TX
Texas House Bill HB1914

Texas 2019 - 86th Regular

Texas House Bill HB1914 Compare Versions

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1-By: Moody, Raymond, Guillen, Oliverson H.B. No. 1914
1+86R9910 PMO-F
2+ By: Moody H.B. No. 1914
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45 A BILL TO BE ENTITLED
56 AN ACT
6- relating to the relationship between health maintenance
7- organizations and preferred provider benefit plans and physicians
8- and health care providers, including prompt payment of the claims
9- of certain physicians and health care providers.
7+ relating to prompt payment of claims to certain physicians and
8+ health care providers.
109 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11- SECTION 1. Section 843.306, Insurance Code, is amended by
12- amending Subsections (a), (b), and (e) and adding Subsections
13- (a-1), (a-2), (b-1), (b-2), (b-3), and (g) to read as follows:
14- (a) Before terminating a contract with a physician or
15- provider, a health maintenance organization shall provide to the
16- physician or provider:
17- (1) written notice of:
18- (A) the health maintenance organization's intent
19- to terminate the physician's or provider's contract;
20- (B) the physician's or provider's right to
21- request a review under Subsection (b); and
22- (C) the physician's or provider's right to
23- request the review be expedited under Section 843.307; and
24- (2) a written explanation of the reasons for
25- termination.
26- (a-1) In a case involving fraud or malfeasance by a
27- provider, the written notice required by Subsection (a) must
28- include notice of the health maintenance organization's right to
29- suspend the provider's participation in the health maintenance
30- organization network during the review process as provided by
31- Subsection (b-1).
32- (a-2) If a health maintenance organization terminates a
33- contract with a physician or provider, the health maintenance
34- organization shall, on request of the physician or provider,
35- provide to the physician or provider a written copy of all
36- information on which the health maintenance organization wholly or
37- partly based the termination, including the economic profile of the
38- physician or provider, the standards by which the physician or
39- provider is measured, and the statistics underlying the profile and
40- standards.
41- (b) On request, before the effective date of the termination
42- and within a period not to exceed 60 days, a physician or provider
43- is entitled to a review by an advisory review panel of the health
44- maintenance organization's proposed termination, except in a case
45- involving:
46- (1) imminent harm to patient health;
47- (2) an action by a state medical or dental board,
48- another medical or dental licensing board, or another licensing
49- board or government agency that effectively impairs the physician's
50- or provider's ability to practice medicine, dentistry, or another
51- profession; or
52- (3) fraud or malfeasance by a physician.
53- (b-1) If a provider requests a review under Subsection (b)
54- in a case involving fraud or malfeasance by the provider, the health
55- maintenance organization may suspend the provider's participation
56- in the health maintenance organization network:
57- (1) beginning not earlier than the date notice is
58- provided under Subsection (a); and
59- (2) ending on the earlier of:
60- (A) the 60th day after the date the provider
61- requests the review;
62- (B) the 30th day after the date the provider
63- requests the review be expedited under Section 843.307, if
64- applicable; or
65- (C) the date the health maintenance organization
66- makes a final determination under Subsection (b-2).
67- (b-2) If a health maintenance organization suspends a
68- provider's participation in the health maintenance organization
69- network under Subsection (b-1), the health maintenance
70- organization shall make a final determination to terminate or
71- resume the provider's participation not later than three business
72- days after the date the health maintenance organization receives
73- the recommendation of the advisory review panel. The health
74- maintenance organization shall immediately notify the provider of
75- the determination.
76- (b-3) Review under Subsection (b) must provide an
77- opportunity for the physician or provider to present evidence to
78- the advisory review panel before the panel makes a recommendation.
79- (e) The health maintenance organization [on request] shall
80- provide to the affected physician or provider a copy of the
81- recommendation of the advisory review panel and the health
82- maintenance organization's determination.
83- (g) A health maintenance organization may not terminate a
84- provider's contract unless the provider fails to comply with a
85- material term of the contract.
86- SECTION 2. Section 843.308, Insurance Code, is amended to
87- read as follows:
88- Sec. 843.308. NOTIFICATION OF PATIENTS OF DESELECTED OR
89- TERMINATED PHYSICIAN OR PROVIDER. (a) Except as provided by
90- Subsection (b), if a physician or provider is deselected or
91- terminated for a reason other than the request of the physician or
92- provider, a health maintenance organization may not notify patients
93- of the deselection or termination until the later of the effective
94- date of the deselection or termination, or, if a review is
95- requested, the date the advisory review panel makes a formal
96- recommendation.
97- (b) If the contract of a physician or provider is deselected
98- or terminated for a reason related to imminent harm, a health
99- maintenance organization may notify patients immediately.
100- SECTION 3. Section 843.309, Insurance Code, is amended to
101- read as follows:
102- Sec. 843.309. CONTRACTS WITH PHYSICIANS OR PROVIDERS:
103- NOTICE TO CERTAIN ENROLLEES OF TERMINATION OF PHYSICIAN OR PROVIDER
104- PARTICIPATION IN PLAN. Subject to Section 843.308, a [A] contract
105- between a health maintenance organization and a physician or
106- provider must provide that reasonable advance notice shall be given
107- to an enrollee of the impending termination from the plan of a
108- physician or provider who is currently treating the enrollee.
109- SECTION 4. Subchapter I, Chapter 843, Insurance Code, is
110- amended by adding Section 843.3095 to read as follows:
111- Sec. 843.3095. WAIVER OF CERTAIN PROVISIONS PROHIBITED.
112- The provisions of this subchapter related to deselection or
113- termination of a contract with a physician or provider may not be
114- waived, voided, or nullified by contract.
115- SECTION 5. Section 843.351, Insurance Code, is amended to
10+ SECTION 1. Section 843.351, Insurance Code, is amended to
11611 read as follows:
11712 Sec. 843.351. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
11813 PROVIDERS. (a) The provisions of this subchapter relating to prompt
11914 payment by a health maintenance organization of a physician or
12015 provider, including Section 843.342, and to verification of health
12116 care services apply to a physician or provider who:
12217 (1) is not included in the health maintenance
12318 organization delivery network; and
12419 (2) provides to an enrollee:
12520 (A) care related to an emergency or its attendant
12621 episode of care as required by state or federal law; or
12722 (B) specialty or other health care services at
12823 the request of the health maintenance organization or a physician
12924 or provider who is included in the health maintenance organization
13025 delivery network because the services are not reasonably available
13126 within the network.
13227 (b) For purposes of calculating a penalty under Section
13328 843.342 related to a claim by a physician or provider described by
13429 Subsection (a), the contracted rate for the health care service
13530 provided by the physician or provider is the usual and customary
13631 rate for the service in the geographic area in which the service is
13732 provided.
138- SECTION 6. Section 1301.053, Insurance Code, is amended to
139- read as follows:
140- Sec. 1301.053. APPEAL RELATING TO DESIGNATION AS PREFERRED
141- PROVIDER. (a) An insurer that does not designate a physician or
142- health care provider [practitioner] as a preferred provider shall
143- provide a reasonable mechanism for reviewing that action. The
144- review mechanism must incorporate, in an advisory role only, a
145- review panel.
146- (b) A review panel must be composed of at least three
147- individuals selected by the insurer from a list of participating
148- physicians or health care providers [practitioners] and must
149- include one member who is a physician or health care provider
150- [practitioner] in the same or similar specialty as the affected
151- physician or health care provider [practitioner], if available.
152- The physicians or health care providers [practitioners]
153- contracting with the insurer in the applicable service area shall
154- provide the list of physicians or health care providers
155- [practitioners] to the insurer.
156- (c) On request, the insurer shall provide to the affected
157- physician or health care provider [practitioner]:
158- (1) the panel's recommendation, if any; and
159- (2) a written explanation of the insurer's
160- determination, if that determination is contrary to the panel's
161- recommendation.
162- SECTION 7. Section 1301.057, Insurance Code, is amended to
163- read as follows:
164- Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED
165- REVIEW PROCESS. (a) Before terminating a contract with a preferred
166- provider, an insurer shall:
167- (1) provide written notice of:
168- (A) the insurer's intent to terminate the
169- preferred provider's contract;
170- (B) the preferred provider's right to request a
171- review under this section; and
172- (C) the preferred provider's right to request the
173- review be expedited under Subsection (d);
174- (2) provide written reasons for the termination; and
175- (3) [(2) if the affected provider is a practitioner,]
176- provide, on request, a reasonable review mechanism, except in a
177- case involving:
178- (A) imminent harm to a patient's health;
179- (B) an action by a state medical or other
180- physician licensing board or other government agency that
181- effectively impairs the physician's or health care provider's
182- [practitioner's] ability to practice medicine, dentistry, or
183- another profession; or
184- (C) fraud or malfeasance by a physician.
185- (a-1) In a case involving fraud or malfeasance by a health
186- care provider, the written notice required by Subsection (a) must
187- include notice of the insurer's right to suspend the health care
188- provider's participation in the preferred provider benefit plan
189- during the review process as provided by Subsection (a-3).
190- (a-2) An insurer may not terminate a health care provider's
191- contract unless the provider fails to comply with a material term of
192- the contract.
193- (a-3) If a health care provider requests a review under
194- Subsection (a) in a case involving fraud or malfeasance by the
195- health care provider, the insurer may suspend the health care
196- provider's participation in the preferred provider benefit plan:
197- (1) beginning not earlier than the date notice is
198- provided under Subsection (a); and
199- (2) ending on the earlier of:
200- (A) the 60th day after the date the health care
201- provider requests the review;
202- (B) the 30th day after the date the health care
203- provider requests the review be expedited, if applicable; or
204- (C) the date the insurer makes a final
205- determination under Subsection (a-4).
206- (a-4) If an insurer suspends a health care provider's
207- participation in the preferred provider benefit plan under
208- Subsection (a-3), the insurer shall make a final determination to
209- terminate or resume the health care provider's participation not
210- later than three business days after the date the insurer receives
211- the recommendation of the review panel described by Subsection (b).
212- The insurer shall immediately notify the health care provider of
213- the insurer's determination.
214- (b) The review mechanism described by Subsection (a)(3)
215- [(a)(2)] must incorporate, in an advisory role only, a review panel
216- selected in the manner described by Section 1301.053(b) and must be
217- completed within a period not to exceed 60 days.
218- (b-1) Review under Subsection (a)(3) must provide an
219- opportunity for the affected physician or health care provider to
220- present evidence to the review panel before the panel makes a
221- recommendation.
222- (c) The insurer shall provide to the affected physician or
223- health care provider [practitioner]:
224- (1) the review panel's recommendation, if any; and
225- (2) [on request,] a written explanation of the
226- insurer's determination, if that determination is contrary to the
227- panel's recommendation.
228- (d) On request, an insurer shall provide to a physician or
229- health care provider [practitioner] whose participation in a
230- preferred provider benefit plan is being terminated:
231- (1) an expedited review conducted in accordance with a
232- process that complies with rules established by the commissioner;
233- and
234- (2) all information on which the insurer wholly or
235- partly based the termination, including the economic profile of the
236- preferred provider, the standards by which the physician or health
237- care provider is measured, and the statistics underlying the
238- profile and standards.
239- (e) The provisions of this section may not be waived,
240- voided, or nullified by contract.
241- SECTION 8. Section 1301.069, Insurance Code, is amended to
33+ SECTION 2. Section 1301.069, Insurance Code, is amended to
24234 read as follows:
24335 Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
24436 HEALTH CARE PROVIDERS. (a) The provisions of this chapter relating
24537 to prompt payment by an insurer of a physician or health care
24638 provider, including Section 1301.137, and to verification of
24739 medical care or health care services apply to a physician or
24840 provider who:
24941 (1) is not a preferred provider included in the
25042 preferred provider network; and
25143 (2) provides to an insured:
25244 (A) care related to an emergency or its attendant
25345 episode of care as required by state or federal law; or
25446 (B) specialty or other medical care or health
25547 care services at the request of the insurer or a preferred provider
25648 because the services are not reasonably available from a preferred
25749 provider who is included in the preferred delivery network.
25850 (b) For purposes of calculating a penalty under Section
25951 1301.137 related to a claim by a physician or health care provider
26052 described by Subsection (a) or Section 1301.0053, the contracted
26153 rate for the health care service provided by the physician or
26254 provider is the usual and customary rate for the service in the
26355 geographic area in which the service is provided.
264- SECTION 9. Section 1301.160, Insurance Code, is amended by
265- amending Subsections (a) and (c) and adding Subsection (d) to read
266- as follows:
267- (a) If a physician's or health care provider's
268- [practitioner's] participation in a preferred provider benefit
269- plan is terminated for a reason other than at the physician's or
270- health care provider's [practitioner's] request, an insurer may not
271- notify insureds of the termination until the later of:
272- (1) the effective date of the termination; or
273- (2) if a review is requested, the time at which a
274- review panel makes a formal recommendation regarding the
275- termination.
276- (c) If a physician's or health care provider's
277- [practitioner's] participation in a preferred provider benefit
278- plan is terminated for reasons related to imminent harm, an insurer
279- may notify insureds immediately.
280- (d) The provisions of this section may not be waived,
281- voided, or nullified by contract.
282- SECTION 10. (a) Except as provided by Subsection (b) of this
283- section, the changes in law made by this Act apply only to a
284- contract entered into, amended, or renewed on or after the
285- effective date of this Act. A contract entered into, amended, or
286- renewed before the effective date of this Act is governed by the law
287- as it existed immediately before the effective date of this Act, and
288- that law is continued in effect for that purpose.
289- (b) Sections 843.351 and 1301.069, Insurance Code, as
290- amended by this Act, apply only to a claim filed on or after the
56+ SECTION 3. Sections 843.351 and 1301.069, Insurance Code,
57+ as amended by this Act, apply only to a claim filed on or after the
29158 effective date of this Act.
292- SECTION 11. This Act takes effect September 1, 2019.
59+ SECTION 4. This Act takes effect September 1, 2019.