|
|
|
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: |
|
|
|
Allergy and Immunology |
30 |
15 |
|
|
|
|
|
|
Cardiothoracic Surgery |
30 |
15 |
|
|
|
|
|
|
|
|
Ear, Nose, and Throat/Otolaryngology |
30 |
15 |
|
|
|
|
|
|
Gynecology and Obstetrics |
10 |
5 |
|
|
Infectious Diseases |
30 |
15 |
|
|
|
|
|
|
|
|
Oncology: Medical, Surgical |
20 |
10 |
|
|
Oncology: Radiation |
30 |
15 |
|
|
|
|
|
|
Physical Medicine and Rehabilitation |
30 |
15 |
|
|
|
|
Primary Care: Adults |
10 |
5 |
|
|
Primary Care: Pediatric |
10 |
5 |
|
|
|
|
|
|
|
|
|
|
|
|
(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: |
|
|
|
|
|
|
Occupational 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: |
|
|
|
|
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 |
|
|
|
|
|
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: |
|
|
|
|
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) |
10 |
5 |
|
|
|
|
(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: |
|
|
|
|
Allergy and Immunology |
45 |
30 |
|
|
|
|
|
|
|
Cardiothoracic Surgery |
60 |
40 |
|
|
|
|
|
|
|
|
|
Ear, Nose, and Throat/Otolaryngology |
45 |
30 |
|
|
|
|
|
|
|
Gynecology and Obstetrics |
15 |
10 |
|
|
|
Infectious Diseases |
60 |
40 |
|
|
|
|
|
|
|
|
|
Oncology: Medical, Surgical |
45 |
30 |
|
|
|
Oncology: Radiation |
60 |
40 |
|
|
|
|
|
|
|
Physical Medicine and Rehabilitation |
45 |
30 |
|
|
|
|
|
Primary Care: Adults |
15 |
10 |
|
|
|
Primary Care: Pediatric |
15 |
10 |
|
|
|
|
|
|
|
|
|
|
|
|
(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: |
|
|
|
|
|
|
Occupational 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: |
|
|
|
|
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 |
|
|
|
|
|
Behavioral Health Facility Services |
70 |
45 |
|
|
|
|
|
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: |
|
|
|
|
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) |
15 |
10 |
|
|
|
|
(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: |
|
|
|
|
Allergy and Immunology |
80 |
60 |
|
|
|
|
|
|
|
Cardiothoracic Surgery |
100 |
75 |
|
|
|
|
|
|
|
|
|
Ear, Nose, and Throat/Otolaryngology |
80 |
60 |
|
|
|
|
|
|
|
Gynecology and Obstetrics |
30 |
20 |
|
|
|
Infectious Diseases |
100 |
75 |
|
|
|
|
|
|
|
|
|
Oncology: Medical, Surgical |
60 |
45 |
|
|
|
Oncology: Radiation |
100 |
75 |
|
|
|
|
|
|
|
Physical Medicine and Rehabilitation |
80 |
60 |
|
|
|
|
|
Primary Care: Adults |
30 |
20 |
|
|
|
Primary Care: Pediatric |
30 |
20 |
|
|
|
|
|
|
|
|
|
|
|
|
(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: |
|
|
|
|
|
|
Occupational 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: |
|
|
|
|
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 |
|
|
|
|
|
Behavioral Health Facility Services |
100 |
75 |
|
|
|
|
|
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: |
|
|
|
|
Outpatient Clinical Behavioral Health (Texas Licensed, Accredited, or Certified) |
30 |
20 |
|
|
|
|
(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: |
|
|
|
|
Allergy and Immunology |
90 |
75 |
|
|
|
|
|
|
|
Cardiothoracic Surgery |
110 |
90 |
|
|
|
|
|
|
|
|
|
Ear, Nose, and Throat/Otolaryngology |
90 |
75 |
|
|
|
|
|
|
|
Gynecology and Obstetrics |
40 |
30 |
|
|
|
Infectious Diseases |
110 |
90 |
|
|
|
|
|
|
|
|
|
Oncology: Medical, Surgical |
75 |
60 |
|
|
|
Oncology: Radiation |
110 |
90 |
|
|
|
|
|
|
|
Physical Medicine and Rehabilitation |
90 |
75 |
|
|
|
|
|
Primary Care: Adults |
40 |
30 |
|
|
|
Primary Care: Pediatric |
40 |
30 |
|
|
|
|
|
|
|
|
|
|
|
|
(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: |
|
|
|
|
|
|
Occupational 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: |
|
|
|
|
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 |
|
|
|
|
|
Behavioral Health Facility Services |
90 |
75 |
|
|
|
|
|
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: |
|
|
|
|
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) |
40 |
30 |
|
|
|
|
(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: |
|
|
|
|
Allergy and Immunology |
125 |
110 |
|
|
|
|
|
|
|
Cardiothoracic Surgery |
145 |
130 |
|
|
|
|
|
Emergency Medicine |
110 |
100 |
|
|
|
|
|
Ear, Nose, and Throat/Otolaryngology |
125 |
110 |
|
|
|
|
|
|
|
Gynecology and Obstetrics |
70 |
60 |
|
|
|
Infectious Diseases |
145 |
130 |
|
|
|
|
|
|
|
|
|
Oncology: Medical, Surgical |
110 |
100 |
|
|
|
Oncology: Radiation |
145 |
130 |
|
|
|
|
|
|
|
Physical Medicine and Rehabilitation |
125 |
110 |
|
|
|
|
|
Primary Care: Adults |
70 |
60 |
|
|
|
Primary Care: Pediatric |
70 |
60 |
|
|
|
|
|
|
|
|
|
|
|
|
(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: |
|
|
|
|
|
|
Occupational 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: |
|
|
|
|
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 |
|
|
|
|
|
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: |
|
|
|
|
Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified) |
70 |
60 |
|
|
|
|
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. |