Texas 2017 - 85th Regular

Texas House Bill HB3124 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	85R23635 SMT-F
2		-	By: Gooden H.B. No. 3124
3		-	Substitute the following for H.B. No. 3124:
4		-	By: Phillips C.S.H.B. No. 3124
	1	+	By: Gooden (Senate Sponsor - Creighton) H.B. No. 3124
	2	+	(In the Senate - Received from the House May 8, 2017;
	3	+	May 9, 2017, read first time and referred to Committee on Business &
	4	+	Commerce; May 17, 2017, reported favorably by the following vote:
	5	+	Yeas 8, Nays 0; May 17, 2017, sent to printer.)
	6	+	Click here to see the committee vote
5	7
6	8
7	9		A BILL TO BE ENTITLED
8	10		AN ACT
9	11		relating to certain physician-specific comparison data compiled by
10	12		a health benefit plan issuer, including the release of that data to
11	13		physicians participating in certain physician-led organizations.
12	14		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	15		SECTION 1. The heading to Chapter 1460, Insurance Code, is
14	16		amended to read as follows:
15	17		CHAPTER 1460. [STANDARDS REQUIRED REGARDING] CERTAIN PHYSICIAN
16	18		RANKINGS AND COST COMPARISONS BY HEALTH BENEFIT PLANS
17	19		SECTION 2. Chapter 1460, Insurance Code, is amended by
18	20		designating Sections 1460.001 and 1460.002 as Subchapter A and
19	21		adding a subchapter heading to read as follows:
20	22		SUBCHAPTER A. GENERAL PROVISIONS
21	23		SECTION 3. Section 1460.001, Insurance Code, is amended to
22	24		read as follows:
23	25		Sec. 1460.001. DEFINITIONS. In this chapter:
24	26		(1) "Accountable care organization" means an entity:
25	27		(A) that is composed of physicians or physicians
26	28		and other health care providers;
27	29		(B) that is owned and controlled by one or more
28	30		physicians licensed in this state and engaged in active clinical
29	31		practice in this state;
30	32		(C) that contracts with a health benefit plan
31	33		issuer to provide medical or health care services to a defined
32	34		population;
33	35		(D) that uses a payment structure that takes into
34	36		account the total costs and quality of the care provided to the
35	37		defined population served by the entity; and
36	38		(E) through which physicians and health care
37	39		providers, if any:
38	40		(i) share in savings created by improvement
39	41		of the quality of, and reduction of cost increases for, care
40	42		delivered to the defined population served by the entity; or
41	43		(ii) are compensated through another
42	44		payment methodology intended to reduce the total cost of care
43	45		delivered to the defined population served by the entity.
44	46		(2) "Cost comparison data" means information compiled
45	47		by a health benefit plan issuer to show the health care costs
46	48		associated with a physician or other health care provider relative
47	49		to another physician or health care provider.
48	50		(3) "Designated entity" means a limited liability
49	51		company in which a majority ownership interest is held by an
50	52		incorporated association whose purpose includes uniting in one
51	53		organization all physicians licensed to practice medicine in this
52	54		state and that has been in continued existence for at least 15
53	55		years.
54	56		(4) "Health benefit plan issuer" means an entity
55	57		authorized under this code or another insurance law of this state
56	58		that provides health insurance or health benefits in this state,
57	59		including:
58	60		(A) an insurance company;
59	61		(B) a group hospital service corporation
60	62		operating under Chapter 842;
61	63		(C) a health maintenance organization operating
62	64		under Chapter 843; and
63	65		(D) a stipulated premium company operating under
64	66		Chapter 884.
65	67		(5) "Participating physician" means a physician who
66	68		participates in an accountable care organization.
67	69		(6) [(2)] "Physician" means an individual licensed to
68	70		practice medicine in this state or another state of the United
69	71		States.
70	72		SECTION 4. Chapter 1460, Insurance Code, is amended by
71	73		designating Sections 1460.003 through 1460.007 as Subchapter B and
72	74		adding a subchapter heading to read as follows:
73	75		SUBCHAPTER B. PHYSICIAN RANKINGS
74	76		SECTION 5. Section 1460.003(a), Insurance Code, is amended
75	77		to read as follows:
76	78		(a) Except as provided by Subchapter C, a [A] health
77	79		benefit plan issuer, including a subsidiary or affiliate, may not
78	80		rank physicians, classify physicians into tiers based on
79	81		performance, or publish physician-specific information that
80	82		includes rankings, tiers, ratings, or other comparisons of a
81	83		physician's performance against standards, measures, or other
82	84		physicians, unless:
83	85		(1) the standards used by the health benefit plan
84	86		issuer conform to nationally recognized standards and guidelines as
85	87		required by rules adopted under Section 1460.005;
86	88		(2) the standards and measurements to be used by the
87	89		health benefit plan issuer are disclosed to each affected physician
88	90		before any evaluation period used by the health benefit plan
89	91		issuer; and
90	92		(3) each affected physician is afforded, before any
91	93		publication or other public dissemination, an opportunity to
92	94		dispute the ranking or classification through a process that, at a
93	95		minimum, includes due process protections that conform to the
94	96		following protections:
95	97		(A) the health benefit plan issuer provides at
96	98		least 45 days' written notice to the physician of the proposed
97	99		rating, ranking, tiering, or comparison, including the
98	100		methodologies, data, and all other information utilized by the
99	101		health benefit plan issuer in its rating, tiering, ranking, or
100	102		comparison decision;
101	103		(B) in addition to any written fair
102	104		reconsideration process, the health benefit plan issuer, upon a
103	105		request for review that is made within 30 days of receiving the
104	106		notice under Paragraph (A), provides a fair reconsideration
105	107		proceeding, at the physician's option:
106	108		(i) by teleconference, at an agreed upon
107	109		time; or
108	110		(ii) in person, at an agreed upon time or
109	111		between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
110	112		(C) the physician has the right to provide
111	113		information at a requested fair reconsideration proceeding for
112	114		determination by a decision-maker, have a representative
113	115		participate in the fair reconsideration proceeding, and submit a
114	116		written statement at the conclusion of the fair reconsideration
115	117		proceeding; and
116	118		(D) the health benefit plan issuer provides a
117	119		written communication of the outcome of a fair reconsideration
118	120		proceeding prior to any publication or dissemination of the rating,
119	121		ranking, tiering, or comparison. The written communication must
120	122		include the specific reasons for the final decision.
121	123		SECTION 6. Section 1460.005(a), Insurance Code, is amended
122	124		to read as follows:
123	125		(a) The commissioner shall adopt rules as necessary to
124	126		implement this subchapter [chapter].
125	127		SECTION 7. Sections 1460.006 and 1460.007, Insurance Code,
126	128		are amended to read as follows:
127	129		Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A
128	130		health benefit plan issuer shall ensure that:
129	131		(1) physicians currently in clinical practice are
130	132		actively involved in the development of the standards used under
131	133		this subchapter [chapter]; and
132	134		(2) the measures and methodology used in the
133	135		comparison programs described by Section 1460.003 are transparent
134	136		and valid.
135	137		Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A
136	138		health benefit plan issuer that violates this subchapter [chapter]
137	139		or a rule adopted under this subchapter [chapter] is subject to
138	140		sanctions and disciplinary actions under Chapters 82 and 84.
139	141		(b) A violation of this subchapter [chapter] by a physician
140	142		constitutes grounds for disciplinary action by the Texas Medical
141	143		Board, including imposition of an administrative penalty.
142	144		SECTION 8. Chapter 1460, Insurance Code, is amended by
143	145		adding Subchapter C to read as follows:
144	146		SUBCHAPTER C. COST COMPARISON DATA
145	147		Sec. 1460.051. PROVISION OF COST COMPARISON DATA
146	148		AUTHORIZED. Notwithstanding Section 1460.003, a health benefit
147	149		plan issuer may provide cost comparison data to a participating
148	150		physician or a designated entity.
149	151		Sec. 1460.052. PROVISION OF CERTAIN COST COMPARISON DATA
150	152		REQUIRED. If cost comparison data associated with health care
151	153		providers other than physicians is available to a health benefit
152	154		plan issuer that provides cost comparison data under Section
153	155		1460.051, the plan issuer shall provide the cost comparison data
154	156		associated with the other health care providers.
155	157		Sec. 1460.053. REQUIRED DISCLOSURES. Not later than the
156	158		15th business day after the date that a health benefit plan issuer
157	159		receives a request from a participating physician, the health
158	160		benefit plan issuer shall disclose to the physician:
159	161		(1) the cost comparison data associated with the
160	162		physician;
161	163		(2) the measures and methodology used to compare
162	164		costs; and
163	165		(3) any other information considered in making the
164	166		cost comparison.
165	167		Sec. 1460.054. RIGHT TO DISPUTE. (a) A health benefit plan
166	168		issuer shall give a physician, regardless of whether the physician
167	169		is a participating physician, a fair opportunity to dispute the
168	170		cost comparison data associated with the physician at least once
169	171		each calendar quarter and when the health benefit plan issuer
170	172		changes the measures and methodology described by Section 1460.053.
171	173		(b) A physician may initiate a dispute by sending to the
172	174		health benefit plan issuer a written statement of the dispute.
173	175		Sec. 1460.055. DISPUTE PROCEEDING. (a) Not later than the
174	176		15th business day after the date a health benefit plan issuer
175	177		receives a statement of the dispute under Section 1460.054, the
176	178		plan issuer shall provide the cost comparison data associated with
177	179		the physician, the measures and methodology used to compare costs,
178	180		and any other information considered in making the cost comparison,
179	181		unless the information was already provided under Section 1460.052.
180	182		(b) In addition to any written fair reconsideration
181	183		process, the health benefit plan issuer shall provide a cost
182	184		comparison data dispute proceeding, at the physician's option:
183	185		(1) by teleconference, at an agreed upon time; or
184	186		(2) in person, at an agreed upon time.
185	187		(c) At the proceeding described by Subsection (b), the
186	188		physician has the right to:
187	189		(1) provide information to a decision-maker;
188	190		(2) have a representative participate in the
189	191		proceeding; and
190	192		(3) submit a written statement at the conclusion of
191	193		the proceeding.
192	194		(d) The health benefit plan issuer shall provide to the
193	195		physician who initiated the dispute process under Section 1460.054
194	196		a written communication of the outcome of the proceeding not later
195	197		than the 60th day after the date the physician initiated the dispute
196	198		process. The written communication must include the specific
197	199		reasons for the final decision.
198	200		Sec. 1460.056. CORRECTIONS REQUIRED. If in a dispute
199	201		process initiated under Section 1460.054 the health benefit plan
200	202		issuer determines that the physician's cost comparison data is
201	203		inaccurate or the measures and methodology used to compare costs
202	204		are invalid, the health benefit plan issuer shall promptly correct
203	205		the data or update the measures and methodology and associated
204	206		data, as applicable.
205	207		Sec. 1460.057. MEASURES AND METHODOLOGY. The measures and
206	208		methodology used to compare costs under this subchapter must use
207	209		risk and severity adjustments to account for health status
208	210		differences among different patient populations.
209	211		Sec. 1460.058. NOTICE REQUIRED. A health benefit plan
210	212		issuer shall provide written notice to a physician who contracts
211	213		with the plan issuer that:
212	214		(1) explains the plan issuer's compilation and use of
213	215		cost comparison data, the purpose and scope of the plan issuer's
214	216		release of cost comparison data under this subchapter, and the
215	217		requirements of this subchapter regarding cost comparison data; and
216	218		(2) informs the physician of the physician's rights
217	219		and duties under this subchapter.
218	220		Sec. 1460.059. CONFIDENTIALITY. A physician who receives
219	221		cost comparison data about another physician under this subchapter
220	222		may not disclose the data to any other person, except for the
221	223		purpose of:
222	224		(1) managing an accountable care organization;
223	225		(2) managing the receiving physician's practice or
224	226		referrals;
225	227		(3) evaluating or disputing the cost comparison data
226	228		associated with the receiving physician;
227	229		(4) obtaining professional advice related to a legal
228	230		claim; or
229	231		(5) reporting, complaining, or responding to a
230	232		governmental agency.
231	233		Sec. 1460.060. CONSTRUCTION OF SUBCHAPTER. Nothing in this
232	234		subchapter may be construed to authorize:
233	235		(1) the disclosure of a contract rate; or
234	236		(2) the publication of cost comparison data to a
235	237		person other than a participating physician or a designated
236	238		entity.
237	239		Sec. 1460.061. RULES. The commissioner shall adopt rules
238	240		as necessary to implement this subchapter.
239	241		Sec. 1460.062. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A
240	242		health benefit plan issuer shall ensure that:
241	243		(1) physicians currently in clinical practice are
242	244		actively involved in the development of the standards used under
243	245		this subchapter; and
244	246		(2) the measures and methodology used in the
245	247		development of cost comparison data described by this subchapter
246	248		are transparent and valid.
247	249		Sec. 1460.063. SANCTIONS; DISCIPLINARY ACTIONS. (a) A
248	250		health benefit plan issuer that violates this subchapter or a rule
249	251		adopted under this subchapter is subject to sanctions and
250	252		disciplinary actions under Chapters 82 and 84.
251	253		(b) A violation of this subchapter by a physician
252	254		constitutes grounds for disciplinary action by the Texas Medical
253	255		Board, including imposition of an administrative penalty.
254	256		SECTION 9. The change in law made by this Act applies only
255	257		to a contract between a physician and a health benefit plan issuer
256	258		entered into or renewed on or after September 1, 2017. A contract
257	259		between a physician and health benefit plan issuer entered into or
258	260		renewed before September 1, 2017, is governed by the law as it
259	261		existed immediately before that date, and that law is continued in
260	262		effect for that purpose.
261	263		SECTION 10. This Act takes effect September 1, 2017.
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