HB1959 - Relating to certain practices of health benefit plan issuers to encourage the use of certain physicians and health care providers and rank physicians.

  89R7882 DNC-F     By: Frank H.B. No. 1959       A BILL TO BE ENTITLED   AN ACT   relating to certain practices of health benefit plan issuers to   encourage the use of certain physicians and health care providers   and rank physicians.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subchapter I, Chapter 843, Insurance Code, is   amended by adding Section 843.322 to read as follows:           Sec.   843.322.     INCENTIVES TO USE CERTAIN PHYSICIANS OR   PROVIDERS. (a)   A health maintenance organization may provide   incentives for enrollees to use certain physicians or providers   through modified deductibles, copayments, coinsurance, or other   cost-sharing provisions.           (b)     A health maintenance organization that encourages an   enrollee to obtain a health care service from a particular   physician or provider, including offering incentives to encourage   enrollees to use specific physicians or providers, or that   introduces or modifies a tiered network plan or assigns physicians   or providers into tiers, has a fiduciary duty to the enrollee or   group contract holder to engage in that conduct only for the primary   benefit of the enrollee or group contract holder.          SECTION 2.  Section 1301.0045(a), Insurance Code, is amended   to read as follows:          (a)  Except as provided by Sections [ Section ] 1301.0046 and   1301.0047 , this chapter may not be construed to limit the level of   reimbursement or the level of coverage, including deductibles,   copayments, coinsurance, or other cost-sharing provisions, that   are applicable to preferred providers or, for plans other than   exclusive provider benefit plans, nonpreferred providers.          SECTION 3.  Subchapter A, Chapter 1301, Insurance Code, is   amended by adding Section 1301.0047 to read as follows:           Sec.   1301.0047.     INCENTIVES TO USE CERTAIN PHYSICIANS OR   HEALTH CARE PROVIDERS. (a)   An insurer may provide incentives for   insureds to use certain physicians or health care providers through   modified deductibles, copayments, coinsurance, or other   cost-sharing provisions.           (b)     An insurer that encourages an insured to obtain a health   care service from a particular physician or health care provider,   including offering incentives to encourage insureds to use specific   physicians or providers, or that introduces or modifies a tiered   network plan or assigns physicians or providers into tiers, has a   fiduciary duty to the insured or policyholder to engage in that   conduct only for the primary benefit of the insured or   policyholder.          SECTION 4.  Section 1460.003, Insurance Code, is amended by   amending Subsection (a) and adding Subsection (a-1) to read as   follows:          (a)  A health benefit plan issuer, including a subsidiary or   affiliate, may not rank physicians or [ , ] classify physicians into   tiers based on performance[ , or publish physician-specific   information that includes rankings, tiers, ratings, or other   comparisons of a physician's performance against standards,   measures, or other physicians, ] unless:                (1)   the standards used by the health benefit plan   issuer to rank or classify are propagated or developed by an   organization designated by the commissioner through rules adopted   under Section 1460.005;                 (2)  the ranking, comparison, or evaluation:                       (A)     is disclosed to each affected physician at   least 45 days before the date the ranking, comparison, or   evaluation is released, published, or distributed to enrollees by   the health benefit plan issuer; and                       (B)     identifies which products or networks   offered by the health benefit plan issuer the ranking, comparison,   or evaluation will be used for; and                 (3)     each affected physician is given an easy-to-use   process to identify discrepancies between the standards and the   ranking, comparison, or evaluation as propagated by the health   benefit plan issuer [ the standards used by the health benefit plan   issuer conform to nationally recognized standards and guidelines as   required by rules adopted under Section 1460.005;                [ (2)     the standards and measurements to be used by the   health benefit plan issuer are disclosed to each affected physician   before any evaluation period used by the health benefit plan   issuer; and                [ (3)     each affected physician is afforded, before any   publication or other public dissemination, an opportunity to   dispute the ranking or classification through a process that, at a   minimum, includes due process protections that conform to the   following protections:                      [ (A)     the health benefit plan issuer provides at   least 45 days' written notice to the physician of the proposed   rating, ranking, tiering, or comparison, including the   methodologies, data, and all other information utilized by the   health benefit plan issuer in its rating, tiering, ranking, or   comparison decision;                      [ (B)     in addition to any written fair   reconsideration process, the health benefit plan issuer, upon a   request for review that is made within 30 days of receiving the   notice under Paragraph (A), provides a fair reconsideration   proceeding, at the physician's option:                            [ (i)     by teleconference, at an agreed upon   time; or                            [ (ii)     in person, at an agreed upon time or   between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;                      [ (C)     the physician has the right to provide   information at a requested fair reconsideration proceeding for   determination by a decision-maker, have a representative   participate in the fair reconsideration proceeding, and submit a   written statement at the conclusion of the fair reconsideration   proceeding; and                      [ (D)     the health benefit plan issuer provides a   written communication of the outcome of a fair reconsideration   proceeding prior to any publication or dissemination of the rating,   ranking, tiering, or comparison.   The written communication must   include the specific reasons for the final decision ].           (a-1)     If a physician submits information to a health benefit   plan issuer under Subsection (a)(3) sufficient to establish a   discrepancy, the health benefit plan issuer must remedy the   discrepancy by the later of:                 (1)  publication; or                 (2)     the 30th day after the date the health benefit plan   issuer receives the information.          SECTION 5.  Section 1460.005(c), Insurance Code, is amended   to read as follows:          (c)  In adopting rules under this section, the commissioner   may only designate [ shall consider the standards, guidelines, and   measures prescribed by nationally recognized ] organizations that   meet the following requirements:                 (1)     the prescribing organization is bona fide and   unbiased toward or against any medical provider;                 (2)     the standards to be used in rankings, comparisons,   or evaluations:                       (A)     are nationally recognized, or based on   expert-provider consensus or leading clinical evidence-based   scholarship;                       (B)  have a publicly transparent methodology; and                       (C)     if based on clinical outcomes, are   risk-adjusted; and                 (3)     the prescribing organization has an easy-to-use   process by which a medical provider may report data, evidentiary,   factual, or mathematical errors for prompt investigation and, if   appropriate, correction [ establish or promote guidelines and   performance measures emphasizing quality of health care, including   the National Quality Forum and the AQA Alliance. If neither the   National Quality Forum nor the AQA Alliance has established   standards or guidelines regarding an issue, the commissioner shall   consider the standards, guidelines, and measures prescribed by the   National Committee on Quality Assurance and other similar national   organizations. If neither the National Quality Forum, nor the AQA   Alliance, nor other national organizations have established   standards or guidelines regarding an issue, the commissioner shall   consider standards, guidelines, and measures based on other bona   fide nationally recognized guidelines, expert-based physician   consensus quality standards, or leading objective clinical   evidence and scholarship ].          SECTION 6.  This Act takes effect September 1, 2025.