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A BILL TO BE ENTITLED
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AN ACT
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relating to the adequacy and effectiveness of managed care plan |
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networks. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 108.002(9), Health and Safety Code, is |
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amended to read as follows: |
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(9) "Health benefit plan" means a plan provided by: |
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(A) a health maintenance organization; |
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(B) a preferred provider or exclusive provider |
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benefit plan issuer under Chapter 1301, Insurance Code; or |
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(C) [(B)] an approved nonprofit health |
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corporation that is certified under Section 162.001, Occupations |
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Code, and that holds a certificate of authority issued by the |
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commissioner of insurance under Chapter 844, Insurance Code. |
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SECTION 2. Section 501.001, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.001. DEFINITIONS [DEFINITION]. In this chapter: |
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(1) "Managed care plan" means: |
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(A) a health maintenance organization plan |
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provided under Chapter 843; |
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(B) a preferred provider benefit plan, as defined |
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by Section 1301.001; or |
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(C) an exclusive provider benefit plan, as |
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defined by Section 1301.001. |
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(2) "Office" [, "office"] means the office of public |
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insurance counsel. |
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SECTION 3. Section 501.151, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.151. POWERS AND DUTIES OF OFFICE. The office: |
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(1) may assess the impact of insurance rates, rules, |
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and forms on insurance consumers in this state; [and] |
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(2) shall advocate in the office's own name positions |
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determined by the public counsel to be most advantageous to a |
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substantial number of insurance consumers; |
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(3) shall monitor the adequacy of networks offered by |
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managed care plans in this state by reviewing related filings, |
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applications, and requests, including filings, applications, and |
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requests related to access plans or waivers of network adequacy |
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requirements, for accuracy, accessibility of health care services, |
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and reasonable access to covered benefits; and |
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(4) may advocate for consumers in the office's own |
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name: |
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(A) positions to strengthen the overall adequacy |
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or oversight of networks offered by managed care plans in this |
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state; and |
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(B) positions to strengthen the adequacy or |
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oversight of a particular network offered by a managed care plan in |
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this state. |
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SECTION 4. Section 501.153, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.153. AUTHORITY TO APPEAR, INTERVENE, OR INITIATE. |
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(a) The public counsel: |
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(1) may appear or intervene, as a party or otherwise, |
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as a matter of right before the commissioner or department on behalf |
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of insurance consumers, as a class, in matters involving: |
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(A) rates, rules, and forms affecting: |
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(i) property and casualty insurance; |
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(ii) title insurance; |
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(iii) credit life insurance; |
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(iv) credit accident and health insurance; |
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or |
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(v) any other line of insurance for which |
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the commissioner or department promulgates, sets, adopts, or |
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approves rates, rules, or forms; |
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(B) rules affecting life, health, or accident |
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insurance; [or] |
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(C) a managed care plan's ability to provide |
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accessible health care services and reasonable access to covered |
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benefits; or |
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(D) withdrawal of approval of policy forms: |
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(i) in proceedings initiated by the |
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department under Sections 1701.055 and 1701.057; or |
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(ii) if the public counsel presents |
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persuasive evidence to the department that the forms do not comply |
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with this code, a rule adopted under this code, or any other law; |
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(2) may initiate or intervene as a matter of right or |
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otherwise appear in a judicial proceeding involving or arising from |
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an action taken by an administrative agency in a proceeding in which |
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the public counsel previously appeared under the authority granted |
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by this chapter; |
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(3) may appear or intervene, as a party or otherwise, |
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as a matter of right on behalf of insurance consumers as a class in |
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any proceeding in which the public counsel determines that |
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insurance consumers are in need of representation, except that the |
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public counsel may not intervene in an enforcement or parens |
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patriae proceeding brought by the attorney general; [and] |
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(4) may appear or intervene before the commissioner or |
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department as a party or otherwise on behalf of small commercial |
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insurance consumers, as a class, in a matter involving rates, |
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rules, or forms affecting commercial insurance consumers, as a |
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class, in any proceeding in which the public counsel determines |
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that small commercial consumers are in need of representation; and |
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(5) may file objections and request a hearing |
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regarding any application, filing, or request that a managed care |
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plan files with the department related to an access plan or waiver |
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of a network adequacy requirement, including an application, |
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filing, or request that is currently pending or that has already |
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been approved. |
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(b) To assist the office in determining whether to request a |
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hearing under Subsection (a)(5), the office is entitled to: |
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(1) review all relevant filings and information that a |
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managed care plan submits to the department, including |
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communications related to the filing; and |
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(2) communicate with a managed care plan regarding a |
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submission described by Subdivision (1). |
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(c) A matter described by Subsection (a)(5) is a contested |
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case that may be subject to informal disposition or heard by the |
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State Office of Administrative Hearings under Chapter 2001, |
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Government Code. |
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(d) Nothing in this chapter may be construed as authorizing |
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a managed care plan to request a waiver of network adequacy |
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requirements or to use an access plan unless otherwise authorized |
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by law or regulation. |
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SECTION 5. Section 501.154, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.154. ACCESS TO INFORMATION. The public counsel: |
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(1) is entitled to the same access as a party, other |
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than department staff, to department records available in a |
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proceeding before the commissioner or department under the |
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authority granted to the public counsel by this chapter; [and] |
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(2) is entitled to obtain discovery under Chapter |
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2001, Government Code, of any nonprivileged matter that is relevant |
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to the subject matter involved in a proceeding or submission before |
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the commissioner or department as authorized by this chapter; and |
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(3) is entitled to all filings, including any |
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attachments and supporting documentation, made by a managed care |
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plan relating to the adequacy of a network offered by the plan, and |
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any regulatory correspondence relating to the filings. |
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SECTION 6. Section 501.157, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.157. PROHIBITED INTERVENTIONS OR APPEARANCES. |
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Except as otherwise provided by this code, the [The] public counsel |
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may not intervene or appear in: |
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(1) any proceeding or hearing before the commissioner |
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or department, or any other proceeding, that relates to approval or |
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consideration of an individual charter, license, certificate of |
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authority, acquisition, merger, or examination; or |
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(2) any proceeding concerning the solvency of an |
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individual insurer, a financial issue, a policy form, advertising, |
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or another regulatory issue affecting an individual insurer or |
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agent. |
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SECTION 7. Section 501.159, Insurance Code, is amended by |
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amending Subsection (a) and adding Subsections (a-1) and (a-2) to |
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read as follows: |
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(a) Notwithstanding this chapter, the office may submit |
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written comments to the commissioner and otherwise participate |
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regarding individual insurer filings: |
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(1) made under Chapters 2251 and 2301 relating to |
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insurance described by Subchapter B, Chapter 2301; or |
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(2) relating to the adequacy of a network offered by a |
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managed care plan, regardless of whether the filing is pending or |
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has already been approved. |
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(a-1) The office may comment on or otherwise participate |
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regarding the effect or implementation of a filing described by |
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Subsection (a)(2), including comments regarding concerns that a |
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managed care plan: |
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(1) is operating with an inadequate network in this |
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state; |
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(2) may be in violation of a network adequacy law or |
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regulation; or |
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(3) has an inaccurate provider network directory. |
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(a-2) For written comments filed with the department |
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regarding filings described by Subsection (a)(2), the department |
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shall: |
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(1) respond to the comments promptly and provide |
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updates to the office and the managed care plan regarding actions |
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taken by the department or other actions taken to address issues |
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raised in the comments; and |
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(2) consider conducting a targeted market conduct |
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examination under Chapter 751 or another form of investigation to |
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determine the existence and extent of potential violations. |
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SECTION 8. The heading to Subchapter F, Chapter 501, |
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Insurance Code, is amended to read as follows: |
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SUBCHAPTER F. DUTIES RELATING TO MANAGED CARE PLANS [HEALTH |
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MAINTENANCE ORGANIZATIONS] |
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SECTION 9. Section 501.251, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.251. COMPARISON OF MANAGED CARE PLANS [HEALTH |
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MAINTENANCE ORGANIZATIONS]. (a) The office shall develop and |
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implement a system to compare and evaluate, on an objective basis, |
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the quality of care provided by, the adequacy of networks offered |
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by, and the performance of managed care plans [health maintenance |
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organizations established under Chapter 843]. |
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(b) In conducting comparisons under the system described by |
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Subsection (a), the office shall compare: |
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(1) health maintenance organizations to other health |
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maintenance organizations; |
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(2) preferred provider benefit plans to other |
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preferred provider benefit plans; and |
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(3) exclusive provider benefit plans to other |
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exclusive provider benefit plans. |
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(c) In developing the system, the office may use information |
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or data from a person, agency, organization, or governmental unit |
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that the office considers reliable. |
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SECTION 10. Section 501.252, Insurance Code, is amended to |
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read as follows: |
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Sec. 501.252. ANNUAL CONSUMER REPORT CARDS. (a) The office |
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shall develop and issue annual consumer report cards that identify |
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and compare, on an objective basis, managed care plans [health |
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maintenance organizations in this state]. |
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(b) The consumer report cards required by Subsection (a) |
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shall: |
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(1) include comparisons of types of managed care plans |
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in the same manner as provided by Section 501.251(b); and |
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(2) at the discretion of the office, be staggered for |
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release throughout the year based on the type of managed care plan |
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that is the subject of the consumer report card. |
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(c) Notwithstanding Subsection (b)(2), all consumer report |
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cards for a particular type of managed care plan must be released at |
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the same time. |
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(d) The consumer report cards may be based on information or |
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data from any person, agency, organization, or governmental unit |
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that the office considers reliable. |
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(e) [(b)] The office may not endorse or recommend a specific |
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managed care [health maintenance organization or] plan, or |
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subjectively rate or rank managed care [health maintenance |
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organizations or] plans or managed care plan issuers, other than |
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through comparison and evaluation of objective criteria. |
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(f) [(c)] The office shall provide a copy of any consumer |
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report card on request on payment of a reasonable fee. |
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SECTION 11. It is the intent of the legislature to provide |
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the office of public insurance counsel with the flexibility to |
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establish a timeline for the implementation, development, and |
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initial issuance of annual consumer report cards under Section |
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501.252, Insurance Code, as amended by this Act, in a manner that |
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best uses current office of public insurance counsel resources. |
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SECTION 12. This Act takes effect September 1, 2023. |