86R10858 SMT-F
By: Lambert H.B. No. 2962
A BILL TO BE ENTITLED
AN ACT
relating to departures from network adequacy standards by a
preferred provider benefit plan.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 1301.0055, Insurance Code, is amended to
read as follows:
Sec. 1301.0055. NETWORK ADEQUACY STANDARDS; DEPARTURE FROM
STANDARDS. (a) The commissioner shall by rule adopt network
adequacy standards that:
(1) are adapted to local markets in which an insurer
offering a preferred provider benefit plan operates;
(2) ensure availability of, and accessibility to, a
full range of contracted physicians and health care providers to
provide health care services to insureds; and
(3) on good cause shown, may allow departure from
local market network adequacy standards if the commissioner posts
on the department's Internet website the name of the preferred
provider plan, the insurer offering the plan, and the affected
local market.
(b) Unless renewed in accordance with this section,
permission to depart from a local market network adequacy standard
under this section expires on the first anniversary of the date the
commissioner grants the request for the departure.
(c) An insurer may request a renewal of permission to depart
from a local market network adequacy standard under this section
not later than the 30th day before the permission expires.
(d) If the commissioner grants an insurer's request for a
departure from a local market network adequacy standard for a
preferred provider benefit plan, the commissioner may not approve a
subsequent request by that insurer to depart from the same standard
for that plan unless the request demonstrates that:
(1) good cause for the requested departure exists;
(2) if a physician or health care provider able to
provide the covered service for which the insurer requests the
departure is available in the local market for which the departure
is requested:
(A) the insurer took reasonable steps to meet the
relevant standard, including taking any steps identified in a
previous request for departure from the standard; and
(B) for each physician or health care provider
described by this subdivision with whom the insurer does not enter a
contract:
(i) if the failure to contract was not based
on reimbursement rates, the insurer made not less than three
reasonable attempts to negotiate the disputed contract terms; or
(ii) if the failure to contract was based on
reimbursement rates, the insurer offered not less than three
materially different rates;
(3) the insurer's termination of a physician or health
care provider without cause is not a contributing factor in the
insurer's need for the requested departure; and
(4) the insurer has not had the highest ratio of claims
to mediation requests under Chapter 1467 in any of the preceding
three years for the relevant service compared to other insurers
subject to that chapter.
(e) The commissioner may impose reasonable conditions on
the grant of a departure request.
SECTION 2. Not later than December 1, 2019, the
commissioner of insurance shall adopt rules necessary to implement
Section 1301.0055, Insurance Code, as amended by this Act.
SECTION 3. The changes in law made by this Act apply only to
an insurance policy delivered, issued for delivery, or renewed on
or after January 1, 2020. An insurance policy delivered, issued for
delivery, or renewed before January 1, 2020, 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.
SECTION 4. This Act takes effect September 1, 2019.