Texas 2019 - 86th Regular

Texas House Bill HB1905 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	~~86R24859~~ SMT-F
	1	+	86R2897 SMT-F
2	2		By: Klick H.B. No. 1905
3		-	Substitute the following for H.B. No. 1905:
4		-	By: Lucio III C.S.H.B. No. 1905
5	3
6	4
7	5		A BILL TO BE ENTITLED
8	6		AN ACT
9	7		relating to the relationship between physicians or health care
10	8		providers and health maintenance organizations or preferred
11	9		provider benefit plans.
12	10		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	11		SECTION 1. Section 843.306, Insurance Code, is amended by
14	12		amending Subsections (a), (b), and (e) and adding Subsections
15	13		(a-1), (a-2), (b-1), (b-2), (b-3), and (g) to read as follows:
16	14		(a) Before terminating a contract with a physician or
17	15		provider, a health maintenance organization shall provide to the
18	16		physician or provider:
19	17		(1) written notice of:
20	18		(A) the health maintenance organization's intent
21	19		to terminate the physician's or provider's contract;
22	20		(B) the physician's or provider's right to
23	21		request a review under Subsection (b); and
24	22		(C) the physician's or provider's right to
25	23		request the review be expedited under Section 843.307; and
26	24		(2) a written explanation of the reasons for
27	25		termination.
28	26		(a-1) In a case involving fraud or malfeasance by a
29	27		provider, the written notice required by Subsection (a) must
30	28		include notice of the health maintenance organization's right to
31	29		suspend the provider's participation in the health maintenance
32	30		organization network during the review process as provided by
33	31		Subsection (b-1).
34	32		(a-2) If a health maintenance organization terminates a
35	33		contract with a physician or provider, the health maintenance
36		-	organization shall, on request of the physician or provider,
37		-	provide to the physician or provider a written copy of all
38		-	information on which the health maintenance organization wholly or
39		-	partly based the termination, including the economic profile of the
40		-	physician or provider, the standards by which the physician or
41		-	provider is measured, and the statistics underlying the profile and
42		-	standards.
	34	+	organization shall provide to the physician or provider a written
	35	+	copy of all information on which the health maintenance
	36	+	organization wholly or partly based the termination, including the
	37	+	economic profile of the physician or provider, the standards by
	38	+	which the physician or provider is measured, and the statistics
	39	+	underlying the profile and standards.
43	40		(b) On request, before the effective date of the termination
44	41		and within a period not to exceed 60 days, a physician or provider
45	42		is entitled to a review by an advisory review panel of the health
46	43		maintenance organization's proposed termination, except in a case
47	44		involving:
48	45		(1) imminent harm to patient health;
49	46		(2) an action by a state medical or dental board,
50	47		another medical or dental licensing board, or another licensing
51	48		board or government agency that effectively impairs the physician's
52	49		or provider's ability to practice medicine, dentistry, or another
53	50		profession; or
54	51		(3) fraud or malfeasance by a physician.
55	52		(b-1) If a provider requests a review under Subsection (b)
56	53		in a case involving fraud or malfeasance by the provider, the health
57	54		maintenance organization may suspend the provider's participation
58	55		in the health maintenance organization network:
59	56		(1) beginning not earlier than the date notice is
60	57		provided under Subsection (a); and
61	58		(2) ending on the earlier of:
62	59		(A) the 60th day after the date the provider
63	60		requests the review;
64	61		(B) the 30th day after the date the provider
65	62		requests the review be expedited under Section 843.307, if
66	63		applicable; or
67	64		(C) the date the health maintenance organization
68	65		makes a final determination under Subsection (b-2).
69	66		(b-2) If a health maintenance organization suspends a
70	67		provider's participation in the health maintenance organization
71	68		network under Subsection (b-1), the health maintenance
72	69		organization shall make a final determination to terminate or
73	70		resume the provider's participation not later than three business
74	71		days after the date the health maintenance organization receives
75	72		the recommendation of the advisory review panel. The health
76	73		maintenance organization shall immediately notify the provider of
77	74		the determination.
78	75		(b-3) Review under Subsection (b) must provide an
79	76		opportunity for the physician or provider to present evidence to
80	77		the advisory review panel before the panel makes a recommendation.
81	78		(e) The health maintenance organization [on request] shall
82	79		provide to the affected physician or provider a copy of the
83	80		recommendation of the advisory review panel and the health
84	81		maintenance organization's determination.
85	82		(g) A health maintenance organization may not terminate a
86		-	provider's contract unless the provider fails to comply with a
87		-	material term of the contract.
	83	+	provider's contract without cause.
88	84		SECTION 2. Section 843.308, Insurance Code, is amended to
89	85		read as follows:
90	86		Sec. 843.308. NOTIFICATION OF PATIENTS OF DESELECTED OR
91	87		TERMINATED PHYSICIAN OR PROVIDER. (a) Except as provided by
92	88		Subsection (b), if a physician or provider is deselected or
93	89		terminated for a reason other than the request of the physician or
94	90		provider, a health maintenance organization may not notify patients
95	91		of the deselection or termination until the later of the effective
96	92		date of the deselection or termination, or, if a review is
97	93		requested, the date the advisory review panel makes a formal
98	94		recommendation.
99	95		(b) If the contract of a physician or provider is deselected
100	96		or terminated for a reason related to imminent harm, a health
101	97		maintenance organization may notify patients immediately.
102	98		SECTION 3. Section 843.309, Insurance Code, is amended to
103	99		read as follows:
104	100		Sec. 843.309. CONTRACTS WITH PHYSICIANS OR PROVIDERS:
105	101		NOTICE TO CERTAIN ENROLLEES OF TERMINATION OF PHYSICIAN OR PROVIDER
106	102		PARTICIPATION IN PLAN. Subject to Section 843.308, a [A] contract
107	103		between a health maintenance organization and a physician or
108	104		provider must provide that reasonable advance notice shall be given
109	105		to an enrollee of the impending termination from the plan of a
110	106		physician or provider who is currently treating the enrollee.
111	107		SECTION 4. Subchapter I, Chapter 843, Insurance Code, is
112	108		amended by adding Section 843.3095 to read as follows:
113	109		Sec. 843.3095. WAIVER OF CERTAIN PROVISIONS PROHIBITED.
114	110		The provisions of this subchapter related to deselection or
115	111		termination of a contract with a physician or provider may not be
116	112		waived, voided, or nullified by contract.
117	113		SECTION 5. Section 1301.053, Insurance Code, is amended to
118	114		read as follows:
119	115		Sec. 1301.053. APPEAL RELATING TO DESIGNATION AS PREFERRED
120	116		PROVIDER. (a) An insurer that does not designate a physician or
121	117		health care provider [practitioner] as a preferred provider shall
122	118		provide a reasonable mechanism for reviewing that action. The
123	119		review mechanism must incorporate, in an advisory role only, a
124	120		review panel.
125	121		(b) A review panel must be composed of at least three
126	122		individuals selected by the insurer from a list of participating
127	123		physicians or health care providers [practitioners] and must
128	124		include one member who is a physician or health care provider
129	125		[practitioner] in the same or similar specialty as the affected
130	126		physician or health care provider [practitioner], if available.
131	127		The physicians or health care providers [practitioners]
132	128		contracting with the insurer in the applicable service area shall
133	129		provide the list of physicians or health care providers
134	130		[practitioners] to the insurer.
135	131		(c) On request, the insurer shall provide to the affected
136	132		physician or health care provider [practitioner]:
137	133		(1) the panel's recommendation, if any; and
138	134		(2) a written explanation of the insurer's
139	135		determination, if that determination is contrary to the panel's
140	136		recommendation.
141	137		SECTION 6. Section 1301.057, Insurance Code, is amended to
142	138		read as follows:
143	139		Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED
144	140		REVIEW PROCESS. (a) Before terminating a contract with a preferred
145	141		provider, an insurer shall:
146	142		(1) provide written notice of:
147	143		(A) the insurer's intent to terminate the
148	144		preferred provider's contract;
149	145		(B) the preferred provider's right to request a
150	146		review under this section; and
151	147		(C) the preferred provider's right to request the
152	148		review be expedited under Subsection (d);
153	149		(2) provide written reasons for the termination; and
154	150		(3) [(2) if the affected provider is a practitioner,]
155	151		provide, on request, a reasonable review mechanism, except in a
156	152		case involving:
157	153		(A) imminent harm to a patient's health;
158	154		(B) an action by a state medical or other
159	155		physician licensing board or other government agency that
160	156		effectively impairs the physician's or health care provider's
161	157		[practitioner's] ability to practice medicine, dentistry, or
162	158		another profession; or
163	159		(C) fraud or malfeasance by a physician.
164	160		(a-1) In a case involving fraud or malfeasance by a health
165	161		care provider, the written notice required by Subsection (a) must
166	162		include notice of the insurer's right to suspend the health care
167	163		provider's participation in the preferred provider benefit plan
168	164		during the review process as provided by Subsection (a-3).
169	165		(a-2) An insurer may not terminate a health care provider's
170		-	contract unless the provider fails to comply with a material term of
171		-	the contract.
	166	+	contract without cause.
172	167		(a-3) If a health care provider requests a review under
173	168		Subsection (a) in a case involving fraud or malfeasance by the
174	169		health care provider, the insurer may suspend the health care
175	170		provider's participation in the preferred provider benefit plan:
176	171		(1) beginning not earlier than the date notice is
177	172		provided under Subsection (a); and
178	173		(2) ending on the earlier of:
179	174		(A) the 60th day after the date the health care
180	175		provider requests the review;
181	176		(B) the 30th day after the date the health care
182	177		provider requests the review be expedited, if applicable; or
183	178		(C) the date the insurer makes a final
184	179		determination under Subsection (a-4).
185	180		(a-4) If an insurer suspends a health care provider's
186	181		participation in the preferred provider benefit plan under
187	182		Subsection (a-3), the insurer shall make a final determination to
188	183		terminate or resume the health care provider's participation not
189	184		later than three business days after the date the insurer receives
190	185		the recommendation of the review panel described by Subsection (b).
191	186		The insurer shall immediately notify the health care provider of
192	187		the insurer's determination.
193	188		(b) The review mechanism described by Subsection (a)(3)
194	189		[(a)(2)] must incorporate, in an advisory role only, a review panel
195	190		selected in the manner described by Section 1301.053(b) and must be
196	191		completed within a period not to exceed 60 days.
197	192		(b-1) Review under Subsection (a)(3) must provide an
198	193		opportunity for the affected physician or health care provider to
199	194		present evidence to the review panel before the panel makes a
200	195		recommendation.
201	196		(c) The insurer shall provide to the affected physician or
202	197		health care provider [practitioner]:
203	198		(1) the review panel's recommendation, if any; and
204	199		(2) [on request,] a written explanation of the
205	200		insurer's determination, if that determination is contrary to the
206	201		panel's recommendation.
207	202		(d) On request, an insurer shall provide to a physician or
208	203		health care provider [practitioner] whose participation in a
209	204		preferred provider benefit plan is being terminated:
210	205		(1) an expedited review conducted in accordance with a
211	206		process that complies with rules established by the commissioner;
212	207		and
213	208		(2) all information on which the insurer wholly or
214	209		partly based the termination, including the economic profile of the
215	210		preferred provider, the standards by which the physician or health
216	211		care provider is measured, and the statistics underlying the
217	212		profile and standards.
218	213		(e) The provisions of this section may not be waived,
219	214		voided, or nullified by contract.
220	215		SECTION 7. Section 1301.160, Insurance Code, is amended by
221	216		amending Subsections (a) and (c) and adding Subsection (d) to read
222	217		as follows:
223	218		(a) If a physician's or health care provider's
224	219		[practitioner's] participation in a preferred provider benefit
225	220		plan is terminated for a reason other than at the physician's or
226	221		health care provider's [practitioner's] request, an insurer may not
227	222		notify insureds of the termination until the later of:
228	223		(1) the effective date of the termination; or
229	224		(2) if a review is requested, the time at which a
230	225		review panel makes a formal recommendation regarding the
231	226		termination.
232	227		(c) If a physician's or health care provider's
233	228		[practitioner's] participation in a preferred provider benefit
234	229		plan is terminated for reasons related to imminent harm, an insurer
235	230		may notify insureds immediately.
236	231		(d) The provisions of this section may not be waived,
237	232		voided, or nullified by contract.
238	233		SECTION 8. The changes in law made by this Act apply only to
239	234		a contract entered into, amended, or renewed on or after the
240	235		effective date of this Act. A contract entered into, amended, or
241	236		renewed before the effective date of this Act is governed by the law
242	237		as it existed immediately before the effective date of this Act, and
243	238		that law is continued in effect for that purpose.
244	239		SECTION 9. This Act takes effect September 1, 2019.