bill lets the insurance counsel challenge thin plan networks

The text as introduced · 1,813 words

89R1174 MEW-F

By: Schwertner
S.B. No. 742

A BILL TO BE ENTITLED

AN ACT

relating to the adequacy and effectiveness of managed care plan

networks.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Section 108.002(9), Health and Safety Code, is

amended to read as follows:

(9) "Health benefit plan" means a plan provided by:

(A) a health maintenance organization;

(B) a preferred provider or exclusive provider

benefit plan issuer under Chapter 1301, Insurance Code; or

(C) [ (B) ] an approved nonprofit health

corporation that is certified under Section 162.001, Occupations

Code, and that holds a certificate of authority issued by the

commissioner of insurance under Chapter 844, Insurance Code.

SECTION 2. Section 501.001, Insurance Code, is amended to

read as follows:

Sec. 501.001. DEFINITIONS [ DEFINITION ]. In this chapter :

(1) "Managed care plan" means:

(A) a health maintenance organization plan

provided under Chapter 843;

(B) a preferred provider benefit plan, as defined

by Section 1301.001; or

(C) an exclusive provider benefit plan, as

defined by Section 1301.001.

(2) "Office" [ , "office" ] means the office of public

insurance counsel.

SECTION 3. Section 501.151, Insurance Code, is amended to

read as follows:

Sec. 501.151. POWERS AND DUTIES OF OFFICE. The office:

(1) may assess the impact of insurance rates, rules,

and forms on insurance consumers in this state; [ and ]

(2) shall advocate in the office's own name positions

determined by the public counsel to be most advantageous to a

substantial number of insurance consumers ;

(3) shall monitor the adequacy of networks offered by

managed care plans in this state by reviewing related filings,

applications, and requests, including filings, applications, and

requests related to access plans or waivers of network adequacy

requirements, for accuracy, accessibility of health care services,

and reasonable access to covered benefits; and

(4) may advocate for consumers in the office's own

name:

(A) positions to strengthen the overall adequacy

or oversight of networks offered by managed care plans in this

state; and

(B) positions to strengthen the adequacy or

oversight of a particular network offered by a managed care plan in

this state .

SECTION 4. Section 501.153, Insurance Code, is amended to

read as follows:

Sec. 501.153. AUTHORITY TO APPEAR, INTERVENE, OR INITIATE.

(a) The public counsel:

(1) may appear or intervene, as a party or otherwise,

as a matter of right before the commissioner or department on behalf

of insurance consumers, as a class, in matters involving:

(A) rates, rules, and forms affecting:

(i) property and casualty insurance;

(ii) title insurance;

(iii) credit life insurance;

(iv) credit accident and health insurance;

or

(v) any other line of insurance for which

the commissioner or department promulgates, sets, adopts, or

approves rates, rules, or forms;

(B) rules affecting life, health, or accident

insurance; [ or ]

(C) a managed care plan's ability to provide

accessible health care services and reasonable access to covered

benefits; or

(D) withdrawal of approval of policy forms:

(i) in proceedings initiated by the

department under Sections 1701.055 and 1701.057; or

(ii) if the public counsel presents

persuasive evidence to the department that the forms do not comply

with this code, a rule adopted under this code, or any other law;

(2) may initiate or intervene as a matter of right or

otherwise appear in a judicial proceeding involving or arising from

an action taken by an administrative agency in a proceeding in which

the public counsel previously appeared under the authority granted

by this chapter;

(3) may appear or intervene, as a party or otherwise,

as a matter of right on behalf of insurance consumers as a class in

any proceeding in which the public counsel determines that

insurance consumers are in need of representation, except that the

public counsel may not intervene in an enforcement or parens

patriae proceeding brought by the attorney general; [ and ]

(4) may appear or intervene before the commissioner or

department as a party or otherwise on behalf of small commercial

insurance consumers, as a class, in a matter involving rates,

rules, or forms affecting commercial insurance consumers, as a

class, in any proceeding in which the public counsel determines

that small commercial consumers are in need of representation ; and

(5) may file objections and request a hearing

regarding any application, filing, or request that a managed care

plan files with the department related to an access plan or waiver

of a network adequacy requirement, including an application,

filing, or request that is currently pending or that has already

been approved .

(b) To assist the office in determining whether to request a

hearing under Subsection (a)(5), the office is entitled to:

(1) review all relevant filings and information that a

managed care plan submits to the department, including

communications related to the filing; and

(2) communicate with a managed care plan regarding a

submission described by Subdivision (1).

(c) A matter described by Subsection (a)(5) is a contested

case that may be subject to informal disposition or heard by the

State Office of Administrative Hearings under Chapter 2001,

Government Code.

(d) Nothing in this chapter may be construed as authorizing

a managed care plan to request a waiver of network adequacy

requirements or to use an access plan unless otherwise authorized

by law or regulation.

SECTION 5. Section 501.154, Insurance Code, is amended to

read as follows:

Sec. 501.154. ACCESS TO INFORMATION. The public counsel:

(1) is entitled to the same access as a party, other

than department staff, to department records available in a

proceeding before the commissioner or department under the

authority granted to the public counsel by this chapter; [ and ]

(2) is entitled to obtain discovery under Chapter

2001, Government Code, of any nonprivileged matter that is relevant

to the subject matter involved in a proceeding or submission before

the commissioner or department as authorized by this chapter ; and

(3) is entitled to all filings, including any

attachments and supporting documentation, made by a managed care

plan relating to the adequacy of a network offered by the plan, and

any regulatory correspondence relating to the filings .

SECTION 6. Section 501.157, Insurance Code, is amended to

read as follows:

Sec. 501.157. PROHIBITED INTERVENTIONS OR APPEARANCES.

Except as otherwise provided by this code, the [ The ] public counsel

may not intervene or appear in:

(1) any proceeding or hearing before the commissioner

or department, or any other proceeding, that relates to approval or

consideration of an individual charter, license, certificate of

authority, acquisition, merger, or examination; or

(2) any proceeding concerning the solvency of an

individual insurer, a financial issue, a policy form, advertising,

or another regulatory issue affecting an individual insurer or

agent.

SECTION 7. Section 501.159, Insurance Code, is amended by

amending Subsection (a) and adding Subsections (a-1) and (a-2) to

read as follows:

(a) Notwithstanding this chapter, the office may submit

written comments to the commissioner and otherwise participate

regarding individual insurer filings :

(1) made under Chapters 2251 and 2301 relating to

insurance described by Subchapter B, Chapter 2301 ; or

(2) relating to the adequacy of a network offered by a

managed care plan, regardless of whether the filing is pending or

has already been approved .

(a-1) The office may comment on or otherwise participate

regarding the effect or implementation of a filing described by

Subsection (a)(2), including comments regarding concerns that a

managed care plan:

(1) is operating with an inadequate network in this

state;

(2) may be in violation of a network adequacy law or

regulation; or

(3) has an inaccurate provider network directory.

(a-2) For written comments filed with the department

regarding filings described by Subsection (a)(2), the department

shall:

(1) respond to the comments promptly and provide

updates to the office and the managed care plan regarding actions

taken by the department or other actions taken to address issues

raised in the comments; and

(2) consider conducting a targeted market conduct

examination under Chapter 751 or another form of investigation to

determine the existence and extent of potential violations.

SECTION 8. The heading to Subchapter F, Chapter 501,

Insurance Code, is amended to read as follows:

SUBCHAPTER F. DUTIES RELATING TO MANAGED CARE PLANS [ HEALTH

MAINTENANCE ORGANIZATIONS ]

SECTION 9. Section 501.251, Insurance Code, is amended to

read as follows:

Sec. 501.251. COMPARISON OF MANAGED CARE PLANS [ HEALTH

MAINTENANCE ORGANIZATIONS ]. (a) The office shall develop and

implement a system to compare and evaluate, on an objective basis,

the quality of care provided by , the adequacy of networks offered

by, and the performance of managed care plans [ health maintenance

organizations established under Chapter 843 ].

(b) In conducting comparisons under the system described by

Subsection (a), the office shall compare:

(1) health maintenance organizations to other health

maintenance organizations;

(2) preferred provider benefit plans to other

preferred provider benefit plans; and

(3) exclusive provider benefit plans to other

exclusive provider benefit plans.

(c) In developing the system, the office may use information

or data from a person, agency, organization, or governmental unit

that the office considers reliable.

SECTION 10. Section 501.252, Insurance Code, is amended to

read as follows:

Sec. 501.252. ANNUAL CONSUMER REPORT CARDS. (a) The office

shall develop and issue annual consumer report cards that identify

and compare, on an objective basis, managed care plans [ health

maintenance organizations in this state ].

(b) The consumer report cards required by Subsection (a)

shall:

(1) include comparisons of types of managed care plans

in the same manner as provided by Section 501.251(b); and

(2) at the discretion of the office, be staggered for

release throughout the year based on the type of managed care plan

that is the subject of the consumer report card.

(c) Notwithstanding Subsection (b)(2), all consumer report

cards for a particular type of managed care plan must be released at

the same time.

(d) The consumer report cards may be based on information or

data from any person, agency, organization, or governmental unit

that the office considers reliable.

(e) [ (b) ] The office may not endorse or recommend a specific

managed care [ health maintenance organization or ] plan, or

subjectively rate or rank managed care [ health maintenance

organizations or ] plans or managed care plan issuers , other than

through comparison and evaluation of objective criteria.

(f) [ (c) ] The office shall provide a copy of any consumer

report card on request on payment of a reasonable fee.

SECTION 11. It is the intent of the legislature to provide

the office of public insurance counsel with the flexibility to

establish a timeline for the implementation, development, and

initial issuance of annual consumer report cards under Section

501.252, Insurance Code, as amended by this Act, in a manner that

best uses current office of public insurance counsel resources.

SECTION 12. This Act takes effect September 1, 2025.