83R8720 SCL-F
By: Taylor S.B. No. 1197
A BILL TO BE ENTITLED
AN ACT
relating to requirements of exclusive provider and preferred
provider benefit plans.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1301.001, Insurance Code, is amended by
adding Subdivisions (9-a) and (9-b) to read as follows:
(9-a) "Procedure code" means an alphanumeric code used
to identify a specific health procedure performed by a health care
provider. The term includes:
(A) the American Medical Association's Current
Procedural Terminology code, also known as the "CPT code";
(B) the Centers for Medicare and Medicaid
Services Healthcare Common Procedure Coding System; and
(C) other analogous codes published by national
organizations and recognized by the commissioner.
(9-b) "Same service" means a health care service under
the same procedure code as another health care service.
SECTION 2. Section 1301.0041(b), Insurance Code, is amended
to read as follows:
(b) The commissioner may not impose a requirement for an
exclusive provider benefit plan that is different from a
requirement for a preferred provider benefit plan unless [Unless]
otherwise specified in this chapter[, an exclusive provider benefit
plan is subject to this chapter in the same manner as a preferred
provider benefit plan]. Except as provided by this chapter, the
commissioner may not impose additional requirements for an
exclusive provider benefit plan, including requirements based on:
(1) an annual network adequacy report;
(2) a complaint process or record;
(3) a document not related to network adequacy;
(4) a filing of a network provider contract with the
commissioner;
(5) a filing of a description of information systems
with the commissioner;
(6) a network certification; and
(7) a qualifying examination.
SECTION 3. Section 1301.005, Insurance Code, is amended by
amending Subsection (b) and adding Subsections (d) and (e) to read
as follows:
(b) If services are not available through a preferred
provider within a designated service area or through a
facility-based physician providing services at a network health
care facility under a preferred provider benefit plan or an
exclusive provider benefit plan, an insurer shall reimburse a
physician or health care provider who is not a preferred provider at
the same percentage level of reimbursement as a preferred provider
would have been reimbursed had the insured been treated by a
preferred provider.
(d) A preferred provider benefit plan is not required to
provide coverage, including credit to applicable deductibles or
out-of-pocket maximums, for the excess amount the physician or
health care provider who is not a preferred provider charges over
the allowable amount covered under the preferred provider benefit
plan.
(e) Each insurance policy, certificate, and outline of
coverage must disclose how reimbursement for services provided by a
physician or health care provider who is not a preferred provider is
calculated. The reimbursements must be calculated pursuant to
appropriate reasonable and objective methodologies, including the
median amount negotiated with preferred providers for the same
service, published claims data, or a percentage of the published
rate allowed by the Centers for Medicare and Medicaid Services for
the same or similar service within the geographic market.
SECTION 4. Section 1301.0055, Insurance Code, is amended to
read as follows:
Sec. 1301.0055. NETWORK ADEQUACY STANDARDS. (a) The
commissioner shall by rule adopt network adequacy standards that:
(1) are adapted to local markets in which an insurer
offering a preferred provider benefit plan operates;
(2) ensure availability of, and accessibility to, a
full range of contracted physicians and health care providers to
provide health care services to insureds; and
(3) on good cause shown, may allow departure from
local market network adequacy standards if the commissioner posts
on the department's Internet website the name of the preferred
provider plan, the insurer offering the plan, and the affected
local market.
(b) A preferred provider benefit plan issuer is not required
to obtain the commissioner's approval for a departure from local
market network adequacy standards, and the standards are not
violated, if there is not a licensed provider of a particular
specialty located within the service area. A preferred provider
plan issuer shall list the areas in which a health care provider of
a particular specialty is not available on the issuer's Internet
website.
SECTION 5. (a) As soon as practicable after the effective
date of this Act, the commissioner of insurance shall adopt revised
rules to implement the change in law made by this Act.
(b) The change in law made by this Act applies to an
insurance policy delivered, issued for delivery, or renewed on or
after the effective date of this Act. A policy delivered, issued
for delivery, or renewed before the effective date of this Act is
governed by the law in effect immediately before the effective date
of this Act, and that law is continued in effect for that purpose.
SECTION 6. 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, 2013.