Texas 2019 - 86th Regular

Texas Senate Bill SB1188 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	86R4498 SMT-F
2	2	By: Buckingham, et al. S.B. No. 1188
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to health benefit plan provider networks; providing an
8	8	administrative penalty; authorizing an assessment.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Section 842.261, Insurance Code, is amended by
11	11	adding Subsection (a-1) and amending Subsection (c) to read as
12	12	follows:
13	13	(a-1) The listing required by Subsection (a) must meet the
14	14	requirements of a provider directory under Sections 1451.504 and
15	15	1451.505. Notwithstanding Subsection (b), the group hospital
16	16	service corporation is subject to the requirements of Sections
17	17	1451.504 and 1451.505, including the time limits for directory
18	18	corrections and updates, with respect to the listing.
19	19	(c) The commissioner may adopt rules as necessary to
20	20	implement this section. The rules may govern the form and content
21	21	of the information required to be provided under this section
22	22	[Subsection (a)].
23	23	SECTION 2. Section 843.2015, Insurance Code, is amended by
24	24	adding Subsection (a-1) and amending Subsection (c) to read as
25	25	follows:
26	26	(a-1) The listing required by Subsection (a) must meet the
27	27	requirements of a provider directory under Sections 1451.504 and
28	28	1451.505. Notwithstanding Subsection (b), the health maintenance
29	29	organization is subject to the requirements of Sections 1451.504
30	30	and 1451.505, including the time limits for directory corrections
31	31	and updates, with respect to the listing.
32	32	(c) The commissioner may adopt rules as necessary to
33	33	implement this section. The rules may govern the form and content
34	34	of the information required to be provided under this section
35	35	[Subsection (a)].
36	36	SECTION 3. Sections 1301.0056(a) and (d), Insurance Code,
37	37	are amended to read as follows:
38	38	(a) The commissioner shall [may] examine an insurer to
39	39	determine the quality and adequacy of a network used by a preferred
40	40	provider benefit plan [an exclusive provider benefit plan] offered
41	41	by the insurer under this chapter. An insurer is subject to a
42	42	qualifying examination of the insurer's preferred provider benefit
43	43	plans [exclusive provider benefit plans] and subsequent quality of
44	44	care and network adequacy examinations by the commissioner at least
45	45	once every two [five] years and whenever the commissioner considers
46	46	an examination necessary. Documentation provided to the
47	47	commissioner during an examination conducted under this section is
48	48	confidential and is not subject to disclosure as public information
49	49	under Chapter 552, Government Code.
50	50	(d) The department shall deposit an assessment collected
51	51	under this section to the credit of the [Texas Department of
52	52	Insurance operating] account with the Texas Treasury Safekeeping
53	53	Trust Company described by Section 401.156. Money deposited under
54	54	this subsection shall be used to pay the salaries and expenses of
55	55	examiners and all other expenses relating to the examination of
56	56	insurers under this section.
57	57	SECTION 4. Section 1301.1591, Insurance Code, is amended by
58	58	adding Subsection (a-1) and amending Subsection (c) to read as
59	59	follows:
60	60	(a-1) The listing required by Subsection (a) must meet the
61	61	requirements of a provider directory under Sections 1451.504 and
62	62	1451.505. Notwithstanding Subsection (b), the insurer is subject
63	63	to the requirements of Sections 1451.504 and 1451.505, including
64	64	the time limits for directory corrections and updates, with respect
65	65	to the listing.
66	66	(c) The commissioner may adopt rules as necessary to
67	67	implement this section. The rules may govern the form and content
68	68	of the information required to be provided under this section
69	69	[Subsection (a)].
70	70	SECTION 5. Section 1451.504(b), Insurance Code, is amended
71	71	to read as follows:
72	72	(b) The directory must include the name, specialty, if any,
73	73	street address, and telephone number of each physician and health
74	74	care provider described by Subsection (a) and indicate whether the
75	75	physician or provider is accepting new patients.
76	76	SECTION 6. The heading to Section 1451.505, Insurance Code,
77	77	is amended to read as follows:
78	78	Sec. 1451.505. ACCESSIBILITY AND ACCURACY OF PHYSICIAN AND
79	79	HEALTH CARE PROVIDER DIRECTORY [ON INTERNET WEBSITE].
80	80	SECTION 7. Section 1451.505, Insurance Code, is amended by
81	81	amending Subsections (c), (d), and (e) and adding Subsections
82	82	(d-1), (d-2), (d-3), and (f) through (p) to read as follows:
83	83	(c) The directory must be:
84	84	(1) electronically searchable by physician or health
85	85	care provider name, specialty, if any, and location; and
86	86	(2) publicly accessible without necessity of
87	87	providing a password, a user name, or personally identifiable
88	88	information.
89	89	(d) The health benefit plan issuer shall conduct an ongoing
90	90	review of the directory and correct or update the information as
91	91	necessary. Except as provided by Subsections (d-1), (d-2), (d-3),
92	92	and (f) [Subsection (e)], corrections and updates, if any, must be
93	93	made not less than once every two business days [each month].
94	94	(d-1) Except as provided by Subsection (d-2), the health
95	95	benefit plan issuer shall update the directory to:
96	96	(1) list a physician or health care provider not later
97	97	than two business days after the effective date of the contract that
98	98	establishes the physician's or other health care provider's
99	99	participation in a network for a health benefit plan offered by the
100	100	issuer; or
101	101	(2) remove a physician or health care provider not
102	102	later than two business days after the effective date of the
103	103	termination of the physician's or health care provider's contract
104	104	if the termination is at the request of the physician or health care
105	105	provider.
106	106	(d-2) Except as provided by Subsection (d-3), if the
107	107	termination of the physician's or health care provider's contract
108	108	was not at the request of the physician or health care provider and
109	109	the health benefit plan issuer is subject to Section 843.308 or
110	110	1301.160, the health benefit plan issuer shall remove the physician
111	111	or health care provider from the directory not later than two
112	112	business days after the later of:
113	113	(1) the date of a formal recommendation under Section
114	114	843.306 or 1301.057, as applicable; or
115	115	(2) the effective date of the termination.
116	116	(d-3) If the termination was related to imminent harm, the
117	117	health benefit plan issuer shall remove the physician or health
118	118	care provider from the directory in the time provided by Subsection
119	119	(d-1)(2).
120	120	(e) The health benefit plan issuer shall conspicuously
121	121	display in at least 10-point boldfaced font in the directory
122	122	required by Section 1451.504 a notice that an individual may report
123	123	an inaccuracy in the directory to the health benefit plan issuer or
124	124	the department. The health benefit plan issuer shall include in the
125	125	notice:
126	126	(1) an e-mail address and a toll-free telephone number
127	127	to which any individual may report any inaccuracy in the directory
128	128	to the health benefit plan issuer; and
129	129	(2) an e-mail address and Internet website address or
130	130	link for the appropriate complaint division of the department.
131	131	(f) Notwithstanding any other law, if [If] the health
132	132	benefit plan issuer receives an oral or written [a] report from any
133	133	person that specifically identified directory information may be
134	134	inaccurate, the issuer shall:
135	135	(1) immediately:
136	136	(A) inform the individual of the individual's
137	137	right to report inaccurate directory information to the department;
138	138	and
139	139	(B) provide the individual with an e-mail address
140	140	and Internet website address or link for the appropriate complaint
141	141	division of the department;
142	142	(2) investigate the report and correct the
143	143	information, as necessary, not later than:
144	144	(A) the second business [seventh] day after the
145	145	date the report is received if the report concerns the health
146	146	benefit plan issuer's representation of the network participation
147	147	status of the physician or health care provider; or
148	148	(B) the fifth day after the date the report is
149	149	received if the report concerns any other type of information in the
150	150	directory; and
151	151	(3) promptly enter the report in the log required
152	152	under Subsection (h).
153	153	(g) A health benefit plan issuer that receives an oral
154	154	report that specifically identified directory information may be
155	155	inaccurate may not require the individual making the oral report to
156	156	file a written report to trigger the time limits and requirements of
157	157	this section.
158	158	(h) The health benefit plan issuer shall create and maintain
159	159	for inspection by the department a log that records all reports
160	160	regarding inaccurate network directories or listings. The log
161	161	required under this subsection must include supporting information
162	162	as required by the commissioner by rule, including:
163	163	(1) the name of the person, if known, who reported the
164	164	inaccuracy and whether the person is an insured, enrollee,
165	165	physician, health care provider, or other individual;
166	166	(2) the alleged inaccuracy that was reported;
167	167	(3) the date of the report;
168	168	(4) steps taken by the health benefit plan issuer to
169	169	investigate the report, including the date each of the steps was
170	170	taken;
171	171	(5) the findings of the investigation of the report;
172	172	(6) a copy of the health benefit plan issuer's
173	173	correction or update, if any, made to the network directory as a
174	174	result of the investigation, including the date of the correction
175	175	or update;
176	176	(7) proof that the health benefit plan issuer made the
177	177	disclosure required by Subsection (f)(1); and
178	178	(8) the total number of reports received each month
179	179	for each network offered by the health benefit plan issuer.
180	180	(i) A health benefit plan issuer shall submit the log
181	181	required by Subsection (h) at least once annually on a date
182	182	specified by the commissioner by rule and as otherwise required by
183	183	Subsection (l).
184	184	(j) A health benefit plan issuer shall retain the log for
185	185	three years after the last entry date unless the commissioner by
186	186	rule requires a longer retention period.
187	187	(k) The following elements of a log provided to the
188	188	department under this section are confidential and are not subject
189	189	to disclosure as public information under Chapter 552, Government
190	190	Code:
191	191	(1) personally identifiable information or medical
192	192	information about the individual making the report; and
193	193	(2) personally identifiable information about a
194	194	physician or health care provider.
195	195	(l) If, in any 30-day period, the health benefit plan issuer
196	196	receives three or more reports that allege the health benefit plan
197	197	issuer's directory inaccurately represents a physician's or a
198	198	health care provider's network participation status and that are
199	199	confirmed by the health benefit plan issuer's investigation, the
200	200	health benefit plan issuer shall immediately report that occurrence
201	201	to the commissioner and provide to the department a copy of the log
202	202	required by Subsection (h).
203	203	(m) The department shall review a log submitted by a health
204	204	benefit plan issuer under Subsection (i) or (l). If the department
205	205	determines that the health benefit plan issuer appears to have
206	206	engaged in a pattern of maintaining an inaccurate network
207	207	directory, the commissioner shall investigate the health benefit
208	208	plan issuer's compliance with Subsections (d-1) and (d-2).
209	209	(n) A health benefit plan issuer investigated under this
210	210	section shall pay the cost of the investigation in an amount
211	211	determined by the commissioner.
212	212	(o) The department shall collect an assessment in an amount
213	213	determined by the commissioner from the health benefit plan issuer
214	214	at the time of the investigation to cover all expenses attributable
215	215	directly to the investigation, including the salaries and expenses
216	216	of department employees and all reasonable expenses of the
217	217	department necessary for the administration of this section. The
218	218	department shall deposit an assessment collected under this section
219	219	to the credit of the account with the Texas Treasury Safekeeping
220	220	Trust Company described by Section 401.156.
221	221	(p) Money deposited under this section shall be used to pay
222	222	the salaries and expenses of investigators and all other expenses
223	223	related to the investigation of a health benefit plan issuer under
224	224	this section.
225	225	SECTION 8. The heading to Chapter 1467, Insurance Code, is
226	226	amended to read as follows:
227	227	CHAPTER 1467. OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION; NETWORK
228	228	ADEQUACY
229	229	SECTION 9. The heading to Subchapter D, Chapter 1467,
230	230	Insurance Code, is amended to read as follows:
231	231	SUBCHAPTER D. COMPLAINTS; CONSUMER PROTECTION; NETWORK ADEQUACY
232	232	SECTION 10. Subchapter D, Chapter 1467, Insurance Code, is
233	233	amended by adding Sections 1467.152 and 1467.153 to read as
234	234	follows:
235	235	Sec. 1467.152. NETWORK ADEQUACY EXAMINATIONS AND FEES. (a)
236	236	At the beginning of each calendar year, the department shall review
237	237	mediation request information collected by the department for the
238	238	preceding calendar year to identify the two insurers with the
239	239	highest percentage of claims that are subject to mediation requests
240	240	under this chapter in comparison to other insurers offering health
241	241	benefit plans subject to mediation for the reviewed year.
242	242	(b) Not later than May 1 of each year, the department shall
243	243	examine any insurer identified under Subsection (a) to determine
244	244	the quality and adequacy of networks offered by the insurer.
245	245	(c) Documentation provided to the commissioner during an
246	246	examination conducted under this section is confidential and is not
247	247	subject to disclosure as public information under Chapter 552,
248	248	Government Code.
249	249	(d) An insurer examined under this section shall pay the
250	250	cost of the examination in an amount determined by the
251	251	commissioner.
252	252	(e) The department shall collect an assessment in an amount
253	253	determined by the commissioner from the insurer at the time of the
254	254	examination to cover all expenses attributable directly to the
255	255	examination, including the salaries and expenses of department
256	256	employees and all reasonable expenses of the department necessary
257	257	for the administration of this section. The department shall
258	258	deposit an assessment collected under this section to the credit of
259	259	the account with the Texas Treasury Safekeeping Trust Company
260	260	described by Section 401.156.
261	261	(f) Money deposited under this section shall be used to pay
262	262	the salaries and expenses of examiners and all other expenses
263	263	related to the examination of an insurer under this section.
264	264	(g) An examination conducted by the department under this
265	265	section is in addition to any examination of an insurer required by
266	266	other law, including Section 1301.0056.
267	267	(h) The commissioner shall publish and make available on the
268	268	department's Internet website for at least 10 years after the date
269	269	of the examination information regarding an examination under this
270	270	section, including:
271	271	(1) the name of an insurer and health benefit plan
272	272	whose networks were examined under this section; and
273	273	(2) each year in which the insurer was subject to an
274	274	examination under this section.
275	275	Sec. 1467.153. TERMINATION WITHOUT CAUSE. (a) In this
276	276	section, "termination without cause" means the termination of the
277	277	provider network or preferred provider contract between a
278	278	physician, practitioner, health care provider, or facility and an
279	279	insurer for a reason other than:
280	280	(1) at the request of the physician, practitioner,
281	281	health care provider, or facility; or
282	282	(2) fraud or a material breach of contract.
283	283	(b) An insurer shall notify the department on the 15th day
284	284	of each month of the total number of terminations without cause made
285	285	by the insurer during the preceding month with respect to a health
286	286	benefit plan that is subject to this chapter. The notification
287	287	shall include information identifying:
288	288	(1) the type and number of physicians, practitioners,
289	289	health care providers, or facilities that were terminated;
290	290	(2) the location of the physician, practitioner,
291	291	health care provider, or facility that was terminated; and
292	292	(3) each health benefit plan offered by the insurer
293	293	that is affected by the termination.
294	294	(c) The department may investigate any insurer notifying
295	295	the department of a significant number of terminations without
296	296	cause with respect to a health benefit plan subject to this chapter.
297	297	The investigation must emphasize terminations without cause that:
298	298	(1) may impact the quality or adequacy of a health
299	299	benefit plan's network; or
300	300	(2) occur within the first three months after an open
301	301	enrollment period closes.
302	302	(d) Except for good cause shown, the department shall impose
303	303	an administrative penalty in accordance with Chapter 84 on an
304	304	insurer if the department makes a determination that the
305	305	terminations without cause made by an insurer caused, wholly or
306	306	partly, an inadequate network to be used by a health benefit plan
307	307	that is offered by the insurer. The department may not grant a
308	308	waiver from any related network adequacy requirements to an insurer
309	309	offering a health benefit plan with an inadequate network caused,
310	310	wholly or partly, by terminations without cause made by the
311	311	insurer.
312	312	(e) Personally identifiable information regarding a
313	313	physician or practitioner included in documentation provided to or
314	314	collected by the department under this section is confidential and
315	315	is not subject to disclosure as public information under Chapter
316	316	552, Government Code.
317	317	SECTION 11. This Act takes effect September 1, 2019.