H.B. No. 1888
AN ACT
relating to standards required for certain rankings of physicians
by health benefit plans.
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. STANDARDS REQUIRED REGARDING CERTAIN PHYSICIAN
RANKINGS BY HEALTH BENEFIT PLANS
Sec. 1460.001. DEFINITIONS. In this chapter:
(1) "Health benefit plan issuer" means an entity
authorized under this code or another insurance law of this state
that provides health insurance or health benefits in this state,
including:
(A) an insurance company;
(B) a group hospital service corporation
operating under Chapter 842;
(C) a health maintenance organization operating
under Chapter 843; and
(D) a stipulated premium company operating under
Chapter 884.
(2) "Physician" means an individual licensed to
practice medicine in this state or another state of the United
States.
Sec. 1460.002. EXEMPTION. This chapter does not apply to:
(1) a Medicaid managed care program operated under
Chapter 533, Government Code;
(2) a Medicaid program operated under Chapter 32,
Human Resources Code;
(3) the child health plan program under Chapter 62,
Health and Safety Code, or the health benefits plan for children
under Chapter 63, Health and Safety Code; or
(4) a Medicare supplement benefit plan, as defined by
Chapter 1652.
Sec. 1460.003. PHYSICIAN RANKING REQUIREMENTS. (a) A
health benefit plan issuer, including a subsidiary or affiliate,
may not rank physicians, classify physicians into tiers based on
performance, or publish physician-specific information that
includes rankings, tiers, ratings, or other comparisons of a
physician's performance against standards, measures, or other
physicians, unless:
(1) the standards used by the health benefit plan
issuer conform to nationally recognized standards and guidelines as
required by rules adopted under Section 1460.005;
(2) the standards and measurements to be used by the
health benefit plan issuer are disclosed to each affected physician
before any evaluation period used by the health benefit plan
issuer; and
(3) each affected physician is afforded, before any
publication or other public dissemination, an opportunity to
dispute the ranking or classification through a process that, at a
minimum, includes due process protections that conform to the
following protections:
(A) the health benefit plan issuer provides at
least 45 days' written notice to the physician of the proposed
rating, ranking, tiering, or comparison, including the
methodologies, data, and all other information utilized by the
health benefit plan issuer in its rating, tiering, ranking, or
comparison decision;
(B) in addition to any written fair
reconsideration process, the health benefit plan issuer, upon a
request for review that is made within 30 days of receiving the
notice under Paragraph (A), provides a fair reconsideration
proceeding, at the physician's option:
(i) by teleconference, at an agreed upon
time; or
(ii) in person, at an agreed upon time or
between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
(C) the physician has the right to provide
information at a requested fair reconsideration proceeding for
determination by a decision-maker, have a representative
participate in the fair reconsideration proceeding, and submit a
written statement at the conclusion of the fair reconsideration
proceeding; and
(D) the health benefit plan issuer provides a
written communication of the outcome of a fair reconsideration
proceeding prior to any publication or dissemination of the rating,
ranking, tiering, or comparison. The written communication must
include the specific reasons for the final decision.
(b) This section does not apply to the publication of a list
of network physicians and providers if ratings or comparisons are
not made and the list is not a product of nor reflects the tiering or
classification of physicians or providers.
Sec. 1460.004. DUTIES OF PHYSICIANS. A physician may not
require or request that a patient of the physician enter into an
agreement under which the patient agrees not to:
(1) rank or otherwise evaluate the physician;
(2) participate in surveys regarding the physician; or
(3) in any way comment on the patient's opinion of the
physician.
Sec. 1460.005. RULES; STANDARDS. (a) The commissioner
shall adopt rules as necessary to implement this chapter.
(b) The commissioner shall adopt rules as necessary to
ensure that a health benefit plan issuer that uses a physician
ranking system complies with the standards and guidelines described
by Subsection (c).
(c) In adopting rules under this section, the commissioner
shall consider the standards, guidelines, and measures prescribed
by nationally recognized organizations that establish or promote
guidelines and performance measures emphasizing quality of health
care, including the National Quality Forum and the AQA Alliance. If
neither the National Quality Forum nor the AQA Alliance has
established standards or guidelines regarding an issue, the
commissioner shall consider the standards, guidelines, and
measures prescribed by the National Committee on Quality Assurance
and other similar national organizations. If neither the National
Quality Forum, nor the AQA Alliance, nor other national
organizations have established standards or guidelines regarding
an issue, the commissioner shall consider standards, guidelines,
and measures based on other bona fide nationally recognized
guidelines, expert-based physician consensus quality standards, or
leading objective clinical evidence and scholarship.
Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A
health benefit plan issuer shall ensure that:
(1) physicians currently in clinical practice are
actively involved in the development of the standards used under
this chapter; and
(2) the measures and methodology used in the
comparison programs described by Section 1460.003 are transparent
and valid.
Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A
health benefit plan issuer that violates this chapter or a rule
adopted under this chapter is subject to sanctions and disciplinary
actions under Chapters 82 and 84.
(b) A violation of this chapter by a physician constitutes
grounds for disciplinary action by the Texas Medical Board,
including imposition of an administrative penalty.
SECTION 2. (a) A health benefit plan issuer shall comply
with Chapter 1460, Insurance Code, as added by this Act, not later
than December 31, 2009.
(b) A health benefit plan issuer is not subject to sanctions
or disciplinary actions under Section 1460.007, Insurance Code, as
added by this Act, before January 1, 2010.
(c) A physician is not subject to sanctions or disciplinary
actions under Section 1460.007, Insurance Code, as added by this
Act, before January 1, 2010.
SECTION 3. This Act takes effect September 1, 2009.
______________________________ ______________________________
President of the Senate Speaker of the House
I certify that H.B. No. 1888 was passed by the House on April
17, 2009, by the following vote: Yeas 148, Nays 0, 1 present, not
voting; and that the House concurred in Senate amendments to H.B.
No. 1888 on May 28, 2009, by the following vote: Yeas 146, Nays 0,
1 present, not voting.
______________________________
Chief Clerk of the House
I certify that H.B. No. 1888 was passed by the Senate, with
amendments, on May 21, 2009, by the following vote: Yeas 31, Nays
0.
______________________________
Secretary of the Senate
APPROVED: __________________
Date
__________________
Governor