86R4498 SMT-F
By: Buckingham, et al. S.B. No. 1188
A BILL TO BE ENTITLED
AN ACT
relating to health benefit plan provider networks; providing an
administrative penalty; authorizing an assessment.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 842.261, Insurance Code, is amended by
adding Subsection (a-1) and amending Subsection (c) to read as
follows:
(a-1) The listing required by Subsection (a) must meet the
requirements of a provider directory under Sections 1451.504 and
1451.505. Notwithstanding Subsection (b), the group hospital
service corporation is subject to the requirements of Sections
1451.504 and 1451.505, including the time limits for directory
corrections and updates, with respect to the listing.
(c) The commissioner may adopt rules as necessary to
implement this section. The rules may govern the form and content
of the information required to be provided under this section
[Subsection (a)].
SECTION 2. Section 843.2015, Insurance Code, is amended by
adding Subsection (a-1) and amending Subsection (c) to read as
follows:
(a-1) The listing required by Subsection (a) must meet the
requirements of a provider directory under Sections 1451.504 and
1451.505. Notwithstanding Subsection (b), the health maintenance
organization is subject to the requirements of Sections 1451.504
and 1451.505, including the time limits for directory corrections
and updates, with respect to the listing.
(c) The commissioner may adopt rules as necessary to
implement this section. The rules may govern the form and content
of the information required to be provided under this section
[Subsection (a)].
SECTION 3. Sections 1301.0056(a) and (d), Insurance Code,
are amended to read as follows:
(a) The commissioner shall [may] examine an insurer to
determine the quality and adequacy of a network used by a preferred
provider benefit plan [an exclusive provider benefit plan] offered
by the insurer under this chapter. An insurer is subject to a
qualifying examination of the insurer's preferred provider benefit
plans [exclusive provider benefit plans] and subsequent quality of
care and network adequacy examinations by the commissioner at least
once every two [five] years and whenever the commissioner considers
an examination necessary. Documentation provided to the
commissioner during an examination conducted under this section is
confidential and is not subject to disclosure as public information
under Chapter 552, Government Code.
(d) The department shall deposit an assessment collected
under this section to the credit of the [Texas Department of
Insurance operating] account with the Texas Treasury Safekeeping
Trust Company described by Section 401.156. Money deposited under
this subsection shall be used to pay the salaries and expenses of
examiners and all other expenses relating to the examination of
insurers under this section.
SECTION 4. Section 1301.1591, Insurance Code, is amended by
adding Subsection (a-1) and amending Subsection (c) to read as
follows:
(a-1) The listing required by Subsection (a) must meet the
requirements of a provider directory under Sections 1451.504 and
1451.505. Notwithstanding Subsection (b), the insurer is subject
to the requirements of Sections 1451.504 and 1451.505, including
the time limits for directory corrections and updates, with respect
to the listing.
(c) The commissioner may adopt rules as necessary to
implement this section. The rules may govern the form and content
of the information required to be provided under this section
[Subsection (a)].
SECTION 5. Section 1451.504(b), Insurance Code, is amended
to read as follows:
(b) The directory must include the name, specialty, if any,
street address, and telephone number of each physician and health
care provider described by Subsection (a) and indicate whether the
physician or provider is accepting new patients.
SECTION 6. The heading to Section 1451.505, Insurance Code,
is amended to read as follows:
Sec. 1451.505. ACCESSIBILITY AND ACCURACY OF PHYSICIAN AND
HEALTH CARE PROVIDER DIRECTORY [ON INTERNET WEBSITE].
SECTION 7. Section 1451.505, Insurance Code, is amended by
amending Subsections (c), (d), and (e) and adding Subsections
(d-1), (d-2), (d-3), and (f) through (p) to read as follows:
(c) The directory must be:
(1) electronically searchable by physician or health
care provider name, specialty, if any, and location; and
(2) publicly accessible without necessity of
providing a password, a user name, or personally identifiable
information.
(d) The health benefit plan issuer shall conduct an ongoing
review of the directory and correct or update the information as
necessary. Except as provided by Subsections (d-1), (d-2), (d-3),
and (f) [Subsection (e)], corrections and updates, if any, must be
made not less than once every two business days [each month].
(d-1) Except as provided by Subsection (d-2), the health
benefit plan issuer shall update the directory to:
(1) list a physician or health care provider not later
than two business days after the effective date of the contract that
establishes the physician's or other health care provider's
participation in a network for a health benefit plan offered by the
issuer; or
(2) remove a physician or health care provider not
later than two business days after the effective date of the
termination of the physician's or health care provider's contract
if the termination is at the request of the physician or health care
provider.
(d-2) Except as provided by Subsection (d-3), if the
termination of the physician's or health care provider's contract
was not at the request of the physician or health care provider and
the health benefit plan issuer is subject to Section 843.308 or
1301.160, the health benefit plan issuer shall remove the physician
or health care provider from the directory not later than two
business days after the later of:
(1) the date of a formal recommendation under Section
843.306 or 1301.057, as applicable; or
(2) the effective date of the termination.
(d-3) If the termination was related to imminent harm, the
health benefit plan issuer shall remove the physician or health
care provider from the directory in the time provided by Subsection
(d-1)(2).
(e) The health benefit plan issuer shall conspicuously
display in at least 10-point boldfaced font in the directory
required by Section 1451.504 a notice that an individual may report
an inaccuracy in the directory to the health benefit plan issuer or
the department. The health benefit plan issuer shall include in the
notice:
(1) an e-mail address and a toll-free telephone number
to which any individual may report any inaccuracy in the directory
to the health benefit plan issuer; and
(2) an e-mail address and Internet website address or
link for the appropriate complaint division of the department.
(f) Notwithstanding any other law, if [If] the health
benefit plan issuer receives an oral or written [a] report from any
person that specifically identified directory information may be
inaccurate, the issuer shall:
(1) immediately:
(A) inform the individual of the individual's
right to report inaccurate directory information to the department;
and
(B) provide the individual with an e-mail address
and Internet website address or link for the appropriate complaint
division of the department;
(2) investigate the report and correct the
information, as necessary, not later than:
(A) the second business [seventh] day after the
date the report is received if the report concerns the health
benefit plan issuer's representation of the network participation
status of the physician or health care provider; or
(B) the fifth day after the date the report is
received if the report concerns any other type of information in the
directory; and
(3) promptly enter the report in the log required
under Subsection (h).
(g) A health benefit plan issuer that receives an oral
report that specifically identified directory information may be
inaccurate may not require the individual making the oral report to
file a written report to trigger the time limits and requirements of
this section.
(h) The health benefit plan issuer shall create and maintain
for inspection by the department a log that records all reports
regarding inaccurate network directories or listings. The log
required under this subsection must include supporting information
as required by the commissioner by rule, including:
(1) the name of the person, if known, who reported the
inaccuracy and whether the person is an insured, enrollee,
physician, health care provider, or other individual;
(2) the alleged inaccuracy that was reported;
(3) the date of the report;
(4) steps taken by the health benefit plan issuer to
investigate the report, including the date each of the steps was
taken;
(5) the findings of the investigation of the report;
(6) a copy of the health benefit plan issuer's
correction or update, if any, made to the network directory as a
result of the investigation, including the date of the correction
or update;
(7) proof that the health benefit plan issuer made the
disclosure required by Subsection (f)(1); and
(8) the total number of reports received each month
for each network offered by the health benefit plan issuer.
(i) A health benefit plan issuer shall submit the log
required by Subsection (h) at least once annually on a date
specified by the commissioner by rule and as otherwise required by
Subsection (l).
(j) A health benefit plan issuer shall retain the log for
three years after the last entry date unless the commissioner by
rule requires a longer retention period.
(k) The following elements of a log provided to the
department under this section are confidential and are not subject
to disclosure as public information under Chapter 552, Government
Code:
(1) personally identifiable information or medical
information about the individual making the report; and
(2) personally identifiable information about a
physician or health care provider.
(l) If, in any 30-day period, the health benefit plan issuer
receives three or more reports that allege the health benefit plan
issuer's directory inaccurately represents a physician's or a
health care provider's network participation status and that are
confirmed by the health benefit plan issuer's investigation, the
health benefit plan issuer shall immediately report that occurrence
to the commissioner and provide to the department a copy of the log
required by Subsection (h).
(m) The department shall review a log submitted by a health
benefit plan issuer under Subsection (i) or (l). If the department
determines that the health benefit plan issuer appears to have
engaged in a pattern of maintaining an inaccurate network
directory, the commissioner shall investigate the health benefit
plan issuer's compliance with Subsections (d-1) and (d-2).
(n) A health benefit plan issuer investigated under this
section shall pay the cost of the investigation in an amount
determined by the commissioner.
(o) The department shall collect an assessment in an amount
determined by the commissioner from the health benefit plan issuer
at the time of the investigation to cover all expenses attributable
directly to the investigation, including the salaries and expenses
of department employees and all reasonable expenses of the
department necessary for the administration of this section. The
department shall deposit an assessment collected under this section
to the credit of the account with the Texas Treasury Safekeeping
Trust Company described by Section 401.156.
(p) Money deposited under this section shall be used to pay
the salaries and expenses of investigators and all other expenses
related to the investigation of a health benefit plan issuer under
this section.
SECTION 8. The heading to Chapter 1467, Insurance Code, is
amended to read as follows:
CHAPTER 1467. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION; NETWORK
ADEQUACY
SECTION 9. The heading to Subchapter D, Chapter 1467,
Insurance Code, is amended to read as follows:
SUBCHAPTER D. COMPLAINTS; CONSUMER PROTECTION; NETWORK ADEQUACY
SECTION 10. Subchapter D, Chapter 1467, Insurance Code, is
amended by adding Sections 1467.152 and 1467.153 to read as
follows:
Sec. 1467.152. NETWORK ADEQUACY EXAMINATIONS AND FEES. (a)
At the beginning of each calendar year, the department shall review
mediation request information collected by the department for the
preceding calendar year to identify the two insurers with the
highest percentage of claims that are subject to mediation requests
under this chapter in comparison to other insurers offering health
benefit plans subject to mediation for the reviewed year.
(b) Not later than May 1 of each year, the department shall
examine any insurer identified under Subsection (a) to determine
the quality and adequacy of networks offered by the insurer.
(c) Documentation provided to the commissioner during an
examination conducted under this section is confidential and is not
subject to disclosure as public information under Chapter 552,
Government Code.
(d) An insurer examined under this section shall pay the
cost of the examination in an amount determined by the
commissioner.
(e) The department shall collect an assessment in an amount
determined by the commissioner from the insurer at the time of the
examination to cover all expenses attributable directly to the
examination, including the salaries and expenses of department
employees and all reasonable expenses of the department necessary
for the administration of this section. The department shall
deposit an assessment collected under this section to the credit of
the account with the Texas Treasury Safekeeping Trust Company
described by Section 401.156.
(f) Money deposited under this section shall be used to pay
the salaries and expenses of examiners and all other expenses
related to the examination of an insurer under this section.
(g) An examination conducted by the department under this
section is in addition to any examination of an insurer required by
other law, including Section 1301.0056.
(h) The commissioner shall publish and make available on the
department's Internet website for at least 10 years after the date
of the examination information regarding an examination under this
section, including:
(1) the name of an insurer and health benefit plan
whose networks were examined under this section; and
(2) each year in which the insurer was subject to an
examination under this section.
Sec. 1467.153. TERMINATION WITHOUT CAUSE. (a) In this
section, "termination without cause" means the termination of the
provider network or preferred provider contract between a
physician, practitioner, health care provider, or facility and an
insurer for a reason other than:
(1) at the request of the physician, practitioner,
health care provider, or facility; or
(2) fraud or a material breach of contract.
(b) An insurer shall notify the department on the 15th day
of each month of the total number of terminations without cause made
by the insurer during the preceding month with respect to a health
benefit plan that is subject to this chapter. The notification
shall include information identifying:
(1) the type and number of physicians, practitioners,
health care providers, or facilities that were terminated;
(2) the location of the physician, practitioner,
health care provider, or facility that was terminated; and
(3) each health benefit plan offered by the insurer
that is affected by the termination.
(c) The department may investigate any insurer notifying
the department of a significant number of terminations without
cause with respect to a health benefit plan subject to this chapter.
The investigation must emphasize terminations without cause that:
(1) may impact the quality or adequacy of a health
benefit plan's network; or
(2) occur within the first three months after an open
enrollment period closes.
(d) Except for good cause shown, the department shall impose
an administrative penalty in accordance with Chapter 84 on an
insurer if the department makes a determination that the
terminations without cause made by an insurer caused, wholly or
partly, an inadequate network to be used by a health benefit plan
that is offered by the insurer. The department may not grant a
waiver from any related network adequacy requirements to an insurer
offering a health benefit plan with an inadequate network caused,
wholly or partly, by terminations without cause made by the
insurer.
(e) Personally identifiable information regarding a
physician or practitioner included in documentation provided to or
collected by the department under this section is confidential and
is not subject to disclosure as public information under Chapter
552, Government Code.
SECTION 11. This Act takes effect September 1, 2019.