85R23635 SMT-F
By: Gooden H.B. No. 3124
Substitute the following for H.B. No. 3124:
By: Phillips C.S.H.B. No. 3124
A BILL TO BE ENTITLED
AN ACT
relating to certain physician-specific comparison data compiled by
a health benefit plan issuer, including the release of that data to
physicians participating in certain physician-led organizations.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to Chapter 1460, Insurance Code, is
amended to read as follows:
CHAPTER 1460. [STANDARDS REQUIRED REGARDING] CERTAIN PHYSICIAN
RANKINGS AND COST COMPARISONS BY HEALTH BENEFIT PLANS
SECTION 2. Chapter 1460, Insurance Code, is amended by
designating Sections 1460.001 and 1460.002 as Subchapter A and
adding a subchapter heading to read as follows:
SUBCHAPTER A. GENERAL PROVISIONS
SECTION 3. Section 1460.001, Insurance Code, is amended to
read as follows:
Sec. 1460.001. DEFINITIONS. In this chapter:
(1) "Accountable care organization" means an entity:
(A) that is composed of physicians or physicians
and other health care providers;
(B) that is owned and controlled by one or more
physicians licensed in this state and engaged in active clinical
practice in this state;
(C) that contracts with a health benefit plan
issuer to provide medical or health care services to a defined
population;
(D) that uses a payment structure that takes into
account the total costs and quality of the care provided to the
defined population served by the entity; and
(E) through which physicians and health care
providers, if any:
(i) share in savings created by improvement
of the quality of, and reduction of cost increases for, care
delivered to the defined population served by the entity; or
(ii) are compensated through another
payment methodology intended to reduce the total cost of care
delivered to the defined population served by the entity.
(2) "Cost comparison data" means information compiled
by a health benefit plan issuer to show the health care costs
associated with a physician or other health care provider relative
to another physician or health care provider.
(3) "Designated entity" means a limited liability
company in which a majority ownership interest is held by an
incorporated association whose purpose includes uniting in one
organization all physicians licensed to practice medicine in this
state and that has been in continued existence for at least 15
years.
(4) "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.
(5) "Participating physician" means a physician who
participates in an accountable care organization.
(6) [(2)] "Physician" means an individual licensed to
practice medicine in this state or another state of the United
States.
SECTION 4. Chapter 1460, Insurance Code, is amended by
designating Sections 1460.003 through 1460.007 as Subchapter B and
adding a subchapter heading to read as follows:
SUBCHAPTER B. PHYSICIAN RANKINGS
SECTION 5. Section 1460.003(a), Insurance Code, is amended
to read as follows:
(a) Except as provided by Subchapter C, 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.
SECTION 6. Section 1460.005(a), Insurance Code, is amended
to read as follows:
(a) The commissioner shall adopt rules as necessary to
implement this subchapter [chapter].
SECTION 7. Sections 1460.006 and 1460.007, Insurance Code,
are amended to read as follows:
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 subchapter [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 subchapter [chapter]
or a rule adopted under this subchapter [chapter] is subject to
sanctions and disciplinary actions under Chapters 82 and 84.
(b) A violation of this subchapter [chapter] by a physician
constitutes grounds for disciplinary action by the Texas Medical
Board, including imposition of an administrative penalty.
SECTION 8. Chapter 1460, Insurance Code, is amended by
adding Subchapter C to read as follows:
SUBCHAPTER C. COST COMPARISON DATA
Sec. 1460.051. PROVISION OF COST COMPARISON DATA
AUTHORIZED. Notwithstanding Section 1460.003, a health benefit
plan issuer may provide cost comparison data to a participating
physician or a designated entity.
Sec. 1460.052. PROVISION OF CERTAIN COST COMPARISON DATA
REQUIRED. If cost comparison data associated with health care
providers other than physicians is available to a health benefit
plan issuer that provides cost comparison data under Section
1460.051, the plan issuer shall provide the cost comparison data
associated with the other health care providers.
Sec. 1460.053. REQUIRED DISCLOSURES. Not later than the
15th business day after the date that a health benefit plan issuer
receives a request from a participating physician, the health
benefit plan issuer shall disclose to the physician:
(1) the cost comparison data associated with the
physician;
(2) the measures and methodology used to compare
costs; and
(3) any other information considered in making the
cost comparison.
Sec. 1460.054. RIGHT TO DISPUTE. (a) A health benefit plan
issuer shall give a physician, regardless of whether the physician
is a participating physician, a fair opportunity to dispute the
cost comparison data associated with the physician at least once
each calendar quarter and when the health benefit plan issuer
changes the measures and methodology described by Section 1460.053.
(b) A physician may initiate a dispute by sending to the
health benefit plan issuer a written statement of the dispute.
Sec. 1460.055. DISPUTE PROCEEDING. (a) Not later than the
15th business day after the date a health benefit plan issuer
receives a statement of the dispute under Section 1460.054, the
plan issuer shall provide the cost comparison data associated with
the physician, the measures and methodology used to compare costs,
and any other information considered in making the cost comparison,
unless the information was already provided under Section 1460.052.
(b) In addition to any written fair reconsideration
process, the health benefit plan issuer shall provide a cost
comparison data dispute proceeding, at the physician's option:
(1) by teleconference, at an agreed upon time; or
(2) in person, at an agreed upon time.
(c) At the proceeding described by Subsection (b), the
physician has the right to:
(1) provide information to a decision-maker;
(2) have a representative participate in the
proceeding; and
(3) submit a written statement at the conclusion of
the proceeding.
(d) The health benefit plan issuer shall provide to the
physician who initiated the dispute process under Section 1460.054
a written communication of the outcome of the proceeding not later
than the 60th day after the date the physician initiated the dispute
process. The written communication must include the specific
reasons for the final decision.
Sec. 1460.056. CORRECTIONS REQUIRED. If in a dispute
process initiated under Section 1460.054 the health benefit plan
issuer determines that the physician's cost comparison data is
inaccurate or the measures and methodology used to compare costs
are invalid, the health benefit plan issuer shall promptly correct
the data or update the measures and methodology and associated
data, as applicable.
Sec. 1460.057. MEASURES AND METHODOLOGY. The measures and
methodology used to compare costs under this subchapter must use
risk and severity adjustments to account for health status
differences among different patient populations.
Sec. 1460.058. NOTICE REQUIRED. A health benefit plan
issuer shall provide written notice to a physician who contracts
with the plan issuer that:
(1) explains the plan issuer's compilation and use of
cost comparison data, the purpose and scope of the plan issuer's
release of cost comparison data under this subchapter, and the
requirements of this subchapter regarding cost comparison data; and
(2) informs the physician of the physician's rights
and duties under this subchapter.
Sec. 1460.059. CONFIDENTIALITY. A physician who receives
cost comparison data about another physician under this subchapter
may not disclose the data to any other person, except for the
purpose of:
(1) managing an accountable care organization;
(2) managing the receiving physician's practice or
referrals;
(3) evaluating or disputing the cost comparison data
associated with the receiving physician;
(4) obtaining professional advice related to a legal
claim; or
(5) reporting, complaining, or responding to a
governmental agency.
Sec. 1460.060. CONSTRUCTION OF SUBCHAPTER. Nothing in this
subchapter may be construed to authorize:
(1) the disclosure of a contract rate; or
(2) the publication of cost comparison data to a
person other than a participating physician or a designated
entity.
Sec. 1460.061. RULES. The commissioner shall adopt rules
as necessary to implement this subchapter.
Sec. 1460.062. 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 subchapter; and
(2) the measures and methodology used in the
development of cost comparison data described by this subchapter
are transparent and valid.
Sec. 1460.063. SANCTIONS; DISCIPLINARY ACTIONS. (a) A
health benefit plan issuer that violates this subchapter or a rule
adopted under this subchapter is subject to sanctions and
disciplinary actions under Chapters 82 and 84.
(b) A violation of this subchapter by a physician
constitutes grounds for disciplinary action by the Texas Medical
Board, including imposition of an administrative penalty.
SECTION 9. The change in law made by this Act applies only
to a contract between a physician and a health benefit plan issuer
entered into or renewed on or after September 1, 2017. A contract
between a physician and health benefit plan issuer entered into or
renewed before September 1, 2017, is governed by the law as it
existed immediately before that date, and that law is continued in
effect for that purpose.
SECTION 10. This Act takes effect September 1, 2017.