By: Bonnen H.B. No. 3359
 
 
 
A BILL TO BE ENTITLED
 
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 hospital in which such
  services or supplies are furnished) after the insured is stabilized
  and as part of outpatient observation or an inpatient or outpatient
  stay with respect to the visit in which the services defined by
  Section 1301.155(a) are furnished.
         SECTION 2.  Section 1301.0046, Insurance Code, is amended to
  read as follows:
         Sec. 1301.0046.  COST-SHARING [COINSURANCE] REQUIREMENTS
  FOR SERVICES OF NONPREFERRED PROVIDERS. (a) The insured's
  coinsurance applicable to payment to nonpreferred providers may not
  exceed 50 percent of the total covered amount applicable to the
  medical or health care services.
         (b)  An insurer shall credit a cost-sharing payment,
  including any copayment, coinsurance, or deductible, paid by or on
  behalf of an insured for services furnished by an out-of-network
  provider to any out-of-pocket maximum that applies to the insured.
  The cost-sharing payment must be applied to the out-of-pocket
  maximum in the same manner as if it were made with respect to
  services furnished by a preferred provider.
         (c)  An insurer may not have separate out-of-pocket maximums
  for in-network and out-of-network services.
         (d)  The commissioner by rule shall set a reasonable cap on
  an out-of-pocket maximum under this section.
         (e)  This section does not apply to an exclusive provider
  benefit plan.
         SECTION 3.  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 4.  Section 1301.005, Insurance Code, is amended by
  amending Subsections (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 the 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:
               (1)  may not divide a county; and
               (2)  must include at least one trauma service area in
  its entirety.
         SECTION 5.  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 insurers 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 insured'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 they were emergency care, as
  defined by Section 1301.155.
         (e)  This section does not apply to claims for post-emergency
  stabilization care if each of the conditions described under 42 USC §
  300gg-111(a)(3)(C)(ii)(II) are met.
         SECTION 6.  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 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 and promptly
  taking any correction action required to ensure the network is
  compliant; [adapted to local markets in which the 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 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 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, and the specific
  network adequacy standards waived;
               (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; and
               (5)  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 in
  Subdivision (4), 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 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 at all insureds are able to receive an
  appointment with a preferred provider within the maximum
  appointment wait times established under Section 1301.0055;
               (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, surgery, hospitalist, intensivist and diagnostic
  services, including radiology and laboratory services at each
  preferred hospital, ambulatory surgical center or freestanding
  emergency medical care facility with credentials for these
  specialties to ensure all insureds are able to receive covered
  benefits 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 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 teaching hospitals that provide indigent care or
  care for uninsured individual as a significant percentage of their
  overall patient load;
               (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
  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.
         SECTION 7.  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) 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.
         (b)  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 physicians:
                     (A)  Designated by physician specialty. The
  preferred provider benefit plan's network must comply with the time
  and distance standards for the following physician specialties:
 
Time Distance
 
Allergy and Immunology 30 15
 
Anesthesiology 20 10
 
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 providers:
                     (A)  Designated by the kind of practitioner or
  institutional provider furnishing the health care service.
                           (i)  The preferred provider benefit plan's
  network must comply with the time and distance standards for
  practitioners licensed to provide health care services in this
  state, in the following disciplines:
 
Time Distance
 
Chiropractic 30 15
 
Occupational Therapy 20 10
 
Physical Therapy 20 10
 
Podiatry 20 10
 
Speech Therapy 20 10
                           (ii)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following kinds of institutional providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency
 
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 Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 20 10
 
Inpatient or Residential Behavioral
 
Health Facility Services 30 15
 
Mammography 20 10
 
Outpatient Infusion/Chemotherapy 20 10
 
Skilled Nursing Facilities 20 10
 
Surgical Services (Outpatient or Ambulatory Surgical Center) 20 10
               (3)  For other settings:
                     (A)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 10 5
 
Urgent Care 20 10
         (c)  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 physicians:
                     (A)  Designated by physician specialty. The
  preferred provider benefit plan's network must comply with the time
  and distance standards for the following physician specialties:
 
Time Distance
 
Allergy and Immunology 45 30
 
Anesthesiology 30 20
 
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 providers:
                     (A)  Designated by the kind of practitioner or
  institutional provider furnishing the health care service.
                           (i)  The preferred provider benefit plan's
  network must comply with the time and distance standards for
  practitioners licensed to provide health care services in this
  state, in the following disciplines:
 
Time Distance
 
Chiropractic 45 30
 
Occupational Therapy 45 30
 
Physical Therapy 45 30
 
Podiatry 45 30
 
Speech Therapy 45 30
                           (ii)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following kinds of institutional providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 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 Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 45 30
 
Inpatient or Residential
 
Behavioral Health Facility Services 70 45
 
Mammography 45 30
 
Outpatient Infusion/Chemotherapy 45 30
 
Skilled Nursing Facilities 45 30
 
Surgical Services (Outpatient or Ambulatory Surgical Center) 45 30
               (3)  For other settings:
                     (A)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 15 10
 
Urgent Care 45 30
         (d)  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 physicians: 
                     (A)  Designated by physician specialty. The
  preferred provider benefit plan's network must comply with the time
  and distance standards for the following physician specialties:
 
Time Distance
 
Allergy and Immunology 80 60
 
Anesthesiology 50 35
 
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 80 60
 
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 providers:
                     (A)  Designated by the kind of practitioner or
  institutional provider furnishing the health care service.
                           (i)  The preferred provider benefit plan's
  network must comply with the time and distance standards for
  practitioners licensed to provide health care services in this
  state, in the following disciplines:
 
Time Distance
 
Chiropractic 80 60
 
Occupational Therapy 80 60
 
Physical Therapy 80 60
 
Podiatry 60 45
 
Speech Therapy 80 60
                           (ii)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following kinds of institutional providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 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 Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 80 60
 
Inpatient or Residential
 
Behavioral Health Facility Services 100 75
 
Mammography 80 60
 
Outpatient Infusion/Chemotherapy 80 60
 
Skilled Nursing Facilities 80 60
 
Surgical Services (Outpatient or Ambulatory Surgical Center) 80 60
               (3)  For other care and settings:
                     (A)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following care and settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health (Texas Licensed, Accredited, or Certified) 30 20
 
Urgent Care 80 60
         (e)  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 physicians: 
                     (A)  Designated by physician specialty. The
  preferred provider benefit plan's network must comply with the time
  and distance standards for the following physician specialties:
 
Time Distance
 
Allergy and Immunology 90 75
 
Anesthesiology 75 60
 
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 providers:
                     (A)  Designated by the kind of practitioner or
  institutional provider furnishing the health care service.
                           (i)  The preferred provider benefit plan's
  network must comply with the time and distance standards for
  practitioners licensed to provide health care services in this
  state, in the following disciplines:
 
Time Distance
 
Chiropractic 90 75
 
Occupational Therapy 75 60
 
Physical Therapy 75 60
 
Podiatry 75 60
 
Speech Therapy 75 60
                           (ii)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following kinds of institutional providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 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 Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 75 60
 
Inpatient or Residential
 
Behavioral Health Facility Services 90 75
 
Mammography 75 60
 
Outpatient Infusion/Chemotherapy 75 60
 
Skilled Nursing Facilities 75 60
 
Surgical Services (Outpatient or Ambulatory Surgical Center) 75 60
               (3)  For other settings:
                     (A)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following settings:
 
Time Distance
 
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) 40 30
 
Urgent Care 75 60
         (f)  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 physicians:
                     (A)  Designated by physician specialty. The
  preferred provider benefit plan's network must comply with the time
  and distance standards for the following physician specialties:
 
Time Distance
 
Allergy and Immunology 125 110
 
Anesthesiology 95 85
 
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 providers:
                     (A)  Designated by the kind of practitioner or
  institutional provider furnishing the health care service.
                           (i)  The preferred provider benefit plan's
  network must comply with the time and distance standards for
  practitioners licensed to provide health care services in this
  state, in the following disciplines:
 
Time Distance
 
Chiropractic 125 110
 
Occupational Therapy 110 100
 
Physical Therapy 110 100
 
Podiatry 110 100
 
Speech Therapy 110 100
                           (ii)  The preferred provider benefit plan's
  network must comply with the time and distance standards for the
  following kinds of institutional providers:
 
Time Distance
 
Acute Inpatient Hospitals (Emergency 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 Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 110 100
 
Inpatient or Residential Behavioral
 
Health Facility Services 155 140
 
Mammography 110 100
 
Outpatient Infusion/Chemotherapy 110 100
 
Skilled Nursing Facilities 95 85
 
Surgical Services (Outpatient or Ambulatory Surgical Center) 110 100
               (3)  For other settings:
                     (A)  The preferred provider benefit plan's
  network must comply with the time and distance standards 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. (a) For any physician specialty not specifically
  listed in Section 1301.00553, the maximum distance, in any county
  classification, is 75 miles.
         (b)  When necessary due to utilization or supply patterns,
  the commissioner may by rule decrease the base maximum 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 8.  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 for delivery the plan to insureds to determine
  whether the plan meets the quality of care and network adequacy
  standards of this chapter. An insurer may not offer [used by] a
  preferred provider benefit plan before [or an exclusive provider
  benefit plan offered by] the commissioner determines that the
  network meets the quality of care and network adequacy standards of
  [insurer under] this chapter.
         (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 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 submit data 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 kind of health care provider or licensure type, as
  applicable;
               (2)  actuarial data of current and projected number of
  insureds by county; and
               (3)  actuarial data of current and projected
  utilization of each preferred provider type listed in Sections
  1301.00553 and 1301.00554(a) 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 9.  Subchapter A, Chapter 1301, Insurance Code, is
  amended by adding Section 1301.00565 to read as follows:
         Sec. 1301.00565.  PUBLIC HEARING ON NETWORK ADEQUACY
  STANDARDS WAIVERS. (a) On the earlier of a request from an insurer
  to receive a waiver from any network adequacy standard or receipt of
  notice under Section 1301.0055 of a material deviation from the
  network adequacy standards of this chapter, the commissioner shall
  set a public hearing for a determination of whether there is good
  cause for a waiver.
         (b)  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. A physician, including a physician group referenced in
  the insurer's waiver request or notice of material deviation, may
  not be identified by name at the hearing unless the physician
  consents to be identified in advance of the hearing.
         (c)  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 and 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 a county and service area being submitted for a waiver.
         (d)  The commissioner may not consider a prohibition on
  balance billing in determining whether to grant a waiver from
  network adequacy standards.
         (e)  The commissioner may not grant a waiver without a public
  hearing.
         (f)  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.
         (g)  A policyholder is entitled to seek judicial review of
  the commissioner's decision to grant a waiver under this section in
  Travis County district court. Review by the district court under
  this subsection is de novo.
         SECTION 10.  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;
                           (xii)  the number of preferred providers;
  [and]
                           (xiii)  any waiver requests made and waivers
  of network adequacy standards granted under Section 1301.00565; and
                           (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 11.  Subchapter B, Chapter 1301, Insurance Code is
  amended by adding Section 1301.0642 to read as follows:
         Sec. 1301.0642.  CONTRACT PROVISIONS ALLOWING CERTAIN
  CHANGE PROHIBITED. (a) In this section, "adverse material change"
  means a change to a preferred provider contract that would decrease
  the preferred provider's payment or compensation; change the
  preferred 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.
  Adverse material change does not include:
               (1)  a decrease in payment or compensation resulting
  soley from a change in a published fee schedule upon which the
  payment or compensation is based and the date of applicability 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 preferred provider's administrative expense, the
  specific applicability of which is clearly identified in the
  contract; or
               (4)  A change that is required by the operation of state
  or federal law.
         (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 120 days after physician or
  health care 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 a
  notice that clearly and conspicuously identifies such amendment as
  proposing an adverse material change to the contract. The notice
  must also clearly and conspicuously state that a physician or
  health care provider may choose not to agree to the amendment and
  that such a decision not to agree to the amendment may not affect
  the terms of the physician or health care provider's existing
  contract with the insurer or the preferred provider's participation
  in other health plans or products.
         (e)  A physician or health care provider's failure to agree
  to an adverse material change to a preferred provider contract
  shall not affect:
               (1)  the terms of the physician or health care
  provider's existing contract or other contracts with the insurer;
  or
               (2)  the preferred 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 shall make an otherwise
  agreed-to adverse material change void and unenforceable.
         SECTION 12.  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 January 1, 2024. A policy delivered, issued for
  delivery, or renewed before January 1, 2024, is governed by the law
  as it existed immediately before the effective date of this Act, and
  the law is continued in effect for that purpose.
         SECTION 13.  This Act takes effect September 1, 2023.