Texas 2013 - 83rd Regular

Texas House Bill HB3270 Compare Versions

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1	1	83R21122 PMO-D
2	2	By: Smithee H.B. No. 3270
3	3	Substitute the following for H.B. No. 3270:
4	4	By: Smithee C.S.H.B. No. 3270
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to preferred provider and exclusive provider network
10	10	regulations; providing administrative sanctions and penalties.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Chapter 1301, Insurance Code, is amended by
13	13	adding Subchapters F, G, and H to read as follows:
14	14	SUBCHAPTER F. NETWORK ADEQUACY STANDARDS
15	15	Sec. 1301.251. NETWORK ADEQUACY REQUIREMENTS. A preferred
16	16	provider benefit plan must include a health care service delivery
17	17	network that complies with this chapter and local market access
18	18	adequacy requirements as established by the commissioner by rule,
19	19	including requirements within the insurer's designated service
20	20	area relating to:
21	21	(1) the sufficiency of:
22	22	(A) the number, size, and geographic
23	23	distribution of networks in relation to:
24	24	(i) the number of insureds;
25	25	(ii) the insureds' relevant characteristics
26	26	and medical and health care needs; and
27	27	(iii) the current and projected utilization
28	28	of covered health care services;
29	29	(B) the number and classes of preferred providers
30	30	to ensure choice, access, and quality of care; and
31	31	(C) the number of preferred provider physicians
32	32	with admitting privileges at one or more preferred provider
33	33	hospitals located within the insurer's designated service area; and
34	34	(2) the availability and accessibility of:
35	35	(A) preferred providers at all times;
36	36	(B) necessary general, specialty, and
37	37	psychiatric hospital services;
38	38	(C) physical and occupational therapy services
39	39	and chiropractic services;
40	40	(D) emergency care at all times;
41	41	(E) urgent care for medical and behavioral health
42	42	conditions; and
43	43	(F) routine care and preventive care on a timely
44	44	basis as determined by the commissioner by rule.
45	45	Sec. 1301.252. SERVICE AREAS. A preferred provider benefit
46	46	plan may have one or more contiguous or noncontiguous service areas
47	47	provided that a service area that is not statewide must comply with
48	48	geographic parameters established by the commissioner by rule.
49	49	Sec. 1301.253. MONITORING AND CORRECTIVE ACTION. An
50	50	insurer shall monitor on an ongoing basis, and take corrective
51	51	action to maintain compliance with, the network requirements
52	52	described by Sections 1301.251 and 1301.252.
53	53	Sec. 1301.254. REQUEST FOR WAIVER OF NETWORK ADEQUACY
54	54	STANDARDS. (a) On an insurer's showing of good cause as described
55	55	by this section, the commissioner may waive one or more adequacy
56	56	standards for the insurer's network imposed under this subchapter
57	57	or adopted by the commissioner by rule.
58	58	(b) The commissioner may find good cause to grant the waiver
59	59	if the insurer demonstrates as described by this section that
60	60	physicians or health care providers necessary for an adequate local
61	61	market access network are not available for contract or have
62	62	refused to contract with the insurer on reasonable terms or any
63	63	terms.
64	64	(c) If physicians or health care providers necessary for an
65	65	adequate local market access network are available within the
66	66	relevant service area for a covered service for which the insurer
67	67	requests a waiver, the insurer's request for waiver must include:
68	68	(1) a list of the physicians or providers within the
69	69	relevant service area that the insurer attempted to contract with,
70	70	identified by name and specialty or facility type;
71	71	(2) a description of the manner in which the insurer
72	72	last contacted each physician or provider and the date of the
73	73	contact;
74	74	(3) a description of each reason each physician or
75	75	provider gave for refusing to contract with the insurer;
76	76	(4) an estimate of total claims cost savings in a year
77	77	the insurer anticipates will result from using a local market
78	78	access plan instead of contracting with physicians or providers
79	79	located within the service area, and the impact of the savings on
80	80	premiums;
81	81	(5) a description of the steps the insurer will take to
82	82	improve the network to avoid future requests to renew the waiver;
83	83	and
84	84	(6) any other information required by the commissioner
85	85	by rule or requested by the commissioner.
86	86	(d) The insurer's request for a waiver must state whether
87	87	any physician or health care provider is available within the
88	88	service area for the covered service or services for which the
89	89	insurer requests the waiver.
90	90	(e) Not later than the 30th day after the date an insurer
91	91	files a request for a waiver, a physician or health care provider
92	92	may file a response to the request in the manner prescribed by the
93	93	commissioner by rule.
94	94	Sec. 1301.255. GRANTING REQUEST FOR WAIVER OF NETWORK
95	95	ADEQUACY STANDARDS. If the commissioner grants a waiver requested
96	96	under Section 1301.254, the department shall post on the
97	97	department's Internet website information relevant to the grant of
98	98	a waiver, including:
99	99	(1) the name of the preferred provider benefit plan
100	100	for which the request is granted;
101	101	(2) the insurer offering the plan; and
102	102	(3) the affected service area.
103	103	Sec. 1301.256. RENEWAL OF WAIVER. (a) An insurer may apply
104	104	annually for renewal of a waiver that has been granted under Section
105	105	1301.254.
106	106	(b) Application for renewal of a waiver must be filed in a
107	107	manner prescribed by the commissioner by rule not less than the 30th
108	108	day before the anniversary of the date the commissioner granted the
109	109	waiver.
110	110	Sec. 1301.257. EXPIRATION OF WAIVER. A waiver of network
111	111	adequacy standards expires on the anniversary of the date the
112	112	commissioner granted the waiver if:
113	113	(1) an insurer fails to timely request a renewal under
114	114	Section 1301.256; or
115	115	(2) the department denies the insurer's request for
116	116	renewal.
117	117	Sec. 1301.258. LOCAL MARKET ACCESS PLAN REQUIRED. (a) Not
118	118	later than the 30th day after the date an insurer's network fails to
119	119	comply with the network adequacy requirements under this subchapter
120	120	for a specific service area, the insurer must:
121	121	(1) establish a local market access plan as described
122	122	by Section 1301.259; and
123	123	(2) request a waiver of network adequacy standards
124	124	under Section 1301.254 seeking approval of the local market access
125	125	plan.
126	126	(b) An insurer must file a local market access plan with the
127	127	request for a waiver under Section 1301.254.
128	128	(c) The local market access plan must be provided to the
129	129	department on request.
130	130	Sec. 1301.259. LOCAL MARKET ACCESS PLAN CONTENTS. A local
131	131	market access plan required under Section 1301.258 must specify for
132	132	each service area that does not meet the network adequacy
133	133	requirements:
134	134	(1) the geographic area within the service area in
135	135	which a sufficient number of preferred providers, identified by
136	136	class of provider, are not available as required by network
137	137	adequacy standards;
138	138	(2) a map, with key and scale, that identifies the
139	139	geographic areas within the service area in which the health care
140	140	services, physicians, or health care providers are not available;
141	141	(3) the reasons that the preferred provider network
142	142	does not meet the network adequacy standards;
143	143	(4) procedures that the insurer will implement to
144	144	assist insureds in obtaining medically necessary services if a
145	145	preferred provider is not reasonably available, including
146	146	procedures to coordinate care to avoid balance billing; and
147	147	(5) the manner in which nonpreferred provider benefit
148	148	claims will be handled when a preferred or otherwise contracted
149	149	provider is not available, including procedures for compliance with
150	150	requirements for claims payments.
151	151	Sec. 1301.260. LOCAL MARKET ACCESS PLAN PROCEDURES. (a) An
152	152	insurer must establish and implement procedures for use in each
153	153	service area for which a local market access plan is submitted,
154	154	including procedures to:
155	155	(1) identify requests for preauthorization of
156	156	services for insureds that are likely to require the provision of
157	157	services by physicians or health care providers that do not have a
158	158	contract with the insurer;
159	159	(2) furnish to insureds, before a health care service
160	160	is provided, an estimate of the amount the insurer will pay the
161	161	physician or health care provider;
162	162	(3) except in the case of an exclusive provider
163	163	benefit plan, notify insureds that they may be liable for any
164	164	amounts charged by the physician or provider that are not paid in
165	165	full by the insurer;
166	166	(4) identify claims filed by nonpreferred providers in
167	167	instances in which a preferred provider was not reasonably
168	168	available to the insured; and
169	169	(5) make initial and, if required, subsequent payment
170	170	of the claims in the manner required by this subchapter.
171	171	(b) A local market access plan may include a process for
172	172	negotiating with a nonpreferred provider before the provider
173	173	provides a health care service.
174	174	Sec. 1301.261. LOCAL MARKET ACCESS PLAN ANNUAL FILINGS. An
175	175	insurer must submit a local market access plan established under
176	176	Section 1301.258 as a part of the annual report on network adequacy
177	177	required under Section 1301.263.
178	178	Sec. 1301.262. PAYMENT OF CERTAIN BASIC BENEFIT CLAIMS;
179	179	DISCLOSURES. (a) Except as provided by Subsection (f), an insurer
180	180	shall pay claims in compliance with this section if a preferred
181	181	provider is not reasonably available to an insured and services are
182	182	provided by a nonpreferred provider, including if:
183	183	(1) emergency care is required;
184	184	(2) a preferred provider is not reasonably available
185	185	within the relevant service area; or
186	186	(3) a nonpreferred provider's service is preapproved
187	187	or preauthorized based on the unavailability of a preferred
188	188	provider in the relevant service area.
189	189	(b) If services are provided to an insured by a nonpreferred
190	190	provider because a preferred provider is not reasonably available
191	191	to the insured, the insurer shall:
192	192	(1) pay not less than the usual or customary charge for
193	193	the service, less any patient coinsurance, copayment, or deductible
194	194	responsibility under the preferred provider benefit plan;
195	195	(2) pay the claim at the preferred benefit coinsurance
196	196	level; and
197	197	(3) in addition to any amounts that would have been
198	198	credited had the provider been a preferred provider, credit any
199	199	out-of-pocket amounts shown by the insured to have been actually
200	200	paid to the nonpreferred provider for covered services in excess of
201	201	the allowed amount toward the insured's deductible and annual
202	202	out-of-pocket maximum applicable to preferred provider services.
203	203	(c) An insurer must calculate the reimbursement of a
204	204	nonpreferred provider for a covered service using an appropriate
205	205	methodology that:
206	206	(1) if based on usual, reasonable, or customary
207	207	charges, is based on generally accepted industry standards and
208	208	practices for determining the customary billed charge for a service
209	209	and that fairly and accurately reflect market rates, including
210	210	geographic differences in costs;
211	211	(2) if based on claims data, is based on sufficient
212	212	data to constitute a representative and statistically valid sample;
213	213	(3) is updated at least annually;
214	214	(4) does not use data that is more than three years
215	215	old; and
216	216	(5) is consistent with nationally recognized and
217	217	generally accepted bundling edits and logic.
218	218	(d) An insurer shall pay all covered basic benefits for
219	219	services obtained from physicians or health care providers at a
220	220	level not less than the preferred provider benefit plan's basic
221	221	benefit level of coverage, regardless of whether the service is
222	222	provided within the designated service area for the plan. The
223	223	insurer may not deny a claim because the services were provided by
224	224	physicians or health care providers outside the designated service
225	225	area for the plan.
226	226	(e) If a service is provided to an insured by a nonpreferred
227	227	facility-based physician and the difference between the allowed
228	228	amount and the billed charge is at least $1,000, the insurer must
229	229	include a notice on the explanation of benefits that the insured may
230	230	have the right to request mediation of the claim of an uncontracted
231	231	facility-based provider under Chapter 1467 and may obtain
232	232	information at the department's Internet website.
233	233	(f) This section does not apply to an exclusive provider
234	234	benefit plan.
235	235	Sec. 1301.263. NETWORK ADEQUACY ANNUAL REPORT. (a) Before
236	236	marketing a preferred provider benefit plan in a new service area
237	237	and not less frequently than annually on a date prescribed by the
238	238	commissioner by rule, an insurer shall file a network adequacy
239	239	report as described by Subsection (b) with the department.
240	240	(b) The network adequacy report must specify:
241	241	(1) the trade name of each preferred provider benefit
242	242	plan in which insureds participate;
243	243	(2) the applicable service area of each plan;
244	244	(3) whether the preferred provider service delivery
245	245	network supporting each plan is adequate under applicable network
246	246	adequacy standards; and
247	247	(4) as required by the commissioner by rule, the
248	248	number of:
249	249	(A) claims for nonpreferred provider benefits,
250	250	excluding claims paid at the preferred benefit coinsurance level;
251	251	(B) claims for nonpreferred provider benefits
252	252	that were paid at the preferred benefit coinsurance level;
253	253	(C) complaints by nonpreferred providers;
254	254	(D) complaints by insureds relating to the amount
255	255	of the insurer's payment for basic benefits or balance billing;
256	256	(E) complaints by insureds relating to the
257	257	availability of preferred providers; and
258	258	(F) complaints by insureds relating to the
259	259	accuracy of preferred provider listings.
260	260	(c) The annual report required under this section must be
261	261	submitted as required by the commissioner by rule.
262	262	Sec. 1301.264. ENFORCEMENT; SANCTIONS. (a) The
263	263	commissioner may impose sanctions under Chapter 82 or issue a cease
264	264	and desist order under Chapter 83 if the commissioner determines,
265	265	after notice and opportunity for hearing, that the insurer's
266	266	network and any local market access plan supporting the network are
267	267	inadequate to ensure the availability and accessibility of:
268	268	(1) preferred provider benefits;
269	269	(2) all medical and health care services and items
270	270	covered under a preferred provider benefit plan; or
271	271	(3) adequate personnel, specialty care, and
272	272	facilities.
273	273	(b) In exercising the authority under Subsection (a), the
274	274	commissioner may order an insurer to:
275	275	(1) reduce a service area of a preferred provider
276	276	benefit plan;
277	277	(2) stop marketing a preferred provider benefit plan
278	278	in all or part of the state; or
279	279	(3) withdraw from the preferred provider benefit plan
280	280	market.
281	281	(c) This section does not limit the authority of the
282	282	commissioner to order any other appropriate corrective action,
283	283	sanction, or penalty.
284	284	SUBCHAPTER G. DISCLOSURES TO INSUREDS
285	285	Sec. 1301.301. MANDATORY DISCLOSURES. (a) An application
286	286	for a health insurance policy that provides preferred provider
287	287	benefits and an endorsement, amendment, or rider to the policy must
288	288	be written in a readable and understandable format adopted by the
289	289	commissioner by rule.
290	290	(b) An insurer shall, on request, provide to a current or
291	291	prospective insured an accurate written description of the policy
292	292	terms that allows the insured to make comparisons and informed
293	293	decisions about selecting a health care plan. The written
294	294	description must be in a readable and understandable format adopted
295	295	by the commissioner by rule and must include a clear, complete, and
296	296	accurate description that:
297	297	(1) discloses the name of the entity providing the
298	298	coverage;
299	299	(2) discloses that the entity providing the coverage
300	300	is an insurance company;
301	301	(3) provides a toll-free telephone number, unless the
302	302	company is exempted by statute or rule from having a toll-free
303	303	telephone number, and a mailing address to enable a current or
304	304	prospective insured to obtain additional information;
305	305	(4) explains the coverage is for, as applicable:
306	306	(A) preferred provider benefits; or
307	307	(B) exclusive provider benefits that only
308	308	provide benefits from preferred providers, except as otherwise
309	309	provided in the policy;
310	310	(5) explains the distinction between preferred and
311	311	nonpreferred providers;
312	312	(6) identifies all covered services and benefits,
313	313	including benefits that provide payment for:
314	314	(A) the services of a preferred provider and a
315	315	nonpreferred provider;
316	316	(B) prescription drug coverage for generic and
317	317	name brand drugs;
318	318	(C) emergency care services and benefits and
319	319	information on access to after-hours care; and
320	320	(D) out-of-area services and benefits;
321	321	(7) explains the insured's financial responsibility
322	322	for payment for any premiums and for deductibles, copayments,
323	323	coinsurance, or other out-of-pocket expenses for noncovered or
324	324	nonpreferred services;
325	325	(8) discloses any limitations and exclusions,
326	326	including the existence of any drug formulary limitations and any
327	327	limitations regarding preexisting conditions;
328	328	(9) discloses any prior authorization requirements,
329	329	including preauthorization review, concurrent review, post-service
330	330	review, and postpayment review, and any penalties or reductions in
331	331	benefits resulting from the failure to obtain required
332	332	authorizations;
333	333	(10) explains provisions for continuity of treatment
334	334	in the event of termination of a preferred provider's participation
335	335	in the plan;
336	336	(11) provides a summary of complaint resolution
337	337	procedures, if any;
338	338	(12) discloses that the insurer is prohibited from
339	339	retaliating against the insured because the insured or another
340	340	person has filed a complaint on behalf of the insured, or against a
341	341	physician or health care provider who, on behalf of the insured, has
342	342	reasonably filed a complaint against the insurer or appealed a
343	343	decision of the insurer;
344	344	(13) in a format required or permitted by the
345	345	commissioner by rule, provides a current list of preferred
346	346	providers and complete descriptions of the provider networks,
347	347	including names and locations of physicians and health care
348	348	providers, and a disclosure of which preferred providers will not
349	349	accept new patients;
350	350	(14) shows the service area or areas; and
351	351	(15) advises that information is updated at least
352	352	annually regarding whether any waivers or local access plans
353	353	approved by the commissioner apply to the plan.
354	354	(c) A copy of the written description of policy terms
355	355	required by Subsection (b) must be filed with the department:
356	356	(1) on the date of the initial filing of the preferred
357	357	provider benefit plan; and
358	358	(2) not later than the 60th day after the date of a
359	359	material change to a policy term.
360	360	Sec. 1301.302. PROMOTIONAL MATERIAL. (a) A preferred
361	361	provider benefit plan and all promotional, solicitation, and
362	362	advertising material related to the plan must clearly describe the
363	363	distinction between preferred and nonpreferred providers. An
364	364	illustration of preferred provider benefits must be in proximity to
365	365	an equally prominent description of basic benefits.
366	366	(b) An insurer that maintains an Internet website providing
367	367	information about the insurer or the health insurance policies
368	368	offered by the insurer for use by current or prospective insureds is
369	369	required to provide:
370	370	(1) an Internet-based provider listing;
371	371	(2) an Internet-based listing of the state regions,
372	372	counties, or postal code areas within the insurer's service area or
373	373	areas;
374	374	(3) an Internet-based listing of the information
375	375	required by Section 1301.301; and
376	376	(4) a statement of whether the network meets or does
377	377	not meet the network adequacy requirements under Subchapter F and
378	378	as prescribed by the commissioner by rule.
379	379	Sec. 1301.303. PREFERRED PROVIDER AND EXCLUSIVE PROVIDER
380	380	NOTICES. (a) An insurer shall provide a notice in all health
381	381	insurance policies that provide preferred provider benefits and
382	382	outlines of coverage in at least 12-point font that must read
383	383	substantially similar to the following:
384	384	You have the right to an adequate network of preferred
385	385	providers (also known as "network providers").
386	386	If you believe that the network is inadequate, you may file a
387	387	complaint with the Texas Department of Insurance.
388	388	If you obtain out-of-network services because a preferred
389	389	provider was not reasonably available, you may be entitled to have
390	390	the claim paid at the in-network rate and your out-of-pocket
391	391	expenses counted toward your in-network deductible and
392	392	out-of-pocket maximum.
393	393	You have the right to obtain advance estimates of the amounts
394	394	that:
395	395	(1) a provider may bill for projected services, from
396	396	your out-of-network provider; and
397	397	(2) the insurer may pay for the projected services,
398	398	from your insurer.
399	399	You may obtain a current directory of preferred providers at
400	400	the following website: (insurer's Internet website address or
401	401	marked inapplicable if the insurer does not maintain an Internet
402	402	website) or by calling (insurer's telephone number) for assistance
403	403	in finding available preferred providers. If the directory is
404	404	materially inaccurate, you may be entitled to have an
405	405	out-of-network claim paid at the in-network level of benefits.
406	406	If you are treated by a provider or hospital that is not a
407	407	preferred provider, you may be billed for anything not paid by the
408	408	insurer.
409	409	If the amount you owe to an out-of-network hospital-based
410	410	radiologist, anesthesiologist, pathologist, emergency department
411	411	physician, or neonatologist is greater than $1,000 (not including
412	412	your copayment, coinsurance, and deductible responsibilities) for
413	413	services received in a network hospital, you may be entitled to have
414	414	the parties participate in a teleconference and, if the result is
415	415	not to your satisfaction, in a mandatory mediation at no cost to
416	416	you. You can learn more about mediation at the Texas Department of
417	417	Insurance Internet website.
418	418	(b) An insurer shall provide a notice in all health
419	419	insurance policies that provide exclusive provider benefits and
420	420	outlines of the coverage in at least 12-point font that must read
421	421	substantially similar to the following:
422	422	An exclusive provider benefit plan does not provide benefits
423	423	for services you receive from out-of-network providers, with
424	424	specific exceptions as described in your policy and below.
425	425	You have the right to an adequate network of preferred
426	426	providers (also known as "network providers").
427	427	If you believe that the network is inadequate, you may file a
428	428	complaint with the Texas Department of Insurance.
429	429	If your insurer approves a referral for out-of-network
430	430	services because a preferred provider is not available, or if you
431	431	have received out-of-network emergency care, your insurer must, in
432	432	most cases, resolve the nonpreferred provider's bill so that you
433	433	only have to pay any applicable coinsurance, copay, and deductible
434	434	amounts.
435	435	You may obtain a current directory of preferred providers at
436	436	the following website: (insurer's Internet website address or
437	437	marked inapplicable if the insurer does not maintain an Internet
438	438	website) or by calling (insurer's telephone number) for assistance
439	439	in finding available preferred providers. If the directory is
440	440	materially inaccurate, you may be entitled to have an
441	441	out-of-network claim paid at the in-network level of benefits.
442	442	Sec. 1301.304. ACCESS TO INFORMATION. Not less than
443	443	annually an insurer shall provide notice to all insureds describing
444	444	the manner by which an insured may:
445	445	(1) on a cost-free basis access a current list of all
446	446	preferred providers, including a nonelectronic copy of the list;
447	447	and
448	448	(2) obtain by telephone at a specified telephone
449	449	number during regular business hours assistance to identify
450	450	available preferred providers.
451	451	Sec. 1301.305. PROVIDER LISTING UPDATES. (a) An insurer
452	452	shall update all electronic or nonelectronic listings of preferred
453	453	providers made available to insureds not less than quarterly.
454	454	(b) If an insurer does not maintain a preferred provider
455	455	listing, electronically or otherwise, that an insured may access to
456	456	identify current preferred providers, the insurer shall distribute
457	457	a current preferred provider listing to all insureds not less than
458	458	annually by mail or other method as agreed by the insured.
459	459	Sec. 1301.306. HOSPITAL DISCLOSURES. Preferred provider
460	460	information and listings must include a method by which an insured
461	461	may identify hospitals that have contractually agreed to:
462	462	(1) exercise good faith efforts to accommodate a
463	463	request from an insured to use a preferred provider; and
464	464	(2) provide in a timely manner as prescribed by the
465	465	commissioner by rule information sufficient to enable the insured
466	466	to determine whether an assigned facility-based physician or
467	467	physician group is a preferred provider.
468	468	Sec. 1301.307. PROVIDER DISCLOSURES. Information about a
469	469	preferred provider must:
470	470	(1) disclose whether the provider is accepting new
471	471	patients;
472	472	(2) provide a method by which an insured may notify the
473	473	insurer of inaccurate information in the listing, including
474	474	information related to:
475	475	(A) the provider's contract status; and
476	476	(B) whether the provider is accepting new
477	477	patients;
478	478	(3) identify preferred provider facility-based
479	479	physicians able to provide services at a preferred provider
480	480	facility;
481	481	(4) specifically identify those facilities at which
482	482	the insurer has no contracts with a class of facility-based
483	483	providers; and
484	484	(5) be dated and provided in not less than 10-point
485	485	font.
486	486	Sec. 1301.308. LOCAL MARKET ACCESS PLANS. An insurer
487	487	shall, if applicable, on issuance of a policy or not less than 30
488	488	days before the date a policy is renewed, provide notice that the
489	489	preferred provider benefit plan relies on a local market access
490	490	plan as specified by the commissioner by rule. The contents of the
491	491	notice shall be determined by the commissioner by rule.
492	492	Sec. 1301.309. REIMBURSEMENT RATES FOR NONPREFERRED
493	493	PROVIDERS. An insurer shall disclose in each insurance policy and
494	494	outline of coverage information relating to the reimbursement of
495	495	basic benefit services, including how reimbursements of
496	496	nonpreferred providers are determined and except in an exclusive
497	497	provider benefit plan:
498	498	(1) if an insurer reimburses nonpreferred providers
499	499	based directly or indirectly on usual, customary, or reasonable
500	500	charges, the source of the data, how the data is used in determining
501	501	reimbursements, and the existence of any reduction to a
502	502	reimbursement to nonpreferred providers; and
503	503	(2) if an insurer bases reimbursement of nonpreferred
504	504	providers on an amount other than the total billed charges:
505	505	(A) whether the reimbursement of claims for
506	506	nonpreferred providers is less than the billed charge for the
507	507	service;
508	508	(B) whether the insured may be liable to the
509	509	nonpreferred provider for any amounts not paid by the insurer;
510	510	(C) a description of the methodology by which the
511	511	reimbursement amount for nonpreferred providers is calculated; and
512	512	(D) a method for insureds to obtain a real-time
513	513	estimate of the amount of reimbursement that the insurer will pay to
514	514	a nonpreferred provider for a particular service.
515	515	Sec. 1301.310. FALSE OR MISLEADING INFORMATION PROHIBITED.
516	516	An insurer may not cause or permit the use or distribution of
517	517	information related to a preferred provider benefit plan that is
518	518	untrue or misleading.
519	519	Sec. 1301.311. PROVIDER LISTING BINDING IN CERTAIN CASES.
520	520	An insurer shall pay a claim for services provided by a nonpreferred
521	521	provider at the applicable preferred benefit coinsurance
522	522	percentage if the insured demonstrates that:
523	523	(1) the insured reasonably relied on a statement that
524	524	a physician or provider was a preferred provider as specified in:
525	525	(A) a provider listing; or
526	526	(B) provider information; and
527	527	(2) the statement was obtained from the insurer, the
528	528	insurer's Internet website, or the Internet website of a third
529	529	party designated by the insurer to provide the listing for use by
530	530	the insureds not more than 30 days before the date of service.
531	531	SUBCHAPTER H. CONSUMER PROTECTIONS FOR EXCLUSIVE PROVIDER BENEFIT
532	532	PLANS
533	533	Sec. 1301.351. EXCLUSIVE PROVIDER BENEFIT PLAN
534	534	REQUIREMENTS. This subchapter applies only to exclusive provider
535	535	benefit plans.
536	536	Sec. 1301.352. NETWORK APPROVAL REQUIRED. An insurer may
537	537	not offer, deliver, or issue for delivery an exclusive provider
538	538	benefit plan in this state unless the commissioner has:
539	539	(1) completed a qualifying examination of the plan to
540	540	determine compliance with this chapter; and
541	541	(2) approved the insurer's exclusive provider network
542	542	in the relevant service area.
543	543	Sec. 1301.353. NETWORK APPROVAL: APPLICATION. An
544	544	applicant for approval of an exclusive provider network must submit
545	545	to the department a complete application disclosing the following
546	546	information:
547	547	(1) a statement that the filing is:
548	548	(A) an application for approval; or
549	549	(B) a modification to an approved application;
550	550	(2) organizational information for the applicant,
551	551	including:
552	552	(A) the full name of the applicant;
553	553	(B) the applicant's license or certificate
554	554	number issued by the department;
555	555	(C) the applicant's home office address; and
556	556	(D) the applicant's telephone number;
557	557	(3) the name and telephone number of a contact person
558	558	who will facilitate requests relating to the application from the
559	559	department;
560	560	(4) an attestation signed by the applicant's corporate
561	561	president or secretary or the president's or secretary's authorized
562	562	representative that:
563	563	(A) the person has read the application, is
564	564	familiar with its contents, and the information submitted in the
565	565	application, including the attachments, is true and complete; and
566	566	(B) the network, including any requested or
567	567	granted waiver and any access plan if applicable, is adequate for
568	568	the services to be provided under the exclusive provider benefit
569	569	plan;
570	570	(5) a description and a map of the service area, with
571	571	key and scale, identifying the area to be served within the
572	572	parameters established by the commissioner by rule;
573	573	(6) a list of all plan documents and each plan document
574	574	pending the department's approval or review, including each
575	575	associated form number or filing identification number;
576	576	(7) each form of physician and health care provider
577	577	contracts to demonstrate inclusion of provisions required by the
578	578	commissioner by rule or a sworn statement by the attestator that the
579	579	physician and health care provider contracts comply with the
580	580	requirements of this chapter;
581	581	(8) a description of the quality improvement program
582	582	and work plan that must include a process for medical peer review
583	583	and that explains arrangements to ensure confidentiality of medical
584	584	records shared among preferred providers;
585	585	(9) network configuration information, including:
586	586	(A) a map for each specialty demonstrating the
587	587	location and distribution of the physician and health care provider
588	588	network within the proposed service area as prescribed by the
589	589	commissioner by rule; and
590	590	(B) a list of each of the following:
591	591	(i) each physician and individual health
592	592	care practitioner who is a preferred provider, including license
593	593	type and specialization and an indication of whether the provider
594	594	is accepting new patients; and
595	595	(ii) each institutional provider that is a
596	596	preferred provider;
597	597	(10) documentation demonstrating that:
598	598	(A) the exclusive provider benefit plan
599	599	documents and procedures comply with Section 1301.363;
600	600	(B) without regard to whether the physician or
601	601	health care provider has a contractual or other arrangement to
602	602	provide items or services to insureds, the plan contains the
603	603	provisions and procedures that comply with Section 1301.363; and
604	604	(C) the insurer maintains a complaint system that
605	605	provides reasonable procedures to resolve a written complaint
606	606	initiated by a complainant; and
607	607	(11) the physical address of the location of all books
608	608	and records described by Section 1301.354.
609	609	Sec. 1301.354. NETWORK APPROVAL: QUALIFYING EXAMINATIONS.
610	610	An applicant shall make available for examination at the physical
611	611	address designated by the insurer under Section 1301.353(11) the
612	612	policy and certificate of insurance and documents relating to:
613	613	(1) quality improvement, including a program
614	614	description and work plan required by Section 1301.359;
615	615	(2) utilization management, including a program
616	616	description, policies and procedures, criteria used to determine
617	617	medical necessity, and examples of adverse determination letters,
618	618	adverse determination logs, and independent review organization
619	619	logs;
620	620	(3) network configuration, including information
621	621	demonstrating the adequacy of the exclusive provider network
622	622	described by Section 1301.353(9) and all executed physician and
623	623	provider contracts applicable to the network;
624	624	(4) credentialing;
625	625	(5) marketing of the exclusive provider benefit plan,
626	626	including all written materials to be presented to prospective
627	627	insureds that discuss the exclusive provider network available to
628	628	insureds under the plan and how preferred and nonpreferred
629	629	physicians or health care providers are to be paid under the plan;
630	630	and
631	631	(6) complaints made, including a complaint log
632	632	categorized and completed as prescribed by the commissioner by
633	633	rule.
634	634	Sec. 1301.355. NETWORK MODIFICATIONS. (a) An insurer must
635	635	file with the department an application for approval to implement a
636	636	change to an exclusive provider network configuration that affects
637	637	the adequacy of the network, expands or reduces an existing service
638	638	area, or adds a new service area.
639	639	(b) If a document submitted under Section 1301.353(5), (7),
640	640	or (9) is replaced or materially changed, an insurer must submit a
641	641	replacement or amended document and identify the change before the
642	642	change is implemented.
643	643	(c) Before the department grants approval of an application
644	644	for expansion or reduction of a service area, the insurer must be in
645	645	compliance with the requirements of Section 1301.359 through
646	646	1301.361 in the existing service areas and in the proposed service
647	647	areas.
648	648	(d) Except as provided by Subsection (b), an insurer must
649	649	file with the department any change to information filed under
650	650	Subsection (a) not later than the 30th day after the date the change
651	651	is implemented.
652	652	Sec. 1301.356. NETWORK APPROVAL: REVISED APPLICATIONS. If
653	653	the application for approval under Section 1301.353 or network
654	654	modification under Section 1301.355 is revised or supplemented
655	655	during the review process, the applicant must submit to the
656	656	department a transmittal letter filing the entire revised or
657	657	supplemented page and describing the revision or supplement.
658	658	Sec. 1301.357. EXAMINATIONS. (a) The commissioner shall
659	659	conduct an examination relating to an exclusive provider benefit
660	660	plan not less than once every five years.
661	661	(b) On-site financial, market conduct, complaint, or
662	662	quality of care examinations are conducted under Chapter 401 or 751
663	663	and rules adopted by the commissioner.
664	664	(c) An insurer shall make the books and records relating to
665	665	the insurer's operations available to the department to facilitate
666	666	an examination.
667	667	(d) On request of the commissioner, an insurer must provide
668	668	a copy of any contract, agreement, or other arrangement between the
669	669	insurer and a physician or health care provider. Documentation
670	670	provided to the commissioner under this subsection is confidential
671	671	as described by Section 1301.0056.
672	672	(e) The commissioner may examine and use the records of an
673	673	insurer, including records of a quality of care program or medical
674	674	peer review committee as defined by Section 151.002, Occupations
675	675	Code, as necessary to implement this subchapter, including
676	676	commencement and prosecution of an enforcement action under
677	677	Subtitle B, Title 2, or rules adopted by the commissioner.
678	678	Information obtained under this subsection is confidential as
679	679	described by Section 1301.0056.
680	680	(f) An insurer shall make available for examination at the
681	681	physical address designated under Section 1301.353(11)
682	682	documentation relating to:
683	683	(1) quality improvement, including program
684	684	descriptions, work plans, program evaluations, and committee and
685	685	subcommittee meeting minutes;
686	686	(2) utilization management, including program
687	687	descriptions, policies and procedures, criteria used to determine
688	688	medical necessity, and examples of adverse determination letters,
689	689	adverse determination logs, including all levels of appeal, and
690	690	utilization management files;
691	691	(3) complaints made, including complaint files, a
692	692	complaint log categorized and completed as prescribed by rules
693	693	adopted by the commissioner and documentation and details of
694	694	actions taken;
695	695	(4) the satisfaction of insureds, physicians, and
696	696	health care providers, including satisfaction surveys, insured
697	697	disenrollment logs, and termination logs;
698	698	(5) network configuration, including information
699	699	required by Section 1301.353(9);
700	700	(6) credentialing, including credentialing files; and
701	701	(7) any reports submitted by the insurer to any
702	702	federal or state governmental entity.
703	703	Sec. 1301.358. QUALITY IMPROVEMENT PROGRAMS REQUIRED. An
704	704	insurer shall develop and maintain a quality improvement program
705	705	designed to objectively and systematically monitor and evaluate the
706	706	quality and appropriateness of health care services provided under
707	707	a benefit plan and to pursue opportunities for improvement. The
708	708	program must be ongoing and comprehensive, addressing the quality
709	709	of clinical care and health care services. The insurer must
710	710	dedicate adequate resources, including personnel and information
711	711	systems, to the program.
712	712	Sec. 1301.359. QUALITY IMPROVEMENT PROGRAMS: CONTENTS OF
713	713	PROGRAM. The program established under Section 1301.358 must
714	714	include:
715	715	(1) a written description of the program's
716	716	organizational structure, functional responsibilities, and meeting
717	717	frequency;
718	718	(2) an annual work plan designed to reflect the type of
719	719	services and the population served by the benefit plan in terms of
720	720	age groups, disease categories, and special risk status, including:
721	721	(A) objective and measurable goals, planned
722	722	activities to accomplish the goals, time frames for implementation,
723	723	designation of responsible individuals, and evaluation
724	724	methodology; and
725	725	(B) measures to address each program area,
726	726	including:
727	727	(i) network adequacy, availability and
728	728	accessibility of care, and assessment of open and closed physician
729	729	and individual provider panels;
730	730	(ii) continuity of medical and health care
731	731	and related services;
732	732	(iii) the conduct of clinical studies;
733	733	(iv) the adoption and updating of clinical
734	734	practice guidelines or clinical care standards, including
735	735	guidelines and standards for preventive health care services, that
736	736	are communicated to and approved by participating physicians and
737	737	individual providers;
738	738	(v) insured, physician, and individual
739	739	health care provider satisfaction;
740	740	(vi) the complaint process, including
741	741	complaint data, and identification and removal of barriers that may
742	742	impede insureds, physicians, and health care providers from
743	743	effectively making complaints against the insurer;
744	744	(vii) preventive health care, including
745	745	health promotion and outreach activities;
746	746	(viii) claims payment processes;
747	747	(ix) contract monitoring, including
748	748	oversight and compliance with filing requirements;
749	749	(x) utilization review processes;
750	750	(xi) credentialing;
751	751	(xii) insured services; and
752	752	(xiii) pharmacy services, including drug
753	753	utilization;
754	754	(3) an annual written report addressing completed
755	755	activities, trending of clinical and service goals, analysis of
756	756	program performance, and conclusions;
757	757	(4) a process for selection and retention of
758	758	contracted preferred providers that complies with rules
759	759	established by the commissioner; and
760	760	(5) a peer review procedure for physicians and
761	761	individual providers, as required in Chapters 151 through 164,
762	762	Occupations Code, that designates a credentialing committee to
763	763	administer the review and make recommendations regarding
764	764	credentialing decisions.
765	765	Sec. 1301.360. QUALITY IMPROVEMENT PROGRAMS: DUTIES OF
766	766	GOVERNING BODIES. (a) The insurer's governing body shall appoint a
767	767	quality improvement committee that:
768	768	(1) includes practicing physicians and individual
769	769	providers; and
770	770	(2) may include one or more insureds from the
771	771	exclusive provider benefit plan's service area.
772	772	(b) An employee of the insurer may not serve as a committee
773	773	member.
774	774	(c) The governing body is responsible for the program. The
775	775	quality improvement program and the annual work plan may not be
776	776	implemented without the approval of the governing body.
777	777	(d) The governing body must meet not less frequently than
778	778	annually to receive and review reports of the committee or its
779	779	subcommittees and take action when appropriate.
780	780	(e) The governing body must review the annual written report
781	781	on the quality improvement program.
782	782	Sec. 1301.361. QUALITY IMPROVEMENT PROGRAMS: DUTIES OF
783	783	COMMITTEES; SUBCOMMITTEES. (a) The quality improvement committee
784	784	established under Section 1301.360 shall evaluate the overall
785	785	effectiveness of the quality improvement program.
786	786	(b) The committee may delegate duties to subcommittees
787	787	subject to the committee's oversight. A subcommittee may include
788	788	practicing physicians, individual health care providers, and
789	789	insureds from the service area.
790	790	(c) The subcommittees shall:
791	791	(1) collaborate and coordinate efforts to improve the
792	792	quality, availability, and accessibility of health care services;
793	793	(2) meet regularly; and
794	794	(3) report the findings of each meeting, including any
795	795	recommendations, in writing to the quality improvement committee.
796	796	(d) The quality improvement committee shall use
797	797	multidisciplinary teams as necessary to accomplish quality
798	798	improvement program goals.
799	799	Sec. 1301.362. QUALITY IMPROVEMENT PROGRAMS:
800	800	PRESUMPTIONS. (a) Except as provided by Subsection (b), in a
801	801	review of an insurer's quality improvement program, the department
802	802	shall presume the program complies with statutory and regulatory
803	803	requirements if the insurer received nonconditional accreditation
804	804	or certification in connection with quality improvement by:
805	805	(1) the National Committee for Quality Assurance;
806	806	(2) the Joint Commission;
807	807	(3) the Utilization Review Accreditation Commission;
808	808	or
809	809	(4) the Accreditation Association for Ambulatory
810	810	Health Care.
811	811	(b) If the department determines that an accreditation or
812	812	certification program does not adequately address a material
813	813	statutory or regulatory requirement of this state, the department
814	814	may not presume compliance.
815	815	Sec. 1301.363. OUT-OF-NETWORK CLAIMS: PAYMENT. (a) An
816	816	insurer shall fully reimburse a nonpreferred provider at the usual
817	817	and customary rate or at a rate agreed to by the nonpreferred
818	818	provider for services provided before the date the insured can
819	819	reasonably be transferred to a preferred provider if an insured
820	820	cannot reasonably reach a preferred provider for:
821	821	(1) a medical screening examination or other
822	822	evaluation required by state or federal law and necessary to
823	823	determine whether a medical emergency condition exists to be
824	824	provided in a hospital emergency facility, a freestanding emergency
825	825	medical care facility, or a comparable emergency facility; and
826	826	(2) necessary emergency care services, including the
827	827	treatment and stabilization of an emergency medical condition
828	828	provided in a hospital emergency facility, a freestanding emergency
829	829	medical care facility, or a comparable emergency facility.
830	830	(b) If medically necessary covered services other than
831	831	emergency care are not available through a preferred provider, on
832	832	the request of a preferred provider, the insurer:
833	833	(1) must approve a referral to a nonpreferred provider
834	834	in a timely manner appropriate to the delivery of the services and
835	835	the condition of the patient, but not later than five business days
836	836	after the date the insurer receives documentation relating to the
837	837	referral; and
838	838	(2) may not deny a referral until a health care
839	839	provider with expertise in the same specialty as or a specialty
840	840	similar to the type of health care provider to whom a referral is
841	841	requested has reviewed the referral.
842	842	(c) An insurer may facilitate an insured's selection of a
843	843	nonpreferred provider if medically necessary covered services,
844	844	excluding emergency care, are not available through a preferred
845	845	provider and an insured has received a referral from a preferred
846	846	provider.
847	847	(d) If an insurer facilitates an insured's selection as
848	848	described by Subsection (c), the insurer must offer an insured a
849	849	list of not less than three nonpreferred providers with expertise
850	850	in the necessary specialty who are reasonably available considering
851	851	the medical condition and location of the insured.
852	852	(e) An insurer reimbursing a nonpreferred provider under
853	853	Subsection (a), (b), or (d) must:
854	854	(1) ensure that the insured is held harmless for any
855	855	amounts in excess of the copayment and deductible amount and
856	856	coinsurance percentage that the insured would have paid had the
857	857	insured received services from a preferred provider; and
858	858	(2) issue payment to the nonpreferred provider at the
859	859	usual and customary rate or at a rate agreed to by the nonpreferred
860	860	provider.
861	861	(f) An insurer must provide with the payment an explanation
862	862	of benefits to the insured and request that the insured notify the
863	863	insurer if the nonpreferred provider bills the insured for amounts
864	864	in excess of the amount paid by the insurer.
865	865	(g) An insurer must pay any amounts that the nonpreferred
866	866	provider bills the insured in excess of the amount paid by the
867	867	insurer in a manner consistent with Subsection (e).
868	868	(h) If the insured selects a nonpreferred provider that is
869	869	not included in the list provided under Subsection (d) by the
870	870	insurer, notwithstanding Section 1301.262(f), the insurer must pay
871	871	the claim in accordance with Section 1301.262.
872	872	Sec. 1301.364. OUT-OF-NETWORK CLAIMS: MEDIATION. (a) An
873	873	insurer may require that an insured request mediation under Chapter
874	874	1467 or under provisions adopted by the commissioner by rule. The
875	875	insurer must notify the insured when mediation is available and
876	876	inform the insured of how to request mediation. The insurer may
877	877	not:
878	878	(1) except as provided by Subsection (b), penalize the
879	879	insured for failing to request mediation; or
880	880	(2) require the insured to participate in the
881	881	mediation.
882	882	(b) Notwithstanding Subsection (a)(1), an insurer that
883	883	requests that the insured initiate mediation is not responsible for
884	884	any balance bill the insured receives from the nonpreferred
885	885	provider until the insured requests mediation.
886	886	(c) Eligibility for mediation under this section is based on
887	887	the entire unpaid amount of the nonpreferred provider bills, less
888	888	any applicable copayment, deductible, and coinsurance.
889	889	(d) The insurer's payment must be based on the amount due
890	890	resulting from the mediation process.
891	891	Sec. 1301.365. OUT-OF-NETWORK CLAIMS: PAYMENT
892	892	METHODOLOGIES. Any methodology used by an insurer to calculate
893	893	reimbursement of nonpreferred providers for services that are
894	894	covered under an exclusive provider benefit plan must be:
895	895	(1) based on:
896	896	(A) generally accepted industry standards and
897	897	practices for determining the usual, reasonable, or customary fee
898	898	for a service to ensure market rates, including geographic
899	899	differences in costs, are fairly and accurately reflected; or
900	900	(B) claims data that is:
901	901	(i) sufficient to constitute a
902	902	representative and statistically valid sample;
903	903	(ii) updated not less than annually; and
904	904	(iii) not more than three years old; and
905	905	(2) consistent with nationally recognized and
906	906	generally accepted bundling edits and logic.
907	907	SECTION 2. Section 1301.005(b), Insurance Code, is amended
908	908	to read as follows:
909	909	(b) Subject to Sections 1301.262, 1301.309, and 1301.363,
910	910	if [If] services are not available through a preferred provider
911	911	within a designated service area under a preferred provider benefit
912	912	plan or an exclusive provider benefit plan, an insurer shall
913	913	reimburse a physician or health care provider who is not a preferred
914	914	provider at the same percentage level of reimbursement as a
915	915	preferred provider would have been reimbursed had the insured been
916	916	treated by a preferred provider.
917	917	SECTION 3. Section 1301.0051(a), Insurance Code, is amended
918	918	to read as follows:
919	919	(a) An insurer that offers an exclusive provider benefit
920	920	plan shall establish procedures in compliance with Section 1301.358
921	921	to ensure that health care services are provided to insureds under
922	922	reasonable standards of quality of care that are consistent with
923	923	prevailing professionally recognized standards of care or
924	924	practice. The procedures must include:
925	925	(1) mechanisms to ensure availability, accessibility,
926	926	quality, and continuity of care;
927	927	(2) subject to Section 1301.059, a continuing quality
928	928	improvement program to monitor and evaluate services provided under
929	929	the plan, including primary and specialist physician services and
930	930	ancillary and preventive health care services, provided in
931	931	institutional or noninstitutional settings;
932	932	(3) a method of recording formal proceedings of
933	933	quality improvement program activities and maintaining quality
934	934	improvement program documentation in a confidential manner;
935	935	(4) subject to Section 1301.059, a physician review
936	936	panel to assist the insurer in reviewing medical guidelines or
937	937	criteria;
938	938	(5) a patient record system that facilitates
939	939	documentation and retrieval of clinical information for the
940	940	insurer's evaluation of continuity and coordination of services and
941	941	assessment of the quality of services provided to insureds under
942	942	the plan;
943	943	(6) a mechanism for making available to the
944	944	commissioner the clinical records of insureds for examination and
945	945	review by the commissioner on request of the commissioner; and
946	946	(7) a specific procedure for the periodic reporting of
947	947	quality improvement program activities to:
948	948	(A) the governing body and appropriate staff of
949	949	the insurer; and
950	950	(B) physicians and health care providers that
951	951	provide health care services under the plan.
952	952	SECTION 4. Sections 1301.0052, Insurance Code, is amended
953	953	to read as follows:
954	954	Sec. 1301.0052. EXCLUSIVE PROVIDER BENEFIT PLANS:
955	955	REFERRALS FOR MEDICALLY NECESSARY SERVICES. (a) If a covered
956	956	service is medically necessary and is not available through a
957	957	preferred provider, the issuer of an exclusive provider benefit
958	958	plan, on the request of a preferred provider, shall subject to
959	959	Subchapter H:
960	960	(1) approve the referral of an insured to a
961	961	nonpreferred provider within a reasonable period; and
962	962	(2) fully reimburse the nonpreferred provider at the
963	963	usual and customary rate or at a rate agreed to by the issuer and the
964	964	nonpreferred provider.
965	965	(b) Subject to Section 1301.363, an [An] exclusive provider
966	966	benefit plan must provide for a review by a health care provider
967	967	with expertise in the same specialty as or a specialty similar to
968	968	the type of health care provider to whom a referral is requested
969	969	under Subsection (a) before the issuer of the plan may deny the
970	970	referral.
971	971	SECTION 5. Section 1301.0053, Insurance Code, is amended to
972	972	read as follows:
973	973	Sec. 1301.0053. EXCLUSIVE PROVIDER BENEFIT PLANS:
974	974	EMERGENCY CARE. If a nonpreferred provider provides emergency care
975	975	as defined by Section 1301.155 to an enrollee in an exclusive
976	976	provider benefit plan, the issuer of the plan shall, subject to
977	977	Section 1301.363(a), reimburse the nonpreferred provider at the
978	978	usual and customary rate or at a rate agreed to by the issuer and the
979	979	nonpreferred provider for the provision of the services.
980	980	SECTION 6. Section 1301.0055, Insurance Code, is amended to
981	981	read as follows:
982	982	Sec. 1301.0055. NETWORK ADEQUACY STANDARDS. The
983	983	commissioner shall by rule adopt network adequacy standards in
984	984	compliance with Subchapters F, G, and H and that:
985	985	(1) are adapted to local markets in which an insurer
986	986	offering a preferred provider benefit plan operates;
987	987	(2) ensure availability of, and accessibility to, a
988	988	full range of contracted physicians and health care providers to
989	989	provide health care services to insureds; and
990	990	(3) on good cause shown, may allow departure from
991	991	local market network adequacy standards if the commissioner posts
992	992	on the department's Internet website the name of the preferred
993	993	provider plan, the insurer offering the plan, and the affected
994	994	local market.
995	995	SECTION 7. Section 1301.006(a), Insurance Code, is amended
996	996	to read as follows:
997	997	(a) Subject to Subchapter F, an [An] insurer that markets a
998	998	preferred provider benefit plan shall contract with physicians and
999	999	health care providers to ensure that all medical and health care
1000	1000	services and items contained in the package of benefits for which
1001	1001	coverage is provided, including treatment of illnesses and
1002	1002	injuries, will be provided under the health insurance policy in a
1003	1003	manner ensuring availability of and accessibility to adequate
1004	1004	personnel, specialty care, and facilities.
1005	1005	SECTION 8. Section 1301.009(a), Insurance Code, is amended
1006	1006	to read as follows:
1007	1007	(a) In addition to the reports required under Section
1008	1008	1301.263, not [Not] later than March 1 of each year, an insurer
1009	1009	shall file with the commissioner a report relating to the preferred
1010	1010	provider benefit plan offered under this chapter and covering the
1011	1011	preceding calendar year.
1012	1012	SECTION 9. Section 1301.056(a), Insurance Code, is amended
1013	1013	to read as follows:
1014	1014	(a) Subject to Subchapters F, G, and H, an [An] insurer or
1015	1015	third-party administrator may not reimburse a physician or other
1016	1016	practitioner, institutional provider, or organization of
1017	1017	physicians and health care providers on a discounted fee basis for
1018	1018	covered services that are provided to an insured unless:
1019	1019	(1) the insurer or third-party administrator has
1020	1020	contracted with either:
1021	1021	(A) the physician or other practitioner,
1022	1022	institutional provider, or organization of physicians and health
1023	1023	care providers; or
1024	1024	(B) a preferred provider organization that has a
1025	1025	network of preferred providers and that has contracted with the
1026	1026	physician or other practitioner, institutional provider, or
1027	1027	organization of physicians and health care providers;
1028	1028	(2) the physician or other practitioner,
1029	1029	institutional provider, or organization of physicians and health
1030	1030	care providers has agreed to the contract and has agreed to provide
1031	1031	health care services under the terms of the contract; and
1032	1032	(3) the insurer or third-party administrator has
1033	1033	agreed to provide coverage for those health care services under the
1034	1034	health insurance policy.
1035	1035	SECTION 10. Section 1301.059(b), Insurance Code, is amended
1036	1036	to read as follows:
1037	1037	(b) Except as provided in Subchapter H, an [An] insurer may
1038	1038	not engage in quality assessment except through a panel of at least
1039	1039	three physicians selected by the insurer from among a list of
1040	1040	physicians contracting with the insurer. The physicians
1041	1041	contracting with the insurer in the applicable service area shall
1042	1042	provide the list of physicians to the insurer.
1043	1043	SECTION 11. This Act applies only to an insurance policy
1044	1044	that is delivered, issued for delivery, or renewed on or after
1045	1045	January 1, 2014. A policy delivered, issued for delivery, or
1046	1046	renewed before January 1, 2014, is governed by the law as it existed
1047	1047	immediately before the effective date of this Act, and that law is
1048	1048	continued in effect for that purpose.
1049	1049	SECTION 12. This Act takes effect September 1, 2013.