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.