2023 Texas Statutes › Insurance Code › Title 8 - Health Insurance and Other Health Coverages › Subtitle D - Provider Plans › Chapter 1301 - Preferred Provider Benefit Plans › Subchapter A. General Provisions › Section 1301.0056. Examinations and Fees

Sec. 1301.0056.  EXAMINATIONS AND FEES.  (a)  The commissioner shall by rule adopt a process for the commissioner to examine a preferred provider benefit plan before an insurer offers the plan for delivery to insureds to determine whether the plan meets the quality of care and network adequacy standards of this chapter.  An insurer may not offer a preferred provider benefit plan or an exclusive provider benefit plan before the commissioner determines that the network meets the quality of care and network adequacy standards of this chapter or the insurer receives a waiver under Section 1301.0055.
(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.
(b)  An insurer examined under this section shall pay the cost of the examination in an amount determined by the commissioner.
(c)  The department shall collect an assessment in an amount determined by the commissioner from the insurer at the time of the examination to cover all expenses attributable directly to the examination, including the salaries and expenses of department employees and all reasonable expenses of the department necessary for the administration of this chapter.
(d)  The department shall deposit an assessment collected under this section to the credit of the account described by Section 401.156(a).  Money deposited under this subsection shall be used to pay the salaries and expenses of examiners and all other expenses relating to the examination of insurers under this section.
(e)  Rules adopted under this section must require insurers to provide access to or submit data or information necessary for the commissioner to evaluate and make a determination of compliance with quality of care and network adequacy standards.  The rules must require insurers to provide access to or submit data or information that includes:
(1)  a searchable and sortable database of network physicians and health care providers by national provider identifier, county, physician specialty, hospital privileges and credentials, and type of health care provider or licensure, as applicable;
(2)  actuarial data of current and projected number of insureds by county;
(3)  actuarial data of current and projected utilization of each preferred provider type listed in Section 1301.00553 and described by Section 1301.00554 by county; and
(4)  any other data or information considered necessary by the commissioner to make a determination to authorize the use of the preferred provider benefit plan in the most efficient and effective manner possible.
Added by Acts 2011, 82nd Leg., R.S., Ch. 288 (H.B. 1772), Sec. 9, eff. September 1, 2011.
Amended by:
Acts 2019, 86th Leg., R.S., Ch. 1316 (H.B. 3911), Sec. 1, eff. September 1, 2019.
Acts 2023, 88th Leg., R.S., Ch. 740 (H.B. 3359), Sec. 7, eff. September 1, 2023.