Lopez Network Bill Stretches Drive Times, Drops The Wait-Time Standard

The text as introduced · 4,698 words

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; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
30 [ 20 ]
15 [ 10 ]

Inpatient or Residential Behavioral Health Facility Services
40 [ 30 ]
20 [ 15 ]

Inpatient or Residential Behavioral Health Facility Services
40 [ 30 ]
20 [ 15 ]

Mammography
30 [ 20 ]
15 [ 10 ]

Outpatient Infusion/Chemotherapy
30 [ 20 ]
15 [ 10 ]

Skilled Nursing Facilities
30 [ 20 ]
15 [ 10 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
30 [ 20 ]
15 [ 10 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
30 [ 20 ]
15 [ 10 ]

(4) for the following settings:

Time
Distance

Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified)
20 [ 10 ]
10 [ 5 ]

Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified)
20 [ 10 ]
10 [ 5 ]

Urgent Care
30 [ 20 ]
15 [ 10 ]

(d) Maximum travel time in minutes and maximum distance in

miles for preferred provider benefit plans by preferred provider

type for each metro county are:

(1) for the following physicians, as designated by

physician specialty:

Time
Distance

Allergy and Immunology
60 [ 45 ]
40 [ 30 ]

Cardiology
45 [ 30 ]
30 [ 20 ]

Cardiothoracic Surgery
75 [ 60 ]
50 [ 40 ]

Dermatology
60 [ 45 ]
40 [ 30 ]

Emergency Medicine
60 [ 45 ]
40 [ 30 ]

Endocrinology
75 [ 60 ]
50 [ 40 ]

Ear, Nose, and Throat/Otolaryngology
60 [ 45 ]
40 [ 30 ]

Gastroenterology
60 [ 45 ]
40 [ 30 ]

General Surgery
45 [ 30 ]
30 [ 20 ]

Gynecology and Obstetrics
30 [ 15 ]
20 [ 10 ]

Infectious Diseases
75 [ 60 ]
50 [ 40 ]

Nephrology
60 [ 45 ]
40 [ 30 ]

Neurology
60 [ 45 ]
40 [ 30 ]

Neurosurgery
75 [ 60 ]
50 [ 40 ]

Oncology: Medical, Surgical
60 [ 45 ]
40 [ 30 ]

Oncology: Radiation
75 [ 60 ]
50 [ 40 ]

Ophthalmology
45 [ 30 ]
30 [ 20 ]

Orthopedic Surgery
45 [ 30 ]
30 [ 20 ]

Physical Medicine and Rehabilitation
60 [ 45 ]
40 [ 30 ]

Plastic Surgery
75 [ 60 ]
50 [ 40 ]

Primary Care: Adults
30 [ 15 ]
20 [ 10 ]

Primary Care: Pediatric
30 [ 15 ]
20 [ 10 ]

Psychiatry
60 [ 45 ]
40 [ 30 ]

Pulmonology
60 [ 45 ]
40 [ 30 ]

Rheumatology
75 [ 60 ]
50 [ 40 ]

Urology
60 [ 45 ]
40 [ 30 ]

Vascular Surgery
75 [ 60 ]
50 [ 40 ]

(2) for health care practitioners in the following

disciplines:

Time
Distance

Chiropractic
60 [ 45 ]
40 [ 30 ]

Occupational Therapy
60 [ 45 ]
40 [ 30 ]

Physical Therapy
60 [ 45 ]
40 [ 30 ]

Podiatry
60 [ 45 ]
40 [ 30 ]

Speech Therapy
60 [ 45 ]
40 [ 30 ]

(3) for the following types of institutional

providers:

Time
Distance

Acute Inpatient Hospitals (Emergency Services Available 24/7)
60 [ 45 ]
40 [ 30 ]

Acute Inpatient Hospitals (Emergency Services Available 24/7)
60 [ 45 ]
40 [ 30 ]

Cardiac Catheterization Services
75 [ 60 ]
50 [ 40 ]

Cardiac Surgery Program
75 [ 60 ]
50 [ 40 ]

Critical Care Services: Intensive Care Units
60 [ 45 ]
40 [ 30 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
60 [ 45 ]
40 [ 30 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
60 [ 45 ]
40 [ 30 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
60 [ 45 ]
40 [ 30 ]

Inpatient or Residential Behavioral Health Facility Services
85 [ 70 ]
55 [ 45 ]

Inpatient or Residential Behavioral Health Facility Services
85 [ 70 ]
55 [ 45 ]

Mammography
60 [ 45 ]
40 [ 30 ]

Outpatient Infusion/Chemotherapy
60 [ 45 ]
40 [ 30 ]

Skilled Nursing Facilities
60 [ 45 ]
40 [ 30 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
60 [ 45 ]
40 [ 30 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
60 [ 45 ]
40 [ 30 ]

(4) for the following settings:

Time
Distance

Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified)
30 [ 15 ]
20 [ 10 ]

Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified)
30 [ 15 ]
20 [ 10 ]

Urgent Care
60 [ 45 ]
40 [ 30 ]

(e) Maximum travel time in minutes and maximum distance in

miles for preferred provider benefit plans by preferred provider

type for each micro county are:

(1) for the following physicians, as designated by

physician specialty:

Time
Distance

Allergy and Immunology
110 [ 80 ]
80 [ 60 ]

Cardiology
80 [ 50 ]
55 [ 35 ]

Cardiothoracic Surgery
130 [ 100 ]
95 [ 75 ]

Dermatology
90 [ 60 ]
65 [ 45 ]

Emergency Medicine
110 [ 80 ]
80 [ 60 ]

Endocrinology
130 [ 100 ]
95 [ 75 ]

Ear, Nose, and Throat/Otolaryngology
110 [ 80 ]
80 [ 60 ]

Gastroenterology
90 [ 60 ]
65 [ 45 ]

General Surgery
80 [ 50 ]
55 [ 35 ]

Gynecology and Obstetrics
60 [ 30 ]
40 [ 20 ]

Infectious Diseases
130 [ 100 ]
95 [ 75 ]

Nephrology
110 [ 80 ]
80 [ 60 ]

Neurology
90 [ 60 ]
65 [ 45 ]

Neurosurgery
130 [ 100 ]
95 [ 75 ]

Oncology: Medical, Surgical
90 [ 60 ]
65 [ 45 ]

Oncology: Radiation
130 [ 100 ]
95 [ 75 ]

Ophthalmology
80 [ 50 ]
55 [ 35 ]

Orthopedic Surgery
80 [ 50 ]
55 [ 35 ]

Physical Medicine and Rehabilitation
110 [ 80 ]
80 [ 60 ]

Plastic Surgery
130 [ 100 ]
95 [ 75 ]

Primary Care: Adults
60 [ 30 ]
40 [ 20 ]

Primary Care: Pediatric
60 [ 30 ]
40 [ 20 ]

Psychiatry
90 [ 60 ]
65 [ 45 ]

Pulmonology
90 [ 60 ]
65 [ 45 ]

Rheumatology
130 [ 100 ]
95 [ 75 ]

Urology
90 [ 60 ]
65 [ 45 ]

Vascular Surgery
130 [ 100 ]
95 [ 75 ]

(2) for health care practitioners in the following

disciplines:

Time
Distance

Chiropractic
110 [ 80 ]
80 [ 60 ]

Occupational Therapy
110 [ 80 ]
80 [ 60 ]

Physical Therapy
110 [ 80 ]
80 [ 60 ]

Podiatry
90 [ 60 ]
65 [ 45 ]

Speech Therapy
110 [ 80 ]
80 [ 60 ]

(3) for the following types of institutional

providers:

Time
Distance

Acute Inpatient Hospitals (Emergency Services Available 24/7)
110 [ 80 ]
80 [ 60 ]

Acute Inpatient Hospitals (Emergency Services Available 24/7)
110 [ 80 ]
80 [ 60 ]

Cardiac Catheterization Services
190 [ 160 ]
140 [ 120 ]

Cardiac Surgery Program
190 [ 160 ]
140 [ 120 ]

Critical Care Services: Intensive Care Units
190 [ 160 ]
140 [ 120 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
110 [ 80 ]
80 [ 60 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
110 [ 80 ]
80 [ 60 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
110 [ 80 ]
80 [ 60 ]

Inpatient or Residential Behavioral Health Facility Services
130 [ 100 ]
95 [ 75 ]

Inpatient or Residential Behavioral Health Facility Services
130 [ 100 ]
95 [ 75 ]

Mammography
110 [ 80 ]
80 [ 60 ]

Outpatient Infusion/Chemotherapy
110 [ 80 ]
80 [ 60 ]

Skilled Nursing Facilities
110 [ 80 ]
80 [ 60 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
110 [ 80 ]
80 [ 60 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
110 [ 80 ]
80 [ 60 ]

(4) for the following settings:

Time
Distance

Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified)
60 [ 30 ]
40 [ 20 ]

Outpatient Clinical Behavioral Health (Licensed, Accredited, or Certified)
60 [ 30 ]
40 [ 20 ]

Urgent Care
110 [ 80 ]
80 [ 60 ]

(f) Maximum travel time in minutes and maximum distance in

miles for preferred provider benefit plans by preferred provider

type for each rural county are:

(1) for the following physicians, as designated by

physician specialty:

Time
Distance

Allergy and Immunology
120 [ 90 ]
95 [ 75 ]

Cardiology
105 [ 75 ]
80 [ 60 ]

Cardiothoracic Surgery
140 [ 110 ]
110 [ 90 ]

Dermatology
105 [ 75 ]
80 [ 60 ]

Emergency Medicine
105 [ 75 ]
80 [ 60 ]

Endocrinology
140 [ 110 ]
110 [ 90 ]

Ear, Nose, and Throat/Otolaryngology
120 [ 90 ]
95 [ 75 ]

Gastroenterology
105 [ 75 ]
80 [ 60 ]

General Surgery
105 [ 75 ]
80 [ 60 ]

Gynecology and Obstetrics
70 [ 40 ]
50 [ 30 ]

Infectious Diseases
140 [ 110 ]
110 [ 90 ]

Nephrology
120 [ 90 ]
95 [ 75 ]

Neurology
105 [ 75 ]
80 [ 60 ]

Neurosurgery
140 [ 110 ]
110 [ 90 ]

Oncology: Medical, Surgical
105 [ 75 ]
80 [ 60 ]

Oncology: Radiation
140 [ 110 ]
110 [ 90 ]

Ophthalmology
105 [ 75 ]
80 [ 60 ]

Orthopedic Surgery
105 [ 75 ]
80 [ 60 ]

Physical Medicine and Rehabilitation
120 [ 90 ]
95 [ 75 ]

Plastic Surgery
140 [ 110 ]
110 [ 90 ]

Primary Care: Adults
70 [ 40 ]
50 [ 30 ]

Primary Care: Pediatric
70 [ 40 ]
50 [ 30 ]

Psychiatry
105 [ 75 ]
80 [ 60 ]

Pulmonology
105 [ 75 ]
80 [ 60 ]

Rheumatology
140 [ 110 ]
110 [ 90 ]

Urology
105 [ 75 ]
80 [ 60 ]

Vascular Surgery
140 [ 110 ]
110 [ 90 ]

(2) for health care practitioners in the following

disciplines:

Time
Distance

Chiropractic
120 [ 90 ]
95 [ 75 ]

Occupational Therapy
105 [ 75 ]
80 [ 60 ]

Physical Therapy
105 [ 75 ]
80 [ 60 ]

Podiatry
105 [ 75 ]
80 [ 60 ]

Speech Therapy
105 [ 75 ]
80 [ 60 ]

(3) for the following types of institutional

providers:

Time
Distance

Acute Inpatient Hospitals (Emergency Services Available 24/7)
105 [ 75 ]
80 [ 60 ]

Acute Inpatient Hospitals (Emergency Services Available 24/7)
105 [ 75 ]
80 [ 60 ]

Cardiac Catheterization Services
175 [ 145 ]
140 [ 120 ]

Cardiac Surgery Program
175 [ 145 ]
140 [ 120 ]

Critical Care Services: Intensive Care Units
175 [ 145 ]
140 [ 120 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
105 [ 75 ]
80 [ 60 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
105 [ 75 ]
80 [ 60 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
105 [ 75 ]
80 [ 60 ]

Inpatient or Residential Behavioral Health Facility Services
120 [ 90 ]
95 [ 75 ]

Inpatient or Residential Behavioral Health Facility Services
120 [ 90 ]
95 [ 75 ]

Mammography
105 [ 75 ]
80 [ 60 ]

Outpatient Infusion/Chemotherapy
105 [ 75 ]
80 [ 60 ]

Skilled Nursing Facilities
105 [ 75 ]
80 [ 60 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
105 [ 75 ]
80 [ 60 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
105 [ 75 ]
80 [ 60 ]

(4) for the following settings:

Time
Distance

Outpatient Clinical Behavioral

Health (Licensed, Accredited, or Certified)
70 [ 40 ]
50 [ 30 ]

Urgent Care
105 [ 75 ]
80 [ 60 ]

(g) Maximum travel time in minutes and maximum distance in

miles for preferred provider benefit plans by preferred provider

type for each county with extreme access considerations are:

(1) for the following physicians, as designated by

physician specialty:

Time
Distance

Allergy and Immunology
155 [ 125 ]
140 [ 110 ]

Cardiology
125 [ 95 ]
115 [ 85 ]

Cardiothoracic Surgery
175 [ 145 ]
160 [ 130 ]

Dermatology
140 [ 110 ]
130 [ 100 ]

Emergency Medicine
140 [ 110 ]
130 [ 100 ]

Endocrinology
175 [ 145 ]
160 [ 130 ]

Ear, Nose, and Throat/Otolaryngology
155 [ 125 ]
140 [ 110 ]

Gastroenterology
140 [ 110 ]
130 [ 100 ]

General Surgery
125 [ 95 ]
115 [ 85 ]

Gynecology and Obstetrics
100 [ 70 ]
90 [ 60 ]

Infectious Diseases
175 [ 145 ]
160 [ 130 ]

Nephrology
155 [ 125 ]
140 [ 110 ]

Neurology
140 [ 110 ]
130 [ 100 ]

Neurosurgery
175 [ 145 ]
160 [ 130 ]

Oncology: Medical, Surgical
140 [ 110 ]
130 [ 100 ]

Oncology: Radiation
175 [ 145 ]
160 [ 130 ]

Ophthalmology
125 [ 95 ]
115 [ 85 ]

Orthopedic Surgery
125 [ 95 ]
115 [ 85 ]

Physical Medicine and Rehabilitation
155 [ 125 ]
140 [ 110 ]

Plastic Surgery
175 [ 145 ]
160 [ 130 ]

Primary Care: Adults
100 [ 70 ]
90 [ 60 ]

Primary Care: Pediatric
100 [ 70 ]
90 [ 60 ]

Psychiatry
140 [ 110 ]
130 [ 100 ]

Pulmonology
140 [ 110 ]
130 [ 100 ]

Rheumatology
175 [ 145 ]
160 [ 130 ]

Urology
140 [ 110 ]
130 [ 100 ]

Vascular Surgery
175 [ 145 ]
160 [ 130 ]

(2) for health care practitioners in the following

disciplines:

Time
Distance

Chiropractic
155 [ 125 ]
140 [ 110 ]

Occupational Therapy
140 [ 110 ]
130 [ 100 ]

Physical Therapy
140 [ 110 ]
130 [ 100 ]

Podiatry
140 [ 110 ]
130 [ 100 ]

Speech Therapy
140 [ 110 ]
130 [ 100 ]

(3) for the following institutional providers:

Time
Distance

Acute Inpatient Hospitals (Emergency Services Available 24/7)
140 [ 110 ]
130 [ 100 ]

Acute Inpatient Hospitals (Emergency Services Available 24/7)
140 [ 110 ]
130 [ 100 ]

Cardiac Catheterization Services
185 [ 155 ]
170 [ 140 ]

Cardiac Surgery Program
185 [ 155 ]
170 [ 140 ]

Critical Care Services: Intensive Care Units
185 [ 155 ]
170 [ 140 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
140 [ 110 ]
130 [ 100 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
140 [ 110 ]
130 [ 100 ]

Diagnostic Radiology (Freestanding; Hospital Outpatient; Ambulatory Health Facilities with Diagnostic Radiology)
140 [ 110 ]
130 [ 100 ]

Inpatient or Residential Behavioral Health Facility Services
185 [ 155 ]
170 [ 140 ]

Inpatient or Residential Behavioral Health Facility Services
185 [ 155 ]
170 [ 140 ]

Mammography
140 [ 110 ]
130 [ 100 ]

Outpatient Infusion/Chemotherapy
140 [ 110 ]
130 [ 100 ]

Skilled Nursing Facilities
125 [ 95 ]
115 [ 85 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
140 [ 110 ]
130 [ 100 ]

Surgical Services (Outpatient or Ambulatory Surgical Center)
140 [ 110 ]
130 [ 100 ]

(4) for the following settings:

Time
Distance

Outpatient Clinical Behavioral

Health (Licensed, Accredited, or Certified)
100 [ 70 ]
90 [ 60 ]

Urgent Care
140 [ 110 ]
130 [ 100 ]

SECTION 3. Section 1301.0056(a-1), Insurance Code, is

amended to read as follows:

(a-1) An insurer is subject to a qualifying examination of

the insurer's preferred provider benefit plans and subsequent

quality of care and network adequacy examinations by the

commissioner at least once every three years[ , in connection with a

public hearing under Section 1301.00565 concerning a material

deviation from network adequacy standards by a previously

authorized plan or a request for a waiver of a network adequacy

standard, ] and whenever the commissioner considers an examination

necessary. Documentation provided to the commissioner during an

examination conducted under this section is confidential and is not

subject to disclosure as public information under Chapter 552,

Government Code.

SECTION 4. Section 1301.009(b), Insurance Code, is amended

to read as follows:

(b) The report shall:

(1) be verified by at least two principal officers;

(2) be in a form prescribed by the commissioner; and

(3) include:

(A) a financial statement of the insurer,

including its balance sheet and receipts and disbursements for the

preceding calendar year, certified by an independent public

accountant;

(B) the number of individuals enrolled during the

preceding calendar year, the number of enrollees as of the end of

that year, and the number of enrollments terminated during that

year; and

(C) a statement of:

(i) an evaluation of enrollee satisfaction;

(ii) an evaluation of quality of care;

(iii) coverage areas;

(iv) accreditation status;

(v) premium costs;

(vi) plan costs;

(vii) premium increases;

(viii) the range of benefits provided;

(ix) copayments and deductibles;

(x) the accuracy and speed of claims

payment by the insurer for the plan;

(xi) the credentials of physicians who are

preferred providers;

(xii) the number of preferred providers;

(xiii) any waiver requests made and waivers

of network adequacy standards granted under Section 1301.0055

[ 1301.00565 ];

(xiv) any material deviation from network

adequacy standards reported to the department under Section

1301.0055; and

(xv) any corrective actions, sanctions, or

penalties assessed against the insurer by the department for

deficiencies related to the preferred provider benefit plan.

SECTION 5. Sections 1301.00555 and 1301.00565, Insurance

Code, are repealed.

SECTION 6. The changes in law made by this Act apply only to

an insurance policy that is delivered, issued for delivery, or

renewed on or after January 1, 2026. A policy delivered, issued

for delivery, or renewed before January 1, 2026, 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 7. This Act takes effect September 1, 2025.