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A BILL TO BE ENTITLED
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AN ACT
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relating to the relationship between physicians or health care |
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providers and health maintenance organizations or preferred |
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provider benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 843.306, Insurance Code, is amended by |
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amending Subsections (a), (b), and (e) and adding Subsections |
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(a-1), (a-2), (b-1), (b-2), (b-3), and (g) to read as follows: |
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(a) Before terminating a contract with a physician or |
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provider, a health maintenance organization shall provide to the |
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physician or provider: |
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(1) written notice of: |
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(A) the health maintenance organization's intent |
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to terminate the physician's or provider's contract; |
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(B) the physician's or provider's right to |
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request a review under Subsection (b); and |
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(C) the physician's or provider's right to |
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request the review be expedited under Section 843.307; and |
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(2) a written explanation of the reasons for |
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termination. |
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(a-1) In a case involving fraud or malfeasance by a |
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provider, the written notice required by Subsection (a) must |
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include notice of the health maintenance organization's right to |
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suspend the provider's participation in the health maintenance |
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organization network during the review process as provided by |
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Subsection (b-1). |
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(a-2) If a health maintenance organization terminates a |
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contract with a physician or provider, the health maintenance |
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organization shall provide to the physician or provider a written |
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copy of all information on which the health maintenance |
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organization wholly or partly based the termination, including the |
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economic profile of the physician or provider, the standards by |
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which the physician or provider is measured, and the statistics |
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underlying the profile and standards. |
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(b) On request, before the effective date of the termination |
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and within a period not to exceed 60 days, a physician or provider |
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is entitled to a review by an advisory review panel of the health |
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maintenance organization's proposed termination, except in a case |
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involving: |
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(1) imminent harm to patient health; |
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(2) an action by a state medical or dental board, |
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another medical or dental licensing board, or another licensing |
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board or government agency that effectively impairs the physician's |
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or provider's ability to practice medicine, dentistry, or another |
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profession; or |
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(3) fraud or malfeasance by a physician. |
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(b-1) If a provider requests a review under Subsection (b) |
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in a case involving fraud or malfeasance by the provider, the health |
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maintenance organization may suspend the provider's participation |
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in the health maintenance organization network: |
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(1) beginning not earlier than the date notice is |
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provided under Subsection (a); and |
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(2) ending on the earlier of: |
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(A) the 60th day after the date the provider |
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requests the review; |
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(B) the 30th day after the date the provider |
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requests the review be expedited under Section 843.307, if |
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applicable; or |
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(C) the date the health maintenance organization |
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makes a final determination under Subsection (b-2). |
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(b-2) If a health maintenance organization suspends a |
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provider's participation in the health maintenance organization |
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network under Subsection (b-1), the health maintenance |
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organization shall make a final determination to terminate or |
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resume the provider's participation not later than three business |
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days after the date the health maintenance organization receives |
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the recommendation of the advisory review panel. The health |
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maintenance organization shall immediately notify the provider of |
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the determination. |
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(b-3) Review under Subsection (b) must provide an |
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opportunity for the physician or provider to present evidence to |
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the advisory review panel before the panel makes a recommendation. |
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(e) The health maintenance organization [on request] shall |
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provide to the affected physician or provider a copy of the |
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recommendation of the advisory review panel and the health |
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maintenance organization's determination. |
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(g) A health maintenance organization may not terminate a |
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provider's contract without cause. |
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SECTION 2. Section 843.308, Insurance Code, is amended to |
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read as follows: |
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Sec. 843.308. NOTIFICATION OF PATIENTS OF DESELECTED OR |
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TERMINATED PHYSICIAN OR PROVIDER. (a) Except as provided by |
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Subsection (b), if a physician or provider is deselected or |
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terminated for a reason other than the request of the physician or |
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provider, a health maintenance organization may not notify patients |
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of the deselection or termination until the later of the effective |
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date of the deselection or termination, or, if a review is |
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requested, the date the advisory review panel makes a formal |
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recommendation. |
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(b) If the contract of a physician or provider is deselected |
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or terminated for a reason related to imminent harm, a health |
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maintenance organization may notify patients immediately. |
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SECTION 3. Section 843.309, Insurance Code, is amended to |
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read as follows: |
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Sec. 843.309. CONTRACTS WITH PHYSICIANS OR PROVIDERS: |
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NOTICE TO CERTAIN ENROLLEES OF TERMINATION OF PHYSICIAN OR PROVIDER |
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PARTICIPATION IN PLAN. Subject to Section 843.308, a [A] contract |
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between a health maintenance organization and a physician or |
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provider must provide that reasonable advance notice shall be given |
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to an enrollee of the impending termination from the plan of a |
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physician or provider who is currently treating the enrollee. |
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SECTION 4. Subchapter I, Chapter 843, Insurance Code, is |
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amended by adding Section 843.3095 to read as follows: |
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Sec. 843.3095. WAIVER OF CERTAIN PROVISIONS PROHIBITED. |
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The provisions of this subchapter related to deselection or |
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termination of a contract with a physician or provider may not be |
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waived, voided, or nullified by contract. |
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SECTION 5. Section 1301.053, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.053. APPEAL RELATING TO DESIGNATION AS PREFERRED |
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PROVIDER. (a) An insurer that does not designate a physician or |
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health care provider [practitioner] as a preferred provider shall |
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provide a reasonable mechanism for reviewing that action. The |
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review mechanism must incorporate, in an advisory role only, a |
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review panel. |
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(b) A review panel must be composed of at least three |
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individuals selected by the insurer from a list of participating |
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physicians or health care providers [practitioners] and must |
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include one member who is a physician or health care provider |
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[practitioner] in the same or similar specialty as the affected |
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physician or health care provider [practitioner], if available. |
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The physicians or health care providers [practitioners] |
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contracting with the insurer in the applicable service area shall |
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provide the list of physicians or health care providers |
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[practitioners] to the insurer. |
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(c) On request, the insurer shall provide to the affected |
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physician or health care provider [practitioner]: |
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(1) the panel's recommendation, if any; and |
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(2) a written explanation of the insurer's |
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determination, if that determination is contrary to the panel's |
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recommendation. |
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SECTION 6. Section 1301.057, Insurance Code, is amended to |
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read as follows: |
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Sec. 1301.057. TERMINATION OF PARTICIPATION; EXPEDITED |
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REVIEW PROCESS. (a) Before terminating a contract with a preferred |
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provider, an insurer shall: |
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(1) provide written notice of: |
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(A) the insurer's intent to terminate the |
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preferred provider's contract; |
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(B) the preferred provider's right to request a |
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review under this section; and |
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(C) the preferred provider's right to request the |
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review be expedited under Subsection (d); |
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(2) provide written reasons for the termination; and |
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(3) [(2) if the affected provider is a practitioner,] |
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provide, on request, a reasonable review mechanism, except in a |
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case involving: |
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(A) imminent harm to a patient's health; |
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(B) an action by a state medical or other |
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physician licensing board or other government agency that |
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effectively impairs the physician's or health care provider's |
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[practitioner's] ability to practice medicine, dentistry, or |
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another profession; or |
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(C) fraud or malfeasance by a physician. |
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(a-1) In a case involving fraud or malfeasance by a health |
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care provider, the written notice required by Subsection (a) must |
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include notice of the insurer's right to suspend the health care |
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provider's participation in the preferred provider benefit plan |
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during the review process as provided by Subsection (a-3). |
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(a-2) An insurer may not terminate a health care provider's |
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contract without cause. |
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(a-3) If a health care provider requests a review under |
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Subsection (a) in a case involving fraud or malfeasance by the |
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health care provider, the insurer may suspend the health care |
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provider's participation in the preferred provider benefit plan: |
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(1) beginning not earlier than the date notice is |
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provided under Subsection (a); and |
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(2) ending on the earlier of: |
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(A) the 60th day after the date the health care |
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provider requests the review; |
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(B) the 30th day after the date the health care |
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provider requests the review be expedited, if applicable; or |
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(C) the date the insurer makes a final |
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determination under Subsection (a-4). |
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(a-4) If an insurer suspends a health care provider's |
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participation in the preferred provider benefit plan under |
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Subsection (a-3), the insurer shall make a final determination to |
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terminate or resume the health care provider's participation not |
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later than three business days after the date the insurer receives |
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the recommendation of the review panel described by Subsection (b). |
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The insurer shall immediately notify the health care provider of |
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the insurer's determination. |
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(b) The review mechanism described by Subsection (a)(3) |
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[(a)(2)] must incorporate, in an advisory role only, a review panel |
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selected in the manner described by Section 1301.053(b) and must be |
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completed within a period not to exceed 60 days. |
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(b-1) Review under Subsection (a)(3) must provide an |
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opportunity for the affected physician or health care provider to |
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present evidence to the review panel before the panel makes a |
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recommendation. |
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(c) The insurer shall provide to the affected physician or |
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health care provider [practitioner]: |
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(1) the review panel's recommendation, if any; and |
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(2) [on request,] a written explanation of the |
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insurer's determination, if that determination is contrary to the |
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panel's recommendation. |
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(d) On request, an insurer shall provide to a physician or |
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health care provider [practitioner] whose participation in a |
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preferred provider benefit plan is being terminated: |
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(1) an expedited review conducted in accordance with a |
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process that complies with rules established by the commissioner; |
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and |
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(2) all information on which the insurer wholly or |
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partly based the termination, including the economic profile of the |
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preferred provider, the standards by which the physician or health |
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care provider is measured, and the statistics underlying the |
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profile and standards. |
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(e) The provisions of this section may not be waived, |
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voided, or nullified by contract. |
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SECTION 7. Section 1301.160, Insurance Code, is amended by |
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amending Subsections (a) and (c) and adding Subsection (d) to read |
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as follows: |
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(a) If a physician's or health care provider's |
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[practitioner's] participation in a preferred provider benefit |
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plan is terminated for a reason other than at the physician's or |
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health care provider's [practitioner's] request, an insurer may not |
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notify insureds of the termination until the later of: |
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(1) the effective date of the termination; or |
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(2) if a review is requested, the time at which a |
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review panel makes a formal recommendation regarding the |
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termination. |
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(c) If a physician's or health care provider's |
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[practitioner's] participation in a preferred provider benefit |
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plan is terminated for reasons related to imminent harm, an insurer |
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may notify insureds immediately. |
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(d) The provisions of this section may not be waived, |
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voided, or nullified by contract. |
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SECTION 8. The changes in law made by this Act apply only to |
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a contract entered into, amended, or renewed on or after the |
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effective date of this Act. A contract entered into, amended, or |
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renewed before the effective date of this Act is governed by the law |
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as it existed immediately before the effective date of this Act, and |
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that law is continued in effect for that purpose. |
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SECTION 9. This Act takes effect September 1, 2019. |