceeding for |
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determination by a decision-maker, have a representative |
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participate in the fair reconsideration proceeding, and submit a |
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written statement at the conclusion of the fair reconsideration |
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proceeding; and |
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(D) the health benefit plan issuer provides a |
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written communication of the outcome of a fair reconsideration |
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proceeding prior to any publication or dissemination of the rating, |
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ranking, tiering, or comparison. The written communication must |
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include the specific reasons for the final decision. |
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SECTION 6. Section 1460.005(a), Insurance Code, is amended |
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to read as follows: |
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(a) The commissioner shall adopt rules as necessary to |
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implement this subchapter [chapter]. |
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SECTION 7. Sections 1460.006 and 1460.007, Insurance Code, |
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are amended to read as follows: |
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Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A |
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health benefit plan issuer shall ensure that: |
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(1) physicians currently in clinical practice are |
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actively involved in the development of the standards used under |
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this subchapter [chapter]; and |
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(2) the measures and methodology used in the |
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comparison programs described by Section 1460.003 are transparent |
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and valid. |
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Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A |
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health benefit plan issuer that violates this subchapter [chapter] |
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or a rule adopted under this subchapter [chapter] is subject to |
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sanctions and disciplinary actions under Chapters 82 and 84. |
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(b) A violation of this subchapter [chapter] by a physician |
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constitutes grounds for disciplinary action by the Texas Medical |
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Board, including imposition of an administrative penalty. |
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SECTION 8. Chapter 1460, Insurance Code, is amended by |
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adding Subchapter C to read as follows: |
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SUBCHAPTER C. COST COMPARISON DATA |
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Sec. 1460.051. PROVISION OF COST COMPARISON DATA |
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AUTHORIZED. Notwithstanding Section 1460.003, a health benefit |
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plan issuer may provide cost comparison data to a participating |
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physician or a designated entity. |
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Sec. 1460.052. PROVISION OF CERTAIN COST COMPARISON DATA |
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REQUIRED. If cost comparison data associated with health care |
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providers other than physicians is available to a health benefit |
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plan issuer that provides cost comparison data under Section |
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1460.051, the plan issuer shall provide the cost comparison data |
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associated with the other health care providers. |
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Sec. 1460.053. REQUIRED DISCLOSURES. Not later than the |
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15th business day after the date that a health benefit plan issuer |
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receives a request from a participating physician, the health |
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benefit plan issuer shall disclose to the physician: |
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(1) the cost comparison data associated with the |
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physician; |
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(2) the measures and methodology used to compare |
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costs; and |
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(3) any other information considered in making the |
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cost comparison. |
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Sec. 1460.054. RIGHT TO DISPUTE. (a) A health benefit plan |
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issuer shall give a physician, regardless of whether the physician |
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is a participating physician, a fair opportunity to dispute the |
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cost comparison data associated with the physician at least once |
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each calendar quarter and when the health benefit plan issuer |
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changes the measures and methodology described by Section 1460.053. |
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(b) A physician may initiate a dispute by sending to the |
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health benefit plan issuer a written statement of the dispute. |
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Sec. 1460.055. DISPUTE PROCEEDING. (a) Not later than the |
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15th business day after the date a health benefit plan issuer |
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receives a statement of the dispute under Section 1460.054, the |
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plan issuer shall provide the cost comparison data associated with |
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the physician, the measures and methodology used to compare costs, |
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and any other information considered in making the cost comparison, |
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unless the information was already provided under Section 1460.052. |
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(b) In addition to any written fair reconsideration |
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process, the health benefit plan issuer shall provide a cost |
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comparison data dispute proceeding, at the physician's option: |
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(1) by teleconference, at an agreed upon time; or |
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(2) in person, at an agreed upon time. |
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(c) At the proceeding described by Subsection (b), the |
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physician has the right to: |
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(1) provide information to a decision-maker; |
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(2) have a representative participate in the |
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proceeding; and |
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(3) submit a written statement at the conclusion of |
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the proceeding. |
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(d) The health benefit plan issuer shall provide to the |
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physician who initiated the dispute process under Section 1460.054 |
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a written communication of the outcome of the proceeding not later |
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than the 60th day after the date the physician initiated the dispute |
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process. The written communication must include the specific |
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reasons for the final decision. |
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Sec. 1460.056. CORRECTIONS REQUIRED. If in a dispute |
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process initiated under Section 1460.054 the health benefit plan |
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issuer determines that the physician's cost comparison data is |
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inaccurate or the measures and methodology used to compare costs |
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are invalid, the health benefit plan issuer shall promptly correct |
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the data or update the measures and methodology and associated |
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data, as applicable. |
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Sec. 1460.057. MEASURES AND METHODOLOGY. The measures and |
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methodology used to compare costs under this subchapter must use |
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risk and severity adjustments to account for health status |
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differences among different patient populations. |
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Sec. 1460.058. NOTICE REQUIRED. A health benefit plan |
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issuer shall provide written notice to a physician who contracts |
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with the plan issuer that: |
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(1) explains the plan issuer's compilation and use of |
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cost comparison data, the purpose and scope of the plan issuer's |
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release of cost comparison data under this subchapter, and the |
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requirements of this subchapter regarding cost comparison data; and |
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(2) informs the physician of the physician's rights |
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and duties under this subchapter. |
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Sec. 1460.059. CONFIDENTIALITY. A physician who receives |
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cost comparison data about another physician under this subchapter |
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may not disclose the data to any other person, except for the |
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purpose of: |
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(1) managing an accountable care organization; |
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(2) managing the receiving physician's practice or |
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referrals; |
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(3) evaluating or disputing the cost comparison data |
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associated with the receiving physician; |
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(4) obtaining professional advice related to a legal |
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claim; or |
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(5) reporting, complaining, or responding to a |
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governmental agency. |
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Sec. 1460.060. CONSTRUCTION OF SUBCHAPTER. Nothing in this |
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subchapter may be construed to authorize: |
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(1) the disclosure of a contract rate; or |
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(2) the publication of cost comparison data to a |
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person other than a participating physician or a designated |
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entity. |
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Sec. 1460.061. RULES. The commissioner shall adopt rules |
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as necessary to implement this subchapter. |
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Sec. 1460.062. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A |
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health benefit plan issuer shall ensure that: |
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(1) physicians currently in clinical practice are |
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actively involved in the development of the standards used under |
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this subchapter; and |
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(2) the measures and methodology used in the |
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development of cost comparison data described by this subchapter |
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are transparent and valid. |
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Sec. 1460.063. SANCTIONS; DISCIPLINARY ACTIONS. (a) A |
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health benefit plan issuer that violates this subchapter or a rule |
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adopted under this subchapter is subject to sanctions and |
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disciplinary actions under Chapters 82 and 84. |
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(b) A violation of this subchapter by a physician |
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constitutes grounds for disciplinary action by the Texas Medical |
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Board, including imposition of an administrative penalty. |
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SECTION 9. The change in law made by this Act applies only |
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to a contract between a physician and a health benefit plan issuer |
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entered into or renewed on or after September 1, 2017. A contract |
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between a physician and health benefit plan issuer entered into or |
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renewed before September 1, 2017, is governed by the law as it |
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existed immediately before that date, and that law is continued in |
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effect for that purpose. |
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SECTION 10. This Act takes effect September 1, 2017. |
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