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A BILL TO BE ENTITLED
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AN ACT
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relating to standards required for certain rankings 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. Section 1460.003, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsection (a-1) to read as |
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follows: |
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(a) A health benefit plan issuer, including a subsidiary or |
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affiliate, may not rank physicians or[,] classify physicians into |
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tiers based on performance[, or publish physician-specific |
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information that includes rankings, tiers, ratings, or other |
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comparisons of a physician's performance against standards, |
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measures, or other physicians,] unless: |
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(1) the standards used by the health benefit plan |
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issuer to rank or classify are propagated or developed by an |
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organization designated by the commissioner through rules adopted |
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under Section 1460.005; |
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(2) the ranking, comparison, or evaluation: |
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(A) is disclosed to each affected physician at |
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least 45 days before the date the ranking, comparison, or |
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evaluation is released, published, or distributed to enrollees by |
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the health benefit plan issuer; and |
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(B) identifies which products or networks |
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offered by the health benefit plan issuer the ranking, comparison, |
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or evaluation will be used for; and |
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(3) each affected physician is given an easy-to-use |
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process to identify discrepancies between the standards and the |
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ranking, comparison, or evaluation as propagated by the health |
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benefit plan issuer [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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(a-1) If a physician submits information to a health benefit |
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plan issuer under Subsection (a)(3) sufficient to establish a |
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discrepancy, the health benefit plan issuer must remedy the |
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discrepancy by the later of: |
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(1) publication; or |
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(2) the 30th day after the date the health benefit plan |
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issuer receives the information. |
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SECTION 2. Section 1460.005(c), Insurance Code, is amended |
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to read as follows: |
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(c) In adopting rules under this section, the commissioner |
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may only designate [shall consider the standards, guidelines, and |
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measures prescribed by nationally recognized] organizations that |
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meet the following requirements: |
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(1) the prescribing organization is bona fide and |
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unbiased toward or against any medical provider; |
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(2) the standards to be used in rankings, comparisons, |
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or evaluations: |
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(A) are nationally recognized, or based on |
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expert-provider consensus or leading clinical evidence-based |
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scholarship; |
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(B) have a publicly transparent methodology; and |
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(C) if based on clinical outcomes, are |
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risk-adjusted; and |
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(3) the prescribing organization has an easy-to-use |
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process by which a medical provider may report data, evidentiary, |
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factual, or mathematical errors for prompt investigation and, if |
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appropriate, correction [establish or promote guidelines and |
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performance measures emphasizing quality of health care, including |
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the National Quality Forum and the AQA Alliance. If neither the |
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National Quality Forum nor the AQA Alliance has established |
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standards or guidelines regarding an issue, the commissioner shall |
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consider the standards, guidelines, and measures prescribed by the |
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National Committee on Quality Assurance and other similar national |
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organizations. If neither the National Quality Forum, nor the AQA |
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Alliance, nor other national organizations have established |
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standards or guidelines regarding an issue, the commissioner shall |
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consider standards, guidelines, and measures based on other bona |
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fide nationally recognized guidelines, expert-based physician |
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consensus quality standards, or leading objective clinical |
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evidence and scholarship]. |
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SECTION 3. 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, 2023. |