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A BILL TO BE ENTITLED
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AN ACT
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relating to departures from network adequacy standards by a |
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preferred provider benefit plan. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1301.0055, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.0055. NETWORK ADEQUACY STANDARDS; DEPARTURE FROM |
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STANDARDS. (a) The commissioner shall by rule adopt network |
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adequacy standards that: |
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(1) are adapted to local markets in which an insurer |
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offering a preferred provider benefit plan operates; |
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(2) ensure availability of, and accessibility to, a |
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full range of contracted physicians and health care providers to |
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provide health care services to insureds; and |
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(3) on good cause shown, may allow departure from |
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local market network adequacy standards if the commissioner posts |
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on the department's Internet website the name of the preferred |
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provider plan, the insurer offering the plan, and the affected |
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local market. |
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(b) Unless renewed in accordance with this section, |
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permission to depart from a local market network adequacy standard |
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under this section expires on the first anniversary of the date the |
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commissioner grants the request for the departure. |
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(c) An insurer may request a renewal of permission to depart |
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from a local market network adequacy standard under this section |
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not later than the 30th day before the permission expires. |
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(d) If the commissioner grants an insurer's request for a |
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departure from a local market network adequacy standard for a |
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preferred provider benefit plan, the commissioner may not approve a |
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subsequent request by that insurer to depart from the same standard |
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for that plan unless the request demonstrates that: |
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(1) good cause for the requested departure exists; |
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(2) if a physician or health care provider able to |
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provide the covered service for which the insurer requests the |
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departure is available in the local market for which the departure |
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is requested: |
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(A) the insurer took reasonable steps to meet the |
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relevant standard, including taking any steps identified in a |
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previous request for departure from the standard; and |
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(B) for each physician or health care provider |
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described by this subdivision with whom the insurer does not enter a |
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contract: |
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(i) if the failure to contract was not based |
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on reimbursement rates, the insurer made not less than three |
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reasonable attempts to negotiate the disputed contract terms; or |
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(ii) if the failure to contract was based on |
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reimbursement rates, the insurer offered not less than three |
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materially different rates; |
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(3) the insurer's termination of a physician or health |
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care provider without cause is not a contributing factor in the |
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insurer's need for the requested departure; and |
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(4) the insurer has not had the highest ratio of claims |
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to mediation requests under Chapter 1467 in any of the preceding |
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three years for the relevant service compared to other insurers |
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subject to that chapter. |
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(e) The commissioner may impose reasonable conditions on |
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the grant of a departure request. |
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SECTION 2. Not later than December 1, 2019, the |
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commissioner of insurance shall adopt rules necessary to implement |
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Section 1301.0055, Insurance Code, as amended by this Act. |
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SECTION 3. The changes in law made by this Act apply only to |
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an insurance policy delivered, issued for delivery, or renewed on |
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or after January 1, 2020. An insurance policy delivered, issued for |
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delivery, or renewed before January 1, 2020, is governed by the law |
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as it existed immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 4. This Act takes effect September 1, 2019. |