By: Moody, Raymond, Guillen, Oliverson H.B. No. 1914
A BILL TO BE ENTITLED
AN ACT
relating to the relationship between health maintenance
organizations and preferred provider benefit plans and physicians
and health care providers, including prompt payment of the claims
of certain physicians and health care providers.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 843.306, Insurance Code, is amended by
amending Subsections (a), (b), and (e) and adding Subsections
(a-1), (a-2), (b-1), (b-2), (b-3), and (g) to read as follows:
(a) Before terminating a contract with a physician or
provider, a health maintenance organization shall provide to the
physician or provider:
(1) written notice of:
(A) the health maintenance organization's intent
to terminate the physician's or provider's contract;
(B) the physician's or provider's right to
request a review under Subsection (b); and
(C) the physician's or provider's right to
request the review be expedited under Section 843.307; and
(2) a written explanation of the reasons for
termination.
(a-1) In a case involving fraud or malfeasance by a
provider, the written notice required by Subsection (a) must
include notice of the health maintenance organization's right to
suspend the provider's participation in the health maintenance
organization network during the review process as provided by
Subsection (b-1).
(a-2) If a health maintenance organization terminates a
contract with a physician or provider, the health maintenance
organization shall, on request of the physician or provider,
provide to the physician or provider a written copy of all
information on which the health maintenance organization wholly or
partly based the termination, including the economic profile of the
physician or provider, the standards by which the physician or
provider is measured, and the statistics underlying the profile and
standards.
(b) On request, before the effective date of the termination
and within a period not to exceed 60 days, a physician or provider
is entitled to a review by an advisory review panel of the health
maintenance organization's proposed termination, except in a case
involving:
(1) imminent harm to patient health;
(2) an action by a state medical or dental board,
another medical or dental licensing board, or another licensing
board or government agency that effectively impairs the physician's
or provider's ability to practice medicine, dentistry, or another
profession; or
(3) fraud or malfeasance by a physician.
(b-1) If a provider requests a review under Subsection (b)
in a case involving fraud or malfeasance by the provider, the health
maintenance organization may suspend the provider's participation
in the health maintenance organization network:
(1) beginning not earlier than the date notice is
provided under Subsection (a); and
(2) ending on the earlier of:
(A) the 60th day after the date the provider
requests the review;
(B) the 30th day after the date the provider
requests the review be expedited under Section 843.307, if
applicable; or
(C) the date the health maintenance organization
makes a final determination under Subsection (b-2).
(b-2) If a health maintenance organization suspends a
provider's participation in the health maintenance organization
network under Subsection (b-1), the health maintenance
organization shall make a final determination to terminate or
resume the provider's participation not later than three business
days after the date the health maintenance organization receives
the recommendation of the advisory review panel. The health
maintenance organization shall immediately notify the provider of
the determination.
(b-3) Review under Subsection (b) must provide an
opportunity for the physician or provider to present evidence to
the advisory review panel before the panel makes a recommendation.
(e) The health maintenance organization [on request] shall
provide to the affected physician or provider a copy of the
recommendation of the advisory review panel and the health
maintenance organization's determination.
(g) A health maintenance organization may not terminate a
provider's contract unless the provider fails to comply with a
material term of the contract.
SECTION 2. Section 843.308, Insurance Code, is amended to
read as follows:
Sec. 843.308. NOTIFICATION OF PATIENTS OF DESELECTED OR
TERMINATED PHYSICIAN OR PROVIDER. (a) Except as provided by
Subsection (b), if a physician or provider is deselected or
terminated for a reason other than the request of the physician or
provider, a health maintenance organization may not notify patients
of the deselection or termination until the later of the effective
date of the deselection or termination, or, if a review is
requested, the date the advisory review panel makes a formal
recommendation.
(b) If the contract of a physician or provider is deselected
or terminated for a reason related to imminent harm, a health
maintenance organization may notify patients immediately.
SECTION 3. Section 843.309, Insurance Code, is amended to
read as follows:
Sec. 843.309. CONTRACTS WITH PHYSICIANS OR PROVIDERS:
NOTICE TO CERTAIN ENROLLEES OF TERMINATION OF PHYSICIAN OR PROVIDER
PARTICIPATION IN PLAN. Subject to Section 843.308, a [A] contract
between a health maintenance organization and a physician or
provider must provide that reasonable advance notice shall be given
to an enrollee of the impending termination from the plan of a
physician or provider who is currently treating the enrollee.
SECTION 4. Subchapter I, Chapter 843, Insurance Code, is
amended by adding Section 843.3095 to read as follows:
Sec. 843.3095. WAIVER OF CERTAIN PROVISIONS PROHIBITED.
The provisions of this subchapter related to deselection or
termination of a contract with a physician or provider may not be
waived, voided, or nullified by contract.
SECTION 5. Section 843.351, Insurance Code, is amended to
read as follows:
Sec. 843.351. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
PROVIDERS. (a) The provisions of this subchapter relating to prompt
payment by a health maintenance organization of a physician or
provider, including Section 843.342, and to verification of health
care services apply to a physician or provider who:
(1) is not included in the health maintenance
organization delivery network; and
(2) provides to an enrollee:
(A) care related to an emergency or its attendant
episode of care as required by state or federal law; or
(B) specialty or other health care services at
the request of the health maintenance organization or a physician
or provider who is included in the health maintenance organization
delivery network because the services are not reasonably available
within the network.
(b) For purposes of calculating a penalty under Section
843.342 related to a claim by a physician or provider described by
Subsection (a), the contracted rate for the health care service
provided by the physician or provider is the usual and customary
rate for the service in the geographic area in which the service is
provided.
SECTION 6. Section 1301.053, Insurance Code, is amended to
read as follows:
Sec. 1301.053. APPEAL RELATING TO DESIGNATION AS PREFERRED
PROVIDER. (a) An insurer that does not designate a physician or
health care provider [practitioner] as a preferred provider shall
provide a reasonable mechanism for reviewing that action. The
review mechanism must incorporate, in an advisory role only, a
review panel.
(b) A review panel must be composed of at least three
individuals selected by the insurer from a list of participating
physicians or health care providers [practitioners] and must
include one member who is a physician or health care provider
[practitioner] in the same or similar specialty as the affected
physician or health care provider [practitioner], if available.
The physicians or health care providers [practitioners]
contracting with the insurer in the applicable service area shall
provide the list of physicians or health care providers
[practitioners] to the insurer.
(c) On request, the insurer shall provide to the affected
physician or health care provider [practitioner]:
(1) the panel's recommendation, if any; and
(2) a written explanation of the insurer's
determination, if that determination is contrary to the panel's
recommendation.
SECTION 7. Section 1301.057, Insurance Code, is amended to
read as follows:
Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED
REVIEW PROCESS. (a) Before terminating a contract with a preferred
provider, an insurer shall:
(1) provide written notice of:
(A) the insurer's intent to terminate the
preferred provider's contract;
(B) the preferred provider's right to request a
review under this section; and
(C) the preferred provider's right to request the
review be expedited under Subsection (d);
(2) provide written reasons for the termination; and
(3) [(2) if the affected provider is a practitioner,]
provide, on request, a reasonable review mechanism, except in a
case involving:
(A) imminent harm to a patient's health;
(B) an action by a state medical or other
physician licensing board or other government agency that
effectively impairs the physician's or health care provider's
[practitioner's] ability to practice medicine, dentistry, or
another profession; or
(C) fraud or malfeasance by a physician.
(a-1) In a case involving fraud or malfeasance by a health
care provider, the written notice required by Subsection (a) must
include notice of the insurer's right to suspend the health care
provider's participation in the preferred provider benefit plan
during the review process as provided by Subsection (a-3).
(a-2) An insurer may not terminate a health care provider's
contract unless the provider fails to comply with a material term of
the contract.
(a-3) If a health care provider requests a review under
Subsection (a) in a case involving fraud or malfeasance by the
health care provider, the insurer may suspend the health care
provider's participation in the preferred provider benefit plan:
(1) beginning not earlier than the date notice is
provided under Subsection (a); and
(2) ending on the earlier of:
(A) the 60th day after the date the health care
provider requests the review;
(B) the 30th day after the date the health care
provider requests the review be expedited, if applicable; or
(C) the date the insurer makes a final
determination under Subsection (a-4).
(a-4) If an insurer suspends a health care provider's
participation in the preferred provider benefit plan under
Subsection (a-3), the insurer shall make a final determination to
terminate or resume the health care provider's participation not
later than three business days after the date the insurer receives
the recommendation of the review panel described by Subsection (b).
The insurer shall immediately notify the health care provider of
the insurer's determination.
(b) The review mechanism described by Subsection (a)(3)
[(a)(2)] must incorporate, in an advisory role only, a review panel
selected in the manner described by Section 1301.053(b) and must be
completed within a period not to exceed 60 days.
(b-1) Review under Subsection (a)(3) must provide an
opportunity for the affected physician or health care provider to
present evidence to the review panel before the panel makes a
recommendation.
(c) The insurer shall provide to the affected physician or
health care provider [practitioner]:
(1) the review panel's recommendation, if any; and
(2) [on request,] a written explanation of the
insurer's determination, if that determination is contrary to the
panel's recommendation.
(d) On request, an insurer shall provide to a physician or
health care provider [practitioner] whose participation in a
preferred provider benefit plan is being terminated:
(1) an expedited review conducted in accordance with a
process that complies with rules established by the commissioner;
and
(2) all information on which the insurer wholly or
partly based the termination, including the economic profile of the
preferred provider, the standards by which the physician or health
care provider is measured, and the statistics underlying the
profile and standards.
(e) The provisions of this section may not be waived,
voided, or nullified by contract.
SECTION 8. Section 1301.069, Insurance Code, is amended to
read as follows:
Sec. 1301.069. SERVICES PROVIDED BY CERTAIN PHYSICIANS AND
HEALTH CARE PROVIDERS. (a) The provisions of this chapter relating
to prompt payment by an insurer of a physician or health care
provider, including Section 1301.137, and to verification of
medical care or health care services apply to a physician or
provider who:
(1) is not a preferred provider included in the
preferred provider network; and
(2) provides to an insured:
(A) care related to an emergency or its attendant
episode of care as required by state or federal law; or
(B) specialty or other medical care or health
care services at the request of the insurer or a preferred provider
because the services are not reasonably available from a preferred
provider who is included in the preferred delivery network.
(b) For purposes of calculating a penalty under Section
1301.137 related to a claim by a physician or health care provider
described by Subsection (a) or Section 1301.0053, the contracted
rate for the health care service provided by the physician or
provider is the usual and customary rate for the service in the
geographic area in which the service is provided.
SECTION 9. Section 1301.160, Insurance Code, is amended by
amending Subsections (a) and (c) and adding Subsection (d) to read
as follows:
(a) If a physician's or health care provider's
[practitioner's] participation in a preferred provider benefit
plan is terminated for a reason other than at the physician's or
health care provider's [practitioner's] request, an insurer may not
notify insureds of the termination until the later of:
(1) the effective date of the termination; or
(2) if a review is requested, the time at which a
review panel makes a formal recommendation regarding the
termination.
(c) If a physician's or health care provider's
[practitioner's] participation in a preferred provider benefit
plan is terminated for reasons related to imminent harm, an insurer
may notify insureds immediately.
(d) The provisions of this section may not be waived,
voided, or nullified by contract.
SECTION 10. (a) Except as provided by Subsection (b) of this
section, the changes in law made by this Act apply only to a
contract entered into, amended, or renewed on or after the
effective date of this Act. A contract entered into, amended, or
renewed before the effective date of this Act is governed by the law
as it existed immediately before the effective date of this Act, and
that law is continued in effect for that purpose.
(b) Sections 843.351 and 1301.069, Insurance Code, as
amended by this Act, apply only to a claim filed on or after the
effective date of this Act.
SECTION 11. This Act takes effect September 1, 2019.