Bill Text: TX SB744 | 2019-2020 | 86th Legislature | Introduced


Bill Title: Relating to the relationship between physicians or health care providers and health maintenance organizations or preferred provider benefit plans.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2019-03-01 - Referred to Business & Commerce [SB744 Detail]

Download: Texas-2019-SB744-Introduced.html
  86R2897 SMT-F
 
  By: Perry S.B. No. 744
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the relationship between physicians or health care
  providers and health maintenance organizations or preferred
  provider benefit plans.
         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 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 without cause.
         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 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 6.  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 without cause. 
         (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 7.  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 8.  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.
         SECTION 9.  This Act takes effect September 1, 2019.
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