HB3140 - Relating to network adequacy standards for preferred provider benefit plans.

  89R8049 SCF-F     By: Lopez of Cameron H.B. No. 3140       A BILL TO BE ENTITLED   AN ACT   relating to network adequacy standards for preferred provider   benefit plans.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Section 1301.0055, Insurance Code, is amended by   amending Subsections (a) and (b) and adding Subsection (d) to read   as follows:          (a)  The commissioner shall by rule adopt network adequacy   standards that:                (1)  require an insurer offering a preferred provider   benefit plan to:                      (A)  monitor compliance with network adequacy   standards, including provisions of this chapter relating to network   adequacy, on an ongoing basis, reporting any material deviation   from network adequacy standards to the department within 30 days of   the date the material deviation occurred; and                      (B)  promptly take any corrective action required   to ensure that the network is compliant not later than the 90th day   after the date the material deviation occurred unless:                            (i)  there are no uncontracted licensed   physicians or health care providers in the affected county; or                            (ii)  the insurer requests a waiver under   this subsection;                (2)  ensure availability of, and accessibility to, a   full range of contracted physicians and health care providers to   provide current and projected utilization of health care services   for adult and minor insureds;                (3)  may allow a waiver for a departure from network   adequacy standards for a period not to exceed one year if the   commissioner determines [ after receiving public testimony at a   public hearing under Section 1301.00565 ] that good cause is shown   and posts on the department's Internet website the name of the   preferred provider benefit plan, the insurer offering the plan,   each affected county, the specific network adequacy standards   waived, and the insurer's access plan;                (4)  require disclosure by the insurer of the   information described by Subdivision (3) in all promotion and   advertisement of the preferred provider benefit plan for which a   waiver is allowed under that subdivision; and                (5)  [ except as provided by Subdivision (6), limit a   waiver from being issued to a preferred provider benefit plan:                      [ (A)     more than twice consecutively for the same   network adequacy standard in the same county unless the insurer   demonstrates, in addition to the good cause described by   Subdivision (3), multiple good faith attempts to bring the plan   into compliance with the network adequacy standard during each of   the prior consecutive waiver periods; or                      [ (B)     more than a total of four times within a   21-year period for each county in a service area for issues that may   be remedied through good faith efforts; and                [ (6) ]  authorize the commissioner to issue a waiver   [ that would otherwise be unavailable under Subdivision (5) ] if the   waiver request demonstrates, and the department confirms annually,   that there are no uncontracted physicians or health care providers   in the area to meet the specific standard for a county in a service   area.          (b)  The standards described by Subsection (a)(2) must   include factors regarding time and [ , ] distance[ , and appointment   availability ]. The factors must:                (1)  require that all insureds are able to receive an   appointment with a preferred provider within the maximum travel   times and distances established under Sections 1301.00553 and   1301.00554;                (2)  [ require that all insureds are able to receive an   appointment with a preferred provider within the maximum   appointment wait times established under Section 1301.00555;                [ (3) ]  require a preferred provider benefit plan to   ensure sufficient choice, access, and quality of physicians and   health care providers, in number, size, and geographic   distribution, to be capable of providing the health care services   covered by the plan from preferred providers to at least 75 percent   of [ all ] insureds within the insurer's designated service area,   taking into account the insureds' characteristics, medical   conditions, and health care needs, including:                      (A)  the current utilization of covered health   care services within the counties of the service area; and                      (B)  an actuarial projection of utilization of   covered health care services, physicians, and health care providers   needed within the counties of the service area to meet the needs of   the number of projected insureds;                 (3)  [ (4) ]  require a sufficient number of preferred   providers of emergency medicine, anesthesiology, pathology,   radiology, neonatology, oncology, including medical, surgical, and   radiation oncology, surgery, and hospitalist, intensivist, and   diagnostic services, including radiology and laboratory services,   at each preferred hospital, ambulatory surgical center, or   freestanding emergency medical care facility that credentials the   particular specialty to ensure at least 75 percent of [ all ]   insureds are able to receive covered benefits, including access to   clinical trials covered by the health benefit plan, at that   preferred location;                 (4)  [ (5) ]  require that all insureds have the ability   to access a preferred institutional provider listed in Section   1301.00553 within the maximum travel times and distances   established under Section 1301.00553 for the corresponding county   classification;                 (5)  [ (6) ]  require that insureds have the option of   facilities, if available, of pediatric, for-profit, nonprofit, and   tax-supported institutions, with special consideration to   contracting with:                      (A)  teaching hospitals that provide indigent   care or care for uninsured individuals as a significant percentage   of their overall patient load; and                      (B)  teaching facilities that specialize in   providing care for rare and complex medical conditions and   conducting clinical trials;                 (6)  [ (7) ]  require that there is an adequate number of   preferred provider physicians who have admitting privileges at one   or more preferred provider hospitals located within the insurer's   designated service area to make any necessary hospital admissions;                 (7)  [ (8) ]  provide for necessary hospital services by   requiring  contracting with general, pediatric, specialty, and   psychiatric hospitals on a preferred benefit basis within the   insurer's designated service area, as applicable;                 (8)  [ (9) ]  ensure that emergency care, as defined by   Section 1301.155, is available and accessible 24 hours a day, seven   days a week, by preferred providers;                 (9)  [ (10) ]  ensure that covered urgent care is   available and accessible from preferred providers within the   insurer's designated service area within 24 hours for medical and   behavioral health conditions;                 (10)  [ (11) ]  require an adequate number of preferred   providers to be available and accessible to insureds 24 hours a day,   seven days a week, within the insurer's designated service area;   and                 (11)  [ (12) ]  require sufficient numbers and classes of   preferred providers to ensure choice, access, and quality of care   across the insurer's designated service area.           (d)     For the purposes of this section, a preferred provider   within the time and distance requirements of Section 1301.00553 is   considered part of the network adequacy calculation, regardless of   whether the provider's office is located in a different county than   the insured or outside the insurer's service area.          SECTION 2.  Sections 1301.00553(c), (d), (e), (f), and (g),   Insurance Code, are amended to read as follows:          (c)  Maximum travel time in minutes and maximum distance in   miles for preferred provider benefit plans by preferred provider   type for each large metro county are:                (1)  for the following physicians, as designated by   physician specialty:   Time Distance   Allergy and Immunology 40  [ 30 ] 20  [ 15 ]   Cardiology 30  [ 20 ] 15  [ 10 ]   Cardiothoracic Surgery 40  [ 30 ] 20  [ 15 ]   Dermatology 30  [ 20 ] 15  [ 10 ]   Emergency Medicine 30  [ 20 ] 15  [ 10 ]   Endocrinology 40  [ 30 ] 20  [ 15 ]   Ear, Nose, and Throat/Otolaryngology 40  [ 30 ] 20  [ 15 ]   Gastroenterology 30  [ 20 ] 15  [ 10 ]   General Surgery 30  [ 20 ] 15  [ 10 ]   Gynecology and Obstetrics 20  [ 10 ] 10  [ 5 ]   Infectious Diseases 40  [ 30 ] 20  [ 15 ]   Nephrology 40  [ 30 ] 20  [ 15 ]   Neurology 30  [ 20 ] 15  [ 10 ]   Neurosurgery 40  [ 30 ] 20  [ 15 ]   Oncology: Medical, Surgical 30  [ 20 ] 15  [ 10 ]   Oncology: Radiation 40  [ 30 ] 20  [ 15 ]   Ophthalmology 30  [ 20 ] 15  [ 10 ]   Orthopedic Surgery 30  [ 20 ] 15  [ 10 ]   Physical Medicine and Rehabilitation 40  [ 30 ] 20  [ 15 ]   Plastic Surgery 40  [ 30 ] 20  [ 15 ]   Primary Care: Adults 20  [ 10 ] 10  [ 5 ]   Primary Care: Pediatric 20  [ 10 ] 10  [ 5 ]   Psychiatry 30  [ 20 ] 15  [ 10 ]   Pulmonology 30  [ 20 ] 15  [ 10 ]   Rheumatology 40  [ 30 ] 20  [ 15 ]   Urology 30  [ 20 ] 15  [ 10 ]   Vascular Surgery 40  [ 30 ] 20  [ 15 ]                (2)  for health care practitioners in the following   disciplines:   Time Distance   Chiropractic 40  [ 30 ] 20  [ 15 ]   Occupational Therapy 30  [ 20 ] 15  [ 10 ]   Physical Therapy 30  [ 20 ] 15  [ 10 ]   Podiatry 30  [ 20 ] 15  [ 10 ]   Speech Therapy 30  [ 20 ] 15  [ 10 ]                (3)  for the following types of institutional   providers:   Time Distance   Acute Inpatient Hospitals (Emergency Services Available 24/7) 30  [ 20 ] 15  [ 10 ]   Acute Inpatient Hospitals (Emergency Services Available 24/7) 30  [ 20 ] 15  [ 10 ]   Cardiac Catheterization Services 40  [ 30 ] 20  [ 15 ]   Cardiac Surgery Program 40  [ 30 ] 20  [ 15 ]   Critical Care Services: Intensive Care Units 30  [ 20 ] 15  [ 10 ]   Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 30  [ 20 ] 15  [ 10 ]   Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology) 30  [ 20 ] 15  [ 10 ]   Diagnostic Radiology (Freestanding; Hospi [Text truncated for display. 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