87R2567 MEW-F
By: Schwertner S.B. No. 245
A BILL TO BE ENTITLED
AN ACT
relating to the adequacy and effectiveness of managed care plan
networks.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 108.002(9), Health and Safety Code, is
amended to read as follows:
(9) "Health benefit plan" means a plan provided by:
(A) a health maintenance organization;
(B) a preferred provider or exclusive provider
benefit plan issuer under Chapter 1301, Insurance Code; or
(C) [(B)] an approved nonprofit health
corporation that is certified under Section 162.001, Occupations
Code, and that holds a certificate of authority issued by the
commissioner of insurance under Chapter 844, Insurance Code.
SECTION 2. Section 501.001, Insurance Code, is amended to
read as follows:
Sec. 501.001. DEFINITIONS [DEFINITION]. In this chapter:
(1) "Managed care plan" means:
(A) a health maintenance organization plan
provided under Chapter 843;
(B) a preferred provider benefit plan, as defined
by Section 1301.001; or
(C) an exclusive provider benefit plan, as
defined by Section 1301.001.
(2) "Office" [, "office"] means the office of public
insurance counsel.
SECTION 3. Section 501.151, Insurance Code, is amended to
read as follows:
Sec. 501.151. POWERS AND DUTIES OF OFFICE. The office:
(1) may assess the impact of insurance rates, rules,
and forms on insurance consumers in this state; [and]
(2) shall advocate in the office's own name positions
determined by the public counsel to be most advantageous to a
substantial number of insurance consumers;
(3) shall monitor the adequacy of networks offered by
managed care plans in this state; and
(4) may advocate for consumers in the office's own
name:
(A) positions to strengthen the overall adequacy
or oversight of networks offered by managed care plans in this
state; and
(B) positions to strengthen the adequacy or
oversight of a particular network offered by a managed care plan in
this state, including by:
(i) opposing, at the public counsel's
discretion, the department's approval of a managed care plan's
filing, application, or request related to the adequacy of a
network offered by the managed care plan in this state, including
any filings, applications, and requests related to access plans or
waivers of network adequacy requirements, when applicable; and
(ii) filing complaints with the department
regarding the failure of a particular managed care plan to satisfy
applicable network adequacy requirements, including requirements
to maintain accurate provider network directories.
SECTION 4. Section 501.153, Insurance Code, is amended to
read as follows:
Sec. 501.153. AUTHORITY TO APPEAR, INTERVENE, OR INITIATE.
(a) The public counsel:
(1) may appear or intervene, as a party or otherwise,
as a matter of right before the commissioner or department on behalf
of insurance consumers, as a class, in matters involving:
(A) rates, rules, and forms affecting:
(i) property and casualty insurance;
(ii) title insurance;
(iii) credit life insurance;
(iv) credit accident and health insurance;
or
(v) any other line of insurance for which
the commissioner or department promulgates, sets, adopts, or
approves rates, rules, or forms;
(B) rules affecting life, health, or accident
insurance; or
(C) withdrawal of approval of policy forms:
(i) in proceedings initiated by the
department under Sections 1701.055 and 1701.057; or
(ii) if the public counsel presents
persuasive evidence to the department that the forms do not comply
with this code, a rule adopted under this code, or any other law;
(2) may initiate or intervene as a matter of right or
otherwise appear in a judicial proceeding involving or arising from
an action taken by an administrative agency in a proceeding in which
the public counsel previously appeared under the authority granted
by this chapter;
(3) may appear or intervene, as a party or otherwise,
as a matter of right on behalf of insurance consumers as a class in
any proceeding in which the public counsel determines that
insurance consumers are in need of representation, except that the
public counsel may not intervene in an enforcement or parens
patriae proceeding brought by the attorney general; [and]
(4) may appear or intervene before the commissioner or
department as a party or otherwise on behalf of small commercial
insurance consumers, as a class, in a matter involving rates,
rules, or forms affecting commercial insurance consumers, as a
class, in any proceeding in which the public counsel determines
that small commercial consumers are in need of representation;
(5) may appear or intervene in a proceeding or hearing
before the commissioner or department as a party or otherwise on
behalf of consumers, as a class, in a matter relating to the
adequacy of a network offered by a managed care plan; and
(6) may file objections and request a hearing, to be
granted in the sole discretion of the commissioner, regarding any
application, filing, or request that a managed care plan files with
the department related to an access plan or waiver of a network
adequacy requirement.
(b) To assist the office in determining whether to request a
hearing under Subsection (a)(6), a managed care plan must file with
the office, at the same time that it makes such filing with the
department, a copy of:
(1) any network adequacy waiver request, application,
or filing, including any attachments or supporting documentation;
or
(2) any access plan filing, request, or application,
including any attachments or supporting documentation.
(c) Nothing in this chapter may be construed as authorizing
a managed care plan to request a waiver of network adequacy
requirements or to use an access plan unless otherwise authorized
by law or regulation.
SECTION 5. Section 501.154, Insurance Code, is amended to
read as follows:
Sec. 501.154. ACCESS TO INFORMATION. The public counsel:
(1) is entitled to the same access as a party, other
than department staff, to department records available in a
proceeding before the commissioner or department under the
authority granted to the public counsel by this chapter; [and]
(2) is entitled to obtain discovery under Chapter
2001, Government Code, of any nonprivileged matter that is relevant
to the subject matter involved in a proceeding or submission before
the commissioner or department as authorized by this chapter; and
(3) is entitled to all filings, including any
attachments and supporting documentation, made by a managed care
plan relating to the adequacy of a network offered by the plan.
SECTION 6. Section 501.157, Insurance Code, is amended to
read as follows:
Sec. 501.157. PROHIBITED INTERVENTIONS OR APPEARANCES.
Except as otherwise provided by this code, the [The] public counsel
may not intervene or appear in:
(1) any proceeding or hearing before the commissioner
or department, or any other proceeding, that relates to approval or
consideration of an individual charter, license, certificate of
authority, acquisition, merger, or examination; or
(2) any proceeding concerning the solvency of an
individual insurer, a financial issue, a policy form, advertising,
or another regulatory issue affecting an individual insurer or
agent.
SECTION 7. Section 501.159(a), Insurance Code, is amended
to read as follows:
(a) Notwithstanding this chapter, the office may submit
written comments to the commissioner and otherwise participate
regarding individual insurer filings:
(1) made under Chapters 2251 and 2301 relating to
insurance described by Subchapter B, Chapter 2301; or
(2) relating to the adequacy of a network offered by a
managed care plan.
SECTION 8. Subchapter D, Chapter 501, Insurance Code, is
amended by adding Section 501.161 to read as follows:
Sec. 501.161. COMPLAINTS. (a) The office may file a
complaint with the department on discovering that a managed care
plan:
(1) is operating, has operated, or is seeking to
operate with an inadequate network in this state;
(2) potentially is in violation of, has been in
violation of, or seeks to operate in violation of a network adequacy
law or regulation in this state; or
(3) potentially has an inaccurate provider network
directory.
(b) The department shall keep an information file about each
complaint filed with the department by the office under this
section.
(c) If a written complaint is filed with the department, the
department, at least quarterly and until final disposition of the
complaint, shall notify each party to the complaint, including the
office, of the complaint's status unless the notice would
jeopardize an undercover investigation.
(d) Notwithstanding any other law, the office may post on
its Internet website any complaint that the office files with the
department under this section.
SECTION 9. The heading to Subchapter F, Chapter 501,
Insurance Code, is amended to read as follows:
SUBCHAPTER F. DUTIES RELATING TO MANAGED CARE PLANS [HEALTH
MAINTENANCE ORGANIZATIONS]
SECTION 10. Section 501.251, Insurance Code, is amended to
read as follows:
Sec. 501.251. COMPARISON OF MANAGED CARE PLANS [HEALTH
MAINTENANCE ORGANIZATIONS]. (a) The office shall develop and
implement a system to compare and evaluate, on an objective basis,
the quality of care provided by, the adequacy of networks offered
by, and the performance of managed care plans [health maintenance
organizations established under Chapter 843].
(b) In conducting comparisons under the system described by
Subsection (a), the office shall compare:
(1) health maintenance organizations to other health
maintenance organizations;
(2) preferred provider benefit plans to other
preferred provider benefit plans; and
(3) exclusive provider benefit plans to other
exclusive provider benefit plans.
(c) In developing the system, the office may use information
or data from a person, agency, organization, or governmental unit
that the office considers reliable.
SECTION 11. Section 501.252, Insurance Code, is amended to
read as follows:
Sec. 501.252. ANNUAL CONSUMER REPORT CARDS. (a) The office
shall develop and issue annual consumer report cards that identify
and compare, on an objective basis, managed care plans [health
maintenance organizations in this state].
(b) The consumer report cards required by Subsection (a)
shall:
(1) include comparisons of types of managed care plans
in the same manner as provided by Section 501.251(b);
(2) include information, evaluations, and comparisons
regarding the adequacy of networks offered by the particular type
of managed care plan that is the subject of a consumer report card;
and
(3) at the discretion of the office, be staggered for
release throughout the year based on the type of managed care plan
that is the subject of the consumer report card.
(c) Notwithstanding Subsection (b)(3), all consumer report
cards for a particular type of managed care plan must be released at
the same time.
(d) The consumer report cards may be based on information or
data from any person, agency, organization, or governmental unit
that the office considers reliable.
(e) Notwithstanding Subsection (d), in developing the
information required under Subsection (b)(2), the office may use
information or data that is self-reported to the department or to
the public by a managed care plan.
(f) [(b)] The office may not endorse or recommend a specific
managed care [health maintenance organization or] plan, or
subjectively rate or rank managed care [health maintenance
organizations or] plans or managed care plan issuers, other than
through comparison and evaluation of objective criteria.
(g) [(c)] The office shall provide a copy of any consumer
report card on request on payment of a reasonable fee.
SECTION 12. It is the intent of the legislature to provide
the office of public insurance counsel with the flexibility to
establish a timeline for the implementation, development, and
initial issuance of annual consumer report cards under Section
501.252, Insurance Code, as amended by this Act, in a manner that
best uses current office of public insurance counsel resources.
SECTION 13. This Act takes effect September 1, 2021.