81R4062 PB-F
By: Duncan S.B. No. 993
A BILL TO BE ENTITLED
AN ACT
relating to ranking 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. PHYSICIAN RANKING 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. PHYSICIAN RANKING REQUIREMENTS. (a) A
health benefit plan issuer is subject to the requirements of this
chapter if the health benefit plan issuer establishes ranking
programs for use in the provision of medical services by the health
benefit plan under which certain physicians are presented as
superior in:
(1) the quality of medical care provided; or
(2) efficiency in the provision of medical services.
(b) A health benefit plan issuer that establishes ranking
programs must:
(1) provide affected physicians with a complete
description of the ranking program and the factors used to
determine rankings; and
(2) provide a reasonable mechanism for reviewing a
physician's dispute regarding the physician's ranking by the health
benefit plan issuer in accordance with Subsection (c).
(c) A health benefit plan issuer must:
(1) provide for an opportunity for review by an
advisory review panel composed of at least three physicians that
participate in the health benefit plan issuer's network; and
(2) include one member who is a physician in the same
or similar specialty as the affected physician, if available.
(d) The health benefit plan issuer shall provide to the
affected physician:
(1) any recommendation of the advisory review panel;
and
(2) a written explanation of the health benefit plan
issuer's determination, if that determination is contrary to the
advisory review panel's recommendation.
(e) The health benefit plan issuer shall annually report to
the department the number of instances in which the health benefit
plan issuer makes a determination contrary to the recommendation of
the advisory review panel.
Sec. 1460.003. RULES. The commissioner shall adopt rules
in the manner prescribed by Subchapter A, Chapter 36, as necessary
to implement this chapter.
Sec. 1460.004. SANCTIONS. A health benefit plan issuer
that violates this chapter is subject to sanctions under Chapter
82.
SECTION 2. (a) A health benefit plan issuer shall comply
with Chapter 1460, Insurance Code, not later than December 31,
2009.
(b) A health benefit plan issuer is not subject to sanctions
under Section 1460.004, Insurance Code, as added by this Act,
before January 1, 2010.
SECTION 3. This Act takes effect September 1, 2009.