This website will be unavailable from Friday, April 26, 2024 at 6:00 p.m. through Monday, April 29, 2024 at 7:00 a.m. due to data center maintenance.

 
 
  H.B. No. 3359
 
 
 
 
AN ACT
  relating to network adequacy standards and other requirements for
  preferred provider benefit plans.
         BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
         SECTION 1.  Section 1301.001, Insurance Code, is amended by
  adding Subdivision (6-a) to read as follows:
               (6-a)  "Post-emergency stabilization care" means
  health care services that are furnished by an out-of-network
  provider, including an out-of-network hospital, freestanding
  emergency medical care facility, or comparable emergency facility,
  regardless of the department of the facility in which the services
  are furnished, after an insured is stabilized and as part of
  outpatient observation or an inpatient or outpatient stay with
  respect to the visit in which the emergency care, as defined by
  Section 1301.155, is furnished.
         SECTION 2.  The heading to Section 1301.005, Insurance Code,
  is amended to read as follows:
         Sec. 1301.005.  AVAILABILITY OF PREFERRED PROVIDERS;
  SERVICE AREA LIMITATIONS.
         SECTION 3.  Section 1301.005, Insurance Code, is amended by
  amending Subsection (a) and adding Subsection (d) to read as
  follows:
         (a)  An insurer offering a preferred provider benefit plan
  shall ensure that both preferred provider benefits and basic level
  benefits, including benefits for emergency care, as defined by
  Section 1301.155, and post-emergency stabilization care, are
  reasonably available to all insureds within a designated service
  area. This subsection does not apply to an exclusive provider
  benefit plan.
         (d)  A service area, other than a statewide service area, may
  include noncontiguous geographic areas but may not divide a county.
         SECTION 4.  Section 1301.0053, Insurance Code, is amended by
  amending Subsections (a) and (b) and adding Subsections (d) and (e)
  to read as follows:
         (a)  If an out-of-network provider provides emergency care
  as defined by Section 1301.155 or post-emergency stabilization care
  to an enrollee in an exclusive provider benefit plan, the issuer of
  the plan shall reimburse the out-of-network provider at the usual
  and customary rate or at a rate agreed to by the issuer and the
  out-of-network provider for the provision of the services and any
  supply related to those services.  The insurer shall make a payment
  required by this subsection directly to the provider not later
  than, as applicable:
               (1)  the 30th day after the date the insurer receives an
  electronic clean claim as defined by Section 1301.101 for those
  services that includes all information necessary for the insurer to
  pay the claim; or
               (2)  the 45th day after the date the insurer receives a
  nonelectronic clean claim as defined by Section 1301.101 for those
  services that includes all information necessary for the insurer to
  pay the claim.
         (b)  For emergency care or post-emergency stabilization care
  subject to this section or a supply related to that care, an
  out-of-network provider or a person asserting a claim as an agent or
  assignee of the provider may not bill an insured in, and the insured
  does not have financial responsibility for, an amount greater than
  an applicable copayment, coinsurance, and deductible under the
  insured's exclusive provider benefit plan that:
               (1)  is based on:
                     (A)  the amount initially determined payable by
  the insurer; or
                     (B)  if applicable, a modified amount as
  determined under the insurer's internal appeal process; and
               (2)  is not based on any additional amount determined
  to be owed to the provider under Chapter 1467.
         (d)  Post-emergency stabilization care that is subject to
  this section and a supply related to that care are subject to
  Chapter 1467 in the same manner as if the care and supply are
  emergency care, as defined by Section 1301.155.
         (e)  This section does not apply to claims for post-emergency
  stabilization care if all of the conditions described by 42 U.S.C.
  Section 300gg-111(a)(3)(C)(ii)(II) are met.
         SECTION 5.  Section 1301.0055, Insurance Code, is amended to
  read as follows:
         Sec. 1301.0055.  NETWORK ADEQUACY STANDARDS. (a)  The
  commissioner shall by rule adopt network adequacy standards that:
               (1)  require an insurer offering a preferred provider
  benefit plan to:
                     (A)  monitor compliance with network adequacy
  standards, including provisions of this chapter relating to network
  adequacy, on an ongoing basis, reporting any material deviation
  from network adequacy standards to the department within 30 days of
  the date the material deviation occurred; and
                     (B)  promptly take any corrective action required
  to ensure that the network is compliant not later than the 90th day
  after the date the material deviation occurred unless:
                           (i)  there are no uncontracted licensed
  physicians or health care providers in the affected county; or
                           (ii)  the insurer requests a waiver under
  this subsection [are adapted to local markets in which an insurer
  offering a preferred provider benefit plan operates];
               (2)  ensure availability of, and accessibility to, a
  full range of contracted physicians and health care providers to
  provide current and projected utilization of health care services
  for adult and minor [to] insureds; [and]
               (3)  [on good cause shown,] may allow a waiver for a
  departure from [local market] network adequacy standards for a
  period not to exceed one year if the commissioner determines after
  receiving public testimony at a public hearing under Section
  1301.00565 that good cause is shown and posts on the department's
  Internet website the name of the preferred provider benefit plan,
  the insurer offering the plan, each affected county, the specific
  network adequacy standards waived, and the insurer's access plan;
               (4)  require disclosure by the insurer of the
  information described by Subdivision (3) in all promotion and
  advertisement of the preferred provider benefit plan for which a
  waiver is allowed under that subdivision;
               (5)  except as provided by Subdivision (6), limit a
  waiver from being issued to a preferred provider benefit plan:
                     (A)  more than twice consecutively for the same
  network adequacy standard in the same county unless the insurer
  demonstrates, in addition to the good cause described by
  Subdivision (3), multiple good faith attempts to bring the plan
  into compliance with the network adequacy standard during each of
  the prior consecutive waiver periods; or
                     (B)  more than a total of four times within a
  21-year period for each county in a service area for issues that may
  be remedied through good faith efforts; and
               (6)  authorize the commissioner to issue a waiver that
  would otherwise be unavailable under Subdivision (5) if the waiver
  request demonstrates, and the department confirms annually, that
  there are no uncontracted physicians or health care providers in
  the area to meet the specific standard for a county in a service
  area [and the affected local market].
         (b)  The standards described by Subsection (a)(2) must
  include factors regarding time, distance, and appointment
  availability. The factors must:
               (1)  require that all insureds are able to receive an
  appointment with a preferred provider within the maximum travel
  times and distances established under Sections 1301.00553 and
  1301.00554;
               (2)  require that all insureds are able to receive an
  appointment with a preferred provider within the maximum
  appointment wait times established under Section 1301.00555;
               (3)  require a preferred provider benefit plan to
  ensure sufficient choice, access, and quality of physicians and
  health care providers, in number, size, and geographic
  distribution, to be capable of providing the health care services
  covered by the plan from preferred providers to all insureds within
  the insurer's designated service area, taking into account the
  insureds' characteristics, medical conditions, and health care
  needs, including:
                     (A)  the current utilization of covered health
  care services within the counties of the service area; and
                     (B)  an actuarial projection of utilization of
  covered health care services, physicians, and health care providers
  needed within the counties of the service area to meet the needs of
  the number of projected insureds;
               (4)  require a sufficient number of preferred providers
  of emergency medicine, anesthesiology, pathology, radiology,
  neonatology, oncology, including medical, surgical, and radiation
  oncology, surgery, and hospitalist, intensivist, and diagnostic
  services, including radiology and laboratory services, at each
  preferred hospital, ambulatory surgical center, or freestanding
  emergency medical care facility that credentials the particular
  specialty to ensure all insureds are able to receive covered
  benefits, including access to clinical trials covered by the health
  benefit plan, at that preferred location;
               (5)  require that all insureds have the ability to
  access a preferred institutional provider listed in Section
  1301.00553 within the maximum travel times and distances
  established under Section 1301.00553 for the corresponding county
  classification;
               (6)  require that insureds have the option of
  facilities, if available, of pediatric, for-profit, nonprofit, and
  tax-supported institutions, with special consideration to
  contracting with:
                     (A)  teaching hospitals that provide indigent
  care or care for uninsured individuals as a significant percentage
  of their overall patient load; and
                     (B)  teaching facilities that specialize in
  providing care for rare and complex medical conditions and
  conducting clinical trials;
               (7)  require that there is an adequate number of
  preferred provider physicians who have admitting privileges at one
  or more preferred provider hospitals located within the insurer's
  designated service area to make any necessary hospital admissions;
               (8)  provide for necessary hospital services by
  requiring contracting with general, pediatric, specialty, and
  psychiatric hospitals on a preferred benefit basis within the
  insurer's designated service area, as applicable;
               (9)  ensure that emergency care, as defined by Section
  1301.155, is available and accessible 24 hours a day, seven days a
  week, by preferred providers;
               (10)  ensure that covered urgent care is available and
  accessible from preferred providers within the insurer's
  designated service area within 24 hours for medical and behavioral
  health conditions;
               (11)  require an adequate number of preferred providers
  to be available and accessible to insureds 24 hours a day, seven
  days a week, within the insurer's designated service area; and
               (12)  require sufficient numbers and classes of
  preferred providers to ensure choice, access, and quality of care
  across the insurer's designated service area.
         (c)  Subsection (b)(6) does not apply to an exclusive
  provider benefit plan if the plan has:
               (1)  contracted with preferred provider hospitals in
  sufficient number capable of meeting the covered inpatient and
  outpatient health care benefits for current and actuarially
  projected utilization in accordance with Subsection (b)(3); or
               (2)  received a waiver under Subsection (a).
         SECTION 6.  Subchapter A, Chapter 1301, Insurance Code, is
  amended by adding Sections 1301.00553, 1301.00554, and 1301.00555
  to read as follows:
         Sec. 1301.00553.  MAXIMUM TRAVEL TIME AND DISTANCE STANDARDS
  BY PREFERRED PROVIDER TYPE.  (a)  In this section, "maximum
  distance" means the miles calculated to drive by automobile within
  a service area to a particular type of preferred provider.
         (b)  For purposes of this section, each county in this state
  is classified as a large metro, metro, micro, or rural county, or a
  county with extreme access considerations as determined by the
  federal Centers for Medicare and Medicaid Services by population
  and density thresholds as of March 1, 2023.
         (c)  Maximum travel time in minutes and maximum distance in
  miles for preferred provider benefit plans by preferred provider
  type for each large metro county are:
               (1)  for the following physicians, as designated by
  physician specialty:
 
Time Distance
 
Allergy and Immunology 30 15
 
Cardiology 20 10
 
Cardiothoracic Surgery 30 15
 
Dermatology 20 10
 
Emergency Medicine 20 10
 
Endocrinology 30 15
 
Ear, Nose, and Throat/Otolaryngology 30 15
 
Gastroenterology 20 10
 
General Surgery 20 10
 
Gynecology and Obstetrics 10 5
 
Infectious Diseases 30 15
 
Nephrology 30 15
 
Neurology 20 10
 
Neurosurgery 30 15
 
Oncology: Medical, Surgical 20 10
 
Oncology: Radiation 30 15
 
Ophthalmology 20 10
 
Orthopedic Surgery 20 10
 
Physical Medicine and Rehabilitation 30 15
 
Plastic Surgery 30 15
 
Primary Care: Adults 10 5
 
Primary Care: Pediatric 10 5
 
Psychiatry 20 10
 
Pulmonology 20 10
 
Rheumatology 30 15
 
Urology 20 10
 
Vascular Surgery 30 15
               (2)  for health care practitioners in the following
  disciplines:
 
Time Distance
 
Chiropractic 30 15
 
Occupational Therapy 20 10
 
Physical Therapy 20 10
 
Podiatry 20 10
 
Speech Therapy 20 10
               (3)  for the following types of institutional
  providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 20 10
 
Services Available 24/7) 20 10
 
Cardiac Catheterization Services 30 15
 
Cardiac Surgery Program 30 15
 
Critical Care Services: Intensive Care Units 20 10
 
Diagnostic Radiology (Freestanding; Hospital 20 10
 
Outpatient; Ambulatory Health Facilities 20 10
 
with Diagnostic Radiology) 20 10
 
Inpatient or Residential Behavioral Health 30 15
 
Facility Services 30 15
 
Mammography 20 10
 
Outpatient Infusion/Chemotherapy 20 10
 
Skilled Nursing Facilities 20 10
 
Surgical Services (Outpatient or Ambulatory 20 10
 
Surgical Center) 20 10
               (4)  for the following settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health 10 5
 
(Licensed, Accredited, or Certified) 10 5
 
Urgent Care 20 10
         (d)  Maximum travel time in minutes and maximum distance in
  miles for preferred provider benefit plans by preferred provider
  type for each metro county are:
               (1)  for the following physicians, as designated by
  physician specialty:
 
Time Distance
 
Allergy and Immunology 45 30
 
Cardiology 30 20
 
Cardiothoracic Surgery 60 40
 
Dermatology 45 30
 
Emergency Medicine 45 30
 
Endocrinology 60 40
 
Ear, Nose, and Throat/Otolaryngology 45 30
 
Gastroenterology 45 30
 
General Surgery 30 20
 
Gynecology and Obstetrics 15 10
 
Infectious Diseases 60 40
 
Nephrology 45 30
 
Neurology 45 30
 
Neurosurgery 60 40
 
Oncology: Medical, Surgical 45 30
 
Oncology: Radiation 60 40
 
Ophthalmology 30 20
 
Orthopedic Surgery 30 20
 
Physical Medicine and Rehabilitation 45 30
 
Plastic Surgery 60 40
 
Primary Care: Adults 15 10
 
Primary Care: Pediatric 15 10
 
Psychiatry 45 30
 
Pulmonology 45 30
 
Rheumatology 60 40
 
Urology 45 30
 
Vascular Surgery 60 40
               (2)  for health care practitioners in the following
  disciplines:
 
Time Distance
 
Chiropractic 45 30
 
Occupational Therapy 45 30
 
Physical Therapy 45 30
 
Podiatry 45 30
 
Speech Therapy 45 30
               (3)  for the following types of institutional
  providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 45 30
 
Services Available 24/7) 45 30
 
Cardiac Catheterization Services 60 40
 
Cardiac Surgery Program 60 40
 
Critical Care Services: Intensive Care Units 45 30
 
Diagnostic Radiology (Freestanding; Hospital 45 30
 
Outpatient; Ambulatory Health Facilities 45 30
 
with Diagnostic Radiology) 45 30
 
Inpatient or Residential Behavioral Health 70 45
 
Facility Services 70 45
 
Mammography 45 30
 
Outpatient Infusion/Chemotherapy 45 30
 
Skilled Nursing Facilities 45 30
 
Surgical Services (Outpatient or Ambulatory 45 30
 
Surgical Center) 45 30
               (4)  for the following settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health 15 10
 
(Licensed, Accredited, or Certified) 15 10
 
Urgent Care 45 30
         (e)  Maximum travel time in minutes and maximum distance in
  miles for preferred provider benefit plans by preferred provider
  type for each micro county are:
               (1)  for the following physicians, as designated by
  physician specialty:
 
Time Distance
 
Allergy and Immunology 80 60
 
Cardiology 50 35
 
Cardiothoracic Surgery 100 75
 
Dermatology 60 45
 
Emergency Medicine 80 60
 
Endocrinology 100 75
 
Ear, Nose, and Throat/Otolaryngology 80 60
 
Gastroenterology 60 45
 
General Surgery 50 35
 
Gynecology and Obstetrics 30 20
 
Infectious Diseases 100 75
 
Nephrology 80 60
 
Neurology 60 45
 
Neurosurgery 100 75
 
Oncology: Medical, Surgical 60 45
 
Oncology: Radiation 100 75
 
Ophthalmology 50 35
 
Orthopedic Surgery 50 35
 
Physical Medicine and Rehabilitation 80 60
 
Plastic Surgery 100 75
 
Primary Care: Adults 30 20
 
Primary Care: Pediatric 30 20
 
Psychiatry 60 45
 
Pulmonology 60 45
 
Rheumatology 100 75
 
Urology 60 45
 
Vascular Surgery 100 75
               (2)  for health care practitioners in the following
  disciplines:
 
Time Distance
 
Chiropractic 80 60
 
Occupational Therapy 80 60
 
Physical Therapy 80 60
 
Podiatry 60 45
 
Speech Therapy 80 60
               (3)  for the following types of institutional
  providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 80 60
 
Services Available 24/7) 80 60
 
Cardiac Catheterization Services 160 120
 
Cardiac Surgery Program 160 120
 
Critical Care Services: Intensive Care Units 160 120
 
Diagnostic Radiology (Freestanding; Hospital 80 60
 
Outpatient; Ambulatory Health Facilities 80 60
 
with Diagnostic Radiology) 80 60
 
Inpatient or Residential Behavioral Health 100 75
 
Facility Services 100 75
 
Mammography 80 60
 
Outpatient Infusion/Chemotherapy 80 60
 
Skilled Nursing Facilities 80 60
 
Surgical Services (Outpatient or Ambulatory 80 60
 
Surgical Center) 80 60
               (4)  for the following settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health 30 20
 
(Licensed, Accredited, or Certified) 30 20
 
Urgent Care 80 60
         (f)  Maximum travel time in minutes and maximum distance in
  miles for preferred provider benefit plans by preferred provider
  type for each rural county are:
               (1)  for the following physicians, as designated by
  physician specialty:
 
Time Distance
 
Allergy and Immunology 90 75
 
Cardiology 75 60
 
Cardiothoracic Surgery 110 90
 
Dermatology 75 60
 
Emergency Medicine 75 60
 
Endocrinology 110 90
 
Ear, Nose, and Throat/Otolaryngology 90 75
 
Gastroenterology 75 60
 
General Surgery 75 60
 
Gynecology and Obstetrics 40 30
 
Infectious Diseases 110 90
 
Nephrology 90 75
 
Neurology 75 60
 
Neurosurgery 110 90
 
Oncology: Medical, Surgical 75 60
 
Oncology: Radiation 110 90
 
Ophthalmology 75 60
 
Orthopedic Surgery 75 60
 
Physical Medicine and Rehabilitation 90 75
 
Plastic Surgery 110 90
 
Primary Care: Adults 40 30
 
Primary Care: Pediatric 40 30
 
Psychiatry 75 60
 
Pulmonology 75 60
 
Rheumatology 110 90
 
Urology 75 60
 
Vascular Surgery 110 90
               (2)  for health care practitioners in the following
  disciplines:
 
Time Distance
 
Chiropractic 90 75
 
Occupational Therapy 75 60
 
Physical Therapy 75 60
 
Podiatry 75 60
 
Speech Therapy 75 60
               (3)  for the following types of institutional
  providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 75 60
 
Services Available 24/7) 75 60
 
Cardiac Catheterization Services 145 120
 
Cardiac Surgery Program 145 120
 
Critical Care Services: Intensive Care Units 145 120
 
Diagnostic Radiology (Freestanding; Hospital 75 60
 
Outpatient; Ambulatory Health Facilities 75 60
 
with Diagnostic Radiology) 75 60
 
Inpatient or Residential Behavioral Health 90 75
 
Facility Services 90 75
 
Mammography 75 60
 
Outpatient Infusion/Chemotherapy 75 60
 
Skilled Nursing Facilities 75 60
 
Surgical Services (Outpatient or Ambulatory 75 60
 
Surgical Center) 75 60
               (4)  for the following settings:
 
Time Distance
 
Outpatient Clinical Behavioral
 
Health (Licensed, Accredited, or Certified) 40 30
 
Urgent Care 75 60
         (g)  Maximum travel time in minutes and maximum distance in
  miles for preferred provider benefit plans by preferred provider
  type for each county with extreme access considerations are:
               (1)  for the following physicians, as designated by
  physician specialty:
 
Time Distance
 
Allergy and Immunology 125 110
 
Cardiology 95 85
 
Cardiothoracic Surgery 145 130
 
Dermatology 110 100
 
Emergency Medicine 110 100
 
Endocrinology 145 130
 
Ear, Nose, and Throat/Otolaryngology 125 110
 
Gastroenterology 110 100
 
General Surgery 95 85
 
Gynecology and Obstetrics 70 60
 
Infectious Diseases 145 130
 
Nephrology 125 110
 
Neurology 110 100
 
Neurosurgery 145 130
 
Oncology: Medical, Surgical 110 100
 
Oncology: Radiation 145 130
 
Ophthalmology 95 85
 
Orthopedic Surgery 95 85
 
Physical Medicine and Rehabilitation 125 110
 
Plastic Surgery 145 130
 
Primary Care: Adults 70 60
 
Primary Care: Pediatric 70 60
 
Psychiatry 110 100
 
Pulmonology 110 100
 
Rheumatology 145 130
 
Urology 110 100
 
Vascular Surgery 145 130
               (2)  for health care practitioners in the following
  disciplines:
 
Time Distance
 
Chiropractic 125 110
 
Occupational Therapy 110 100
 
Physical Therapy 110 100
 
Podiatry 110 100
 
Speech Therapy 110 100
               (3)  for the following institutional providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 110 100
 
Services Available 24/7) 110 100
 
Cardiac Catheterization Services 155 140
 
Cardiac Surgery Program 155 140
 
Critical Care Services: Intensive Care Units 155 140
 
Diagnostic Radiology (Freestanding; Hospital 110 100
 
Outpatient; Ambulatory Health Facilities 110 100
 
with Diagnostic Radiology) 110 100
 
Inpatient or Residential Behavioral Health 155 140
 
Facility Services 155 140
 
Mammography 110 100
 
Outpatient Infusion/Chemotherapy 110 100
 
Skilled Nursing Facilities 95 85
 
Surgical Services (Outpatient or Ambulatory 110 100
 
Surgical Center) 110 100
               (4)  for the following settings:
 
Time Distance
 
Outpatient Clinical Behavioral
 
Health (Licensed, Accredited, or Certified) 70 60
 
Urgent Care 110 100
         Sec. 1301.00554.  OTHER MAXIMUM DISTANCE STANDARD
  REQUIREMENTS; COMMISSIONER AUTHORITY. (a) In this section,
  "maximum distance" has the meaning assigned by Section 1301.00553.
         (b)  For a physician specialty not specifically listed in
  Section 1301.00553, the maximum distance, in any county
  classification, is 75 miles.
         (c)  When necessary due to utilization or supply patterns,
  the commissioner by rule may decrease the base maximum travel time
  and distance standards listed in this section or Section 1301.00553
  for specific counties.
         Sec. 1301.00555.  MAXIMUM APPOINTMENT WAIT TIME STANDARDS.
  An insurer must ensure that:
               (1)  routine care is available and accessible from
  preferred providers:
                     (A)  within three weeks for medical conditions;
  and
                     (B)  within two weeks for behavioral health
  conditions; and
               (2)  preventive health care services are available and
  accessible from preferred providers:
                     (A)  within two months for a child, or earlier if
  necessary for compliance with recommendations for specific
  preventive health care services; and
                     (B)  within three months for an adult.
         SECTION 7.  Section 1301.0056, Insurance Code, is amended by
  amending Subsection (a) and adding Subsections (a-1) and (e) to
  read as follows:
         (a)  The commissioner shall by rule adopt a process for the
  commissioner to examine a preferred provider benefit plan before an
  insurer offers the plan for delivery to insureds to determine
  whether the plan meets the quality of care and network adequacy
  standards of this chapter. An insurer may not offer [of a network
  used by] a preferred provider benefit plan or an exclusive provider
  benefit plan before [offered by] the commissioner determines that
  the network meets the quality of care and network adequacy
  standards of [insurer under] this chapter or the insurer receives a
  waiver under Section 1301.0055.
         (a-1)  An insurer is subject to a qualifying examination of
  the insurer's preferred provider benefit plans [and exclusive
  provider benefit plans] and subsequent quality of care and network
  adequacy examinations by the commissioner at least once every three
  years, in connection with a public hearing under Section 1301.00565
  concerning a material deviation from network adequacy standards by
  a previously authorized plan or a request for a waiver of a network
  adequacy standard, and whenever the commissioner considers an
  examination necessary. 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.
         (e)  Rules adopted under this section must require insurers
  to provide access to or submit data or information necessary for the
  commissioner to evaluate and make a determination of compliance
  with quality of care and network adequacy standards. The rules must
  require insurers to provide access to or submit data or information
  that includes:
               (1)  a searchable and sortable database of network
  physicians and health care providers by national provider
  identifier, county, physician specialty, hospital privileges and
  credentials, and type of health care provider or licensure, as
  applicable;
               (2)  actuarial data of current and projected number of
  insureds by county;
               (3)  actuarial data of current and projected
  utilization of each preferred provider type listed in Section
  1301.00553 and described by Section 1301.00554 by county; and
               (4)  any other data or information considered necessary
  by the commissioner to make a determination to authorize the use of
  the preferred provider benefit plan in the most efficient and
  effective manner possible.
         SECTION 8.  Subchapter A, Chapter 1301, Insurance Code, is
  amended by adding Sections 1301.00565 and 1301.00566 to read as
  follows:
         Sec. 1301.00565.  PUBLIC HEARING ON NETWORK ADEQUACY
  STANDARDS WAIVERS. (a) In this section, "good faith effort" means
  honesty in fact, timely participation, observance of reasonable
  commercial standards of fair dealing, and prioritizing patients'
  access to in-network care.
         (b)  The commissioner shall set a public hearing for a
  determination of whether there is good cause for a waiver when an
  insurer:
               (1)  requests a waiver that does not satisfy Section
  1301.0055(a)(6);
               (2)  requests a waiver that the commissioner does not
  deny; and
               (3)  does not complete corrective action for a material
  deviation reported under Section 1301.0055.
         (c)  The commissioner shall notify affected physicians and
  health care providers that may be the subject of a discussion of
  good faith efforts on behalf of the insurer to meet network adequacy
  standards and provide the physicians and health care providers with
  an opportunity to submit evidence, including written testimony, and
  to attend the public hearing and offer testimony either in person or
  virtually. An out-of-network physician or hospital, including a
  physician group or health care system referenced in the insurer's
  waiver request or notice of material deviation, may not be
  identified by name at the hearing unless the physician or hospital
  consents to the identification in advance of the hearing.
         (d)  At the hearing, the commissioner shall consider all
  written and oral testimony and evidence submitted by the insurer
  and the public pertinent to the requested waiver, including:
               (1)  the total number of physicians or health care
  providers in each preferred provider type listed in Section
  1301.00553 within the county and service area being submitted for
  the waiver and whether the insurer made a good faith effort to
  contract with those required preferred provider types to meet
  network adequacy standards of this chapter;
               (2)  the total number of facilities, and availability
  of pediatric, for-profit, nonprofit, tax-supported, and teaching
  facilities, within the county and service area being submitted for
  a waiver and whether the insurer made a good faith effort to
  contract with these facilities and facility-based physicians and
  health care providers to meet network adequacy standards of this
  chapter;
               (3)  population, density, and geographical information
  to determine the possibility of meeting travel time and distance
  requirements within the county and service area being submitted for
  a waiver; and
               (4)  availability of services, population, and density
  within the county and service area being submitted for the waiver.
         (e)  The commissioner may not consider a prohibition on
  balance billing in determining whether to grant a waiver from
  network adequacy standards.
         (f)  The commissioner may not grant a waiver without a public
  hearing.
         (g)  Except as provided by this subsection, any evidence
  submitted to the commissioner as evidence for the public hearing
  that is proprietary in nature is confidential and not subject to
  disclosure as public information under Chapter 552, Government
  Code. Information related to provider directories, credentials,
  and privileges, estimates of patient populations, and actuarial
  estimates of needed providers to meet the estimated patient
  population is not protected under this subsection.
         (h)  A policyholder is entitled to seek judicial review of
  the commissioner's decision to grant a waiver under this section in
  a Travis County district court. Review by the district court under
  this subsection is de novo.
         Sec. 1301.00566.  EFFECT OF NETWORK ADEQUACY STANDARDS
  WAIVER ON BALANCE BILLING PROHIBITIONS.  After a network adequacy
  standards waiver is granted by the commissioner, an insurer may
  refer to the provisions prohibiting balance billing under Sections
  1301.0053, 1301.155, 1301.164, or 1301.165, as applicable, in an
  access plan submitted to the department for the sole purpose of
  explaining how the insurer will coordinate care to limit the
  likelihood of a balance bill for services subject to those
  provisions and not to justify a departure from network adequacy
  standards.
         SECTION 9.  Section 1301.009(b), Insurance Code, is amended
  to read as follows:
         (b)  The report shall:
               (1)  be verified by at least two principal officers;
               (2)  be in a form prescribed by the commissioner; and
               (3)  include:
                     (A)  a financial statement of the insurer,
  including its balance sheet and receipts and disbursements for the
  preceding calendar year, certified by an independent public
  accountant;
                     (B)  the number of individuals enrolled during the
  preceding calendar year, the number of enrollees as of the end of
  that year, and the number of enrollments terminated during that
  year; and
                     (C)  a statement of:
                           (i)  an evaluation of enrollee satisfaction;
                           (ii)  an evaluation of quality of care;
                           (iii)  coverage areas;
                           (iv)  accreditation status;
                           (v)  premium costs;
                           (vi)  plan costs;
                           (vii)  premium increases;
                           (viii)  the range of benefits provided;
                           (ix)  copayments and deductibles;
                           (x)  the accuracy and speed of claims
  payment by the insurer for the plan;
                           (xi)  the credentials of physicians who are
  preferred providers; [and]
                           (xii)  the number of preferred providers;
                           (xiii)  any waiver requests made and waivers
  of network adequacy standards granted under Section 1301.00565;
                           (xiv)  any material deviation from network
  adequacy standards reported to the department under Section
  1301.0055; and
                           (xv)  any corrective actions, sanctions, or
  penalties assessed against the insurer by the department for
  deficiencies related to the preferred provider benefit plan.
         SECTION 10.  Subchapter B, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.0642 to read as follows:
         Sec. 1301.0642.  CONTRACT PROVISIONS ALLOWING CERTAIN
  ADVERSE MATERIAL CHANGES PROHIBITED. (a) In this section,
  "adverse material change" means a change to a preferred provider
  contract with a physician, health care practitioner, or
  organization of physicians or health care practitioners that would
  decrease the preferred provider's payment or compensation, change
  the provider's tier to a less preferred tier, or change the
  administrative procedures in a way that may reasonably be expected
  to significantly increase the provider's administrative expenses
  or decrease the provider's payment or compensation. The term does
  not include:
               (1)  a decrease in payment or compensation resulting
  solely from a change in a published governmental fee schedule on
  which the payment or compensation is based if the applicability of
  the schedule is clearly identified in the contract;
               (2)  a decrease in payment or compensation that was
  anticipated under the terms of the contract, if the amount and date
  of applicability of the decrease is clearly identified in the
  contract;
               (3)  an administrative change that may significantly
  increase the provider's administrative expense, the specific
  applicability of which is clearly identified in the contract;
               (4)  a change that is required by federal or state law;
               (5)  a termination for cause; or
               (6)  a termination without cause at the end of the term
  of the contract.
         (b)  An adverse material change to a preferred provider
  contract may only be made during the term of the preferred provider
  contract with the mutual agreement of the parties. A provision in a
  preferred provider contract that allows the insurer to unilaterally
  make an adverse material change during the term of the contract is
  void and unenforceable.
         (c)  Any adverse material change to the preferred provider
  contract may not go into effect until the 120th day after the date
  the preferred provider affirmatively agrees to the adverse material
  change in writing.
         (d)  A proposed amendment by an insurer seeking an adverse
  material change to a preferred provider contract must include
  notice that clearly and conspicuously states that a preferred
  provider may choose to not agree to the amendment and that the
  decision to not agree to the amendment may not affect:
               (1)  the terms of the provider's existing contract with
  the insurer; or
               (2)  the provider's participation in other health plans
  or products.
         (e)  A preferred provider's failure to agree to an adverse
  material change to a preferred provider contract does not affect:
               (1)  the terms of the provider's existing contract with
  the insurer; or
               (2)  the provider's participation in other health care
  products or plans.
         (f)  An insurer's failure to include the notice described by
  Subsection (d) with the proposed amendment makes an otherwise
  agreed-to adverse material change void and unenforceable.
         (g)  This section does not apply to a preferred provider
  contract:
               (1)  with an unspecified and indefinite duration;
               (2)  with no stated or automatic renewal period or
  event; and
               (3)  that may only be terminated by notice from one
  party to the other.
         SECTION 11.  (a) The changes in law made by this Act apply
  only to an insurance policy that is delivered, issued for delivery,
  or renewed on or after September 1, 2024. A policy delivered,
  issued for delivery, or renewed before September 1, 2024, is
  governed by the law as it existed immediately before the effective
  date of this Act, and that law is continued in effect for that
  purpose.
         (b)  Notwithstanding Subsection (a) of this section, maximum
  appointment wait time standards prescribed by Sections
  1301.0055(b) and 1301.00555, Insurance Code, as added by this Act,
  apply only to an insurance policy that is delivered, issued for
  delivery, or renewed on or after September 1, 2025.
         (c)  Section 1301.009(b), Insurance Code, as amended by this
  Act, applies only to a report submitted on or after October 1, 2024.
  A report submitted before October 1, 2024, is governed by the law in
  effect on the date the report was submitted, and that law is
  continued in effect for that purpose.
         (d)  Section 1301.0642, Insurance Code, as added by this Act,
  applies only to a contract entered into, amended, or renewed on or
  after the effective date of this Act.
         SECTION 12.  This Act takes effect September 1, 2023.
 
 
  ______________________________ ______________________________
     President of the Senate Speaker of the House     
 
 
         I certify that H.B. No. 3359 was passed by the House on April
  28, 2023, by the following vote:  Yeas 147, Nays 0, 1 present, not
  voting; and that the House concurred in Senate amendments to H.B.
  No. 3359 on May 25, 2023, by the following vote:  Yeas 138, Nays 0,
  2 present, not voting.
 
  ______________________________
  Chief Clerk of the House   
 
         I certify that H.B. No. 3359 was passed by the Senate, with
  amendments, on May 23, 2023, by the following vote:  Yeas 31, Nays
  0.
 
  ______________________________
  Secretary of the Senate   
  APPROVED: __________________
                  Date       
   
           __________________
                Governor