State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1460-standards-required-regarding-certain-physician-rankings-by-health-benefit-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1460. STANDARDS REQUIRED REGARDING CERTAIN PHYSICIAN

RANKINGS BY HEALTH BENEFIT PLANS

Sec. 1460.001. DEFINITIONS. In this chapter:

(1) "Health benefit plan issuer" means an entity authorized

under this code or another insurance law of this state that

provides health insurance or health benefits in this state,

including:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

(C) a health maintenance organization operating under Chapter

843; and

(D) a stipulated premium company operating under Chapter 884.

(2) "Physician" means an individual licensed to practice

medicine in this state or another state of the United States.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.002. EXEMPTION. This chapter does not apply to:

(1) a Medicaid managed care program operated under Chapter 533,

Government Code;

(2) a Medicaid program operated under Chapter 32, Human

Resources Code;

(3) the child health plan program under Chapter 62, Health and

Safety Code, or the health benefits plan for children under

Chapter 63, Health and Safety Code; or

(4) a Medicare supplement benefit plan, as defined by Chapter

1652.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.003. PHYSICIAN RANKING REQUIREMENTS. (a) A health

benefit plan issuer, including a subsidiary or affiliate, may not

rank physicians, 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 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.

(b) This section does not apply to the publication of a list of

network physicians and providers if ratings or comparisons are

not made and the list is not a product of nor reflects the

tiering or classification of physicians or providers.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.004. DUTIES OF PHYSICIANS. A physician may not

require or request that a patient of the physician enter into an

agreement under which the patient agrees not to:

(1) rank or otherwise evaluate the physician;

(2) participate in surveys regarding the physician; or

(3) in any way comment on the patient's opinion of the

physician.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.005. RULES; STANDARDS. (a) The commissioner shall

adopt rules as necessary to implement this chapter.

(b) The commissioner shall adopt rules as necessary to ensure

that a health benefit plan issuer that uses a physician ranking

system complies with the standards and guidelines described by

Subsection (c).

(c) In adopting rules under this section, the commissioner shall

consider the standards, guidelines, and measures prescribed by

nationally recognized organizations that 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.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A health

benefit plan issuer shall ensure that:

(1) physicians currently in clinical practice are actively

involved in the development of the standards used under this

chapter; and

(2) the measures and methodology used in the comparison programs

described by Section 1460.003 are transparent and valid.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A health

benefit plan issuer that violates this chapter or a rule adopted

under this chapter is subject to sanctions and disciplinary

actions under Chapters 82 and 84.

(b) A violation of this chapter by a physician constitutes

grounds for disciplinary action by the Texas Medical Board,

including imposition of an administrative penalty.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1460-standards-required-regarding-certain-physician-rankings-by-health-benefit-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1460. STANDARDS REQUIRED REGARDING CERTAIN PHYSICIAN

RANKINGS BY HEALTH BENEFIT PLANS

Sec. 1460.001. DEFINITIONS. In this chapter:

(1) "Health benefit plan issuer" means an entity authorized

under this code or another insurance law of this state that

provides health insurance or health benefits in this state,

including:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

(C) a health maintenance organization operating under Chapter

843; and

(D) a stipulated premium company operating under Chapter 884.

(2) "Physician" means an individual licensed to practice

medicine in this state or another state of the United States.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.002. EXEMPTION. This chapter does not apply to:

(1) a Medicaid managed care program operated under Chapter 533,

Government Code;

(2) a Medicaid program operated under Chapter 32, Human

Resources Code;

(3) the child health plan program under Chapter 62, Health and

Safety Code, or the health benefits plan for children under

Chapter 63, Health and Safety Code; or

(4) a Medicare supplement benefit plan, as defined by Chapter

1652.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.003. PHYSICIAN RANKING REQUIREMENTS. (a) A health

benefit plan issuer, including a subsidiary or affiliate, may not

rank physicians, 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 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.

(b) This section does not apply to the publication of a list of

network physicians and providers if ratings or comparisons are

not made and the list is not a product of nor reflects the

tiering or classification of physicians or providers.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.004. DUTIES OF PHYSICIANS. A physician may not

require or request that a patient of the physician enter into an

agreement under which the patient agrees not to:

(1) rank or otherwise evaluate the physician;

(2) participate in surveys regarding the physician; or

(3) in any way comment on the patient's opinion of the

physician.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.005. RULES; STANDARDS. (a) The commissioner shall

adopt rules as necessary to implement this chapter.

(b) The commissioner shall adopt rules as necessary to ensure

that a health benefit plan issuer that uses a physician ranking

system complies with the standards and guidelines described by

Subsection (c).

(c) In adopting rules under this section, the commissioner shall

consider the standards, guidelines, and measures prescribed by

nationally recognized organizations that 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.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A health

benefit plan issuer shall ensure that:

(1) physicians currently in clinical practice are actively

involved in the development of the standards used under this

chapter; and

(2) the measures and methodology used in the comparison programs

described by Section 1460.003 are transparent and valid.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A health

benefit plan issuer that violates this chapter or a rule adopted

under this chapter is subject to sanctions and disciplinary

actions under Chapters 82 and 84.

(b) A violation of this chapter by a physician constitutes

grounds for disciplinary action by the Texas Medical Board,

including imposition of an administrative penalty.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.


State Codes and Statutes


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State Codes and Statutes

Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1460-standards-required-regarding-certain-physician-rankings-by-health-benefit-plans

INSURANCE CODE

TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES

SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS

CHAPTER 1460. STANDARDS REQUIRED REGARDING CERTAIN PHYSICIAN

RANKINGS BY HEALTH BENEFIT PLANS

Sec. 1460.001. DEFINITIONS. In this chapter:

(1) "Health benefit plan issuer" means an entity authorized

under this code or another insurance law of this state that

provides health insurance or health benefits in this state,

including:

(A) an insurance company;

(B) a group hospital service corporation operating under Chapter

842;

(C) a health maintenance organization operating under Chapter

843; and

(D) a stipulated premium company operating under Chapter 884.

(2) "Physician" means an individual licensed to practice

medicine in this state or another state of the United States.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.002. EXEMPTION. This chapter does not apply to:

(1) a Medicaid managed care program operated under Chapter 533,

Government Code;

(2) a Medicaid program operated under Chapter 32, Human

Resources Code;

(3) the child health plan program under Chapter 62, Health and

Safety Code, or the health benefits plan for children under

Chapter 63, Health and Safety Code; or

(4) a Medicare supplement benefit plan, as defined by Chapter

1652.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.003. PHYSICIAN RANKING REQUIREMENTS. (a) A health

benefit plan issuer, including a subsidiary or affiliate, may not

rank physicians, 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 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.

(b) This section does not apply to the publication of a list of

network physicians and providers if ratings or comparisons are

not made and the list is not a product of nor reflects the

tiering or classification of physicians or providers.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.004. DUTIES OF PHYSICIANS. A physician may not

require or request that a patient of the physician enter into an

agreement under which the patient agrees not to:

(1) rank or otherwise evaluate the physician;

(2) participate in surveys regarding the physician; or

(3) in any way comment on the patient's opinion of the

physician.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.005. RULES; STANDARDS. (a) The commissioner shall

adopt rules as necessary to implement this chapter.

(b) The commissioner shall adopt rules as necessary to ensure

that a health benefit plan issuer that uses a physician ranking

system complies with the standards and guidelines described by

Subsection (c).

(c) In adopting rules under this section, the commissioner shall

consider the standards, guidelines, and measures prescribed by

nationally recognized organizations that 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.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.006. DUTIES OF HEALTH BENEFIT PLAN ISSUER. A health

benefit plan issuer shall ensure that:

(1) physicians currently in clinical practice are actively

involved in the development of the standards used under this

chapter; and

(2) the measures and methodology used in the comparison programs

described by Section 1460.003 are transparent and valid.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.

Sec. 1460.007. SANCTIONS; DISCIPLINARY ACTIONS. (a) A health

benefit plan issuer that violates this chapter or a rule adopted

under this chapter is subject to sanctions and disciplinary

actions under Chapters 82 and 84.

(b) A violation of this chapter by a physician constitutes

grounds for disciplinary action by the Texas Medical Board,

including imposition of an administrative penalty.

Added by Acts 2009, 81st Leg., R.S., Ch.

652, Sec. 1, eff. September 1, 2009.


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