81R23728 PB-F
By: Leibowitz, King of Taylor H.B. No. 1392
Substitute the following for H.B. No. 1392:
By: Hopson C.S.H.B. No. 1392
A BILL TO BE ENTITLED
AN ACT
relating to required procedures regarding the ranking of physicians
by health benefit plan issuers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Subtitle F, Title 8, Insurance Code, is amended
by adding Chapter 1460 to read as follows:
CHAPTER 1460. PHYSICIAN RANKING BY HEALTH BENEFIT PLANS
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1460.001. DEFINITIONS. In this chapter:
(1) "Hearing panel" means the physician panel
described by Section 1460.055(a).
(2) "Physician" means an individual licensed to
practice medicine in this state under Subtitle B, Title 3,
Occupations Code.
Sec. 1460.002. APPLICABILITY. This chapter applies to any
health benefit plan that:
(1) provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or sickness,
including an individual, group, blanket, or franchise insurance
policy or insurance agreement, a group hospital service contract,
or an individual or group evidence of coverage that is offered by:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a fraternal benefit society operating under
Chapter 885;
(D) a stipulated premium company operating under
Chapter 884;
(E) a health maintenance organization operating
under Chapter 843;
(F) a multiple employer welfare arrangement that
holds a certificate of authority under Chapter 846;
(G) an approved nonprofit health corporation
that holds a certificate of authority under Chapter 844; or
(H) an entity not authorized under this code or
another insurance law of this state that contracts directly for
health care services on a risk-sharing basis, including a
capitation basis; or
(2) provides health and accident coverage through a
risk pool created under Chapter 172, Local Government Code,
notwithstanding Section 172.014, Local Government Code, or any
other law.
[Sections 1460.003-1460.050 reserved for expansion]
SUBCHAPTER B. RESTRICTIONS ON PHYSICIAN RANKING
Sec. 1460.051. PHYSICIAN RANKING. A health benefit plan
issuer, including a subsidiary or an affiliate of the health
benefit plan issuer, may not, in any manner, disseminate
information to the public that compares, rates, tiers, classifies,
measures, or ranks a physician's performance, efficiency, or
quality of practice against objective standards or the practice of
other physicians unless:
(1) the objective standards or comparison criteria
used by the health benefit plan issuer are disclosed to the
physician prior to the evaluation period;
(2) the data used to establish satisfaction of the
objective criteria or to make the comparison are available to the
physician for verification before any dissemination of information
to the public; and
(3) the health benefit plan issuer provides due
process to the physician as provided by this chapter.
Sec. 1460.052. DUE PROCESS; NOTICE OF INTENT. (a) Before a
health benefit plan issuer declines to invite a physician into a
preferred tier, classifies a physician into a particular tier, or
otherwise differentiates a physician from the physician's peers
based on performance, efficiency, or quality, the issuer must
notify the affected physician of its intent in a written notice
that meets the requirements of this section.
(b) A notice of intent issued under Subsection (a) must
include:
(1) a statement describing the proposed action of the
health benefit plan issuer and the reasons for that proposed
action;
(2) a statement that the affected physician has the
right to request a hearing on the proposed action as provided by
this chapter;
(3) any time limit within which the physician must
request a hearing under this chapter, which may not be less than 30
days from the date on which the notice of intent is issued; and
(4) a summary of the physician's rights under Section
1460.054.
Sec. 1460.053. NOTICE OF HEARING; HEARING BY
TELECONFERENCE. (a) If a hearing is requested by a physician who
receives a notice of intent under Section 1460.052, not later than
the 30th day after the date on which the physician requests the
hearing the physician must be given a written notice of the hearing
that includes:
(1) a statement of the place, time, and date of the
hearing, which must be conducted not less than 30 days after the
date the notice of the hearing is received by the physician; and
(2) a list of the witnesses, if any, expected to
testify at the hearing on behalf of the health benefit plan issuer.
(b) At the request of the affected physician and on
agreement by the health benefit plan issuer, the hearing may be held
by teleconference.
Sec. 1460.054. PHYSICIAN RIGHTS. A physician who requests
a hearing under this chapter has the following rights at the
hearing:
(1) the right to be represented by counsel;
(2) the right to have a record made of the proceedings
and to obtain a copy of the record for a reasonable charge;
(3) the right to call, examine, and cross-examine
witnesses;
(4) the right to present evidence;
(5) the right to submit a written statement to the
hearing panel at the close of the hearing; and
(6) the right to receive, following the hearing, the
written decision of the hearing panel, including a statement of the
basis for any recommendations by the panel.
Sec. 1460.055. HEARING PANEL; CONDUCT OF HEARING; EFFECT OF
DECISION. (a) A hearing requested under this chapter must be held
before a panel of three physicians, appointed by the health benefit
plan issuer, who practice the same medical specialty as the
affected physician or a similar medical specialty.
(b) The decision of the hearing panel is binding.
(c) If the hearing panel's decision is that the health
benefit plan issuer has correctly arrived at the comparison,
rating, ranking, tiering, or classification, the health benefit
plan issuer may make the publication.
(d) If the hearing panel's decision is that the health
benefit plan issuer has not correctly arrived at the comparison,
rating, ranking, tiering, or classification, the panel shall
instruct the health benefit plan issuer to modify the comparison,
rating, tier, classification, measurement, or ranking before
publication.
Sec. 1460.056. EFFECT OF NONAPPEARANCE; WAIVER. (a) The
hearing panel is not precluded from proceeding with a hearing
conducted under this chapter by the failure to appear at all or any
part of the hearing of:
(1) the affected physician or the physician's legal
counsel, if any; or
(2) any witness.
(b) Failure of a physician not represented by counsel or
failure of both a physician and the physician's counsel to appear
at the hearing is deemed a waiver of all procedural rights under
this chapter that could have been exercised by, or on behalf of, the
affected physician at the hearing.
Sec. 1460.057. RULES; STANDARDS. (a) The commissioner
shall adopt rules as necessary to implement this chapter.
(b) The commissioner by rule shall prescribe the standards
to be used by a health benefit plan issuer that uses a physician
ranking, classification, measuring, or tiering system. In adopting
standards, the commissioner shall consider the standards
prescribed by the National Quality Forum or the AQA Alliance.
SECTION 2. This Act takes effect immediately if it receives
a vote of two-thirds of all the members elected to each house, as
provided by Section 39, Article III, Texas Constitution. If this
Act does not receive the vote necessary for immediate effect, this
Act takes effect September 1, 2009.