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A BILL TO BE ENTITLED
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AN ACT
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relating to the method of payment for certain health care and |
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certain contract provisions affecting health care reimbursement |
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rates. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Chapter 1204, Insurance Code, is amended by |
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adding Subchapter G to read as follows: |
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SUBCHAPTER G. DIRECT PAYMENT OF PHYSICIAN OR HEALTH CARE PROVIDER |
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Sec. 1204.301. DEFINITIONS. In this subchapter: |
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(1) "Enrollee" means an individual who is enrolled in |
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a health care plan or entitled to coverage under a health benefit |
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plan. |
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(2) "Health benefit plan" means an individual, group, |
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blanket, or franchise insurance policy, a group hospital service |
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contract, or a group subscriber contract or evidence of coverage |
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issued by a health maintenance organization, that provides benefits |
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for health care services. |
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(3) "Health care provider" means a person who provides |
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health care services under a license, certificate, registration, or |
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other similar evidence of regulation issued by this or another |
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state of the United States. |
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(4) "Health care service" means a service to diagnose, |
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prevent, alleviate, cure, or heal a human illness or injury that is |
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provided to a covered person by a physician or other health care |
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provider. |
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(5) "Physician" means an individual licensed to |
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practice medicine in this or another state of the United States. |
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Sec. 1204.302. APPLICABILITY TO CERTAIN PLANS. In addition |
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to the health benefit plans described by Section 1204.301, |
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notwithstanding any other law, this subchapter applies to: |
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(1) a basic coverage plan under Chapter 1551; |
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(2) a basic plan under Chapter 1575; |
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(3) a primary care coverage plan under Chapter 1579; |
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and |
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(4) a plan providing basic coverage under Chapter |
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1601. |
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Sec. 1204.303. PAYMENT IN LIEU OF CLAIM FOR BENEFITS; OTHER |
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DIRECT PAYMENTS. (a) A physician or health care provider may not |
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be prohibited from accepting directly from an enrollee full payment |
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for a health care service in lieu of submitting a claim to the |
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enrollee's health benefit plan. |
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(b) Notwithstanding Section 552.003 or any other law, the |
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charge for a health care service for which a physician or health |
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care provider accepts a payment as described by Subsection (a) or |
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from a patient without a health benefit plan may not exceed the |
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lowest contract rate for the health care service allowable under |
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any health benefit plan with respect to which the physician or |
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health care provider is a contracted, preferred, or participating |
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provider. |
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SECTION 2. Section 1458.001, Insurance Code, is amended by |
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adding Subdivision (5-a) to read as follows: |
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(5-a) "Most favored nation clause" means a provision |
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in a provider network contract that: |
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(A) prohibits or grants an option to prohibit: |
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(i) a provider from contracting with |
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another contracting entity to provide health care services at a |
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lower rate; or |
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(ii) a contracting entity from contracting |
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with another provider to provide health care services at a higher |
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rate; |
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(B) requires or grants an option to require: |
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(i) a provider to accept a lower rate for |
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health care services if the provider agrees with another |
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contracting entity to accept a lower rate for the services; or |
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(ii) a contracting entity to pay a higher |
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rate for health care services if the entity agrees with another |
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provider to pay a higher rate for the services; |
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(C) requires or grants an option to require |
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termination or renegotiation of an existing provider network |
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contract if: |
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(i) a provider agrees with another |
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contracting entity to accept a lower rate for providing health care |
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services; or |
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(ii) a contracting entity agrees with a |
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provider to pay a higher rate for health care services; or |
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(D) requires: |
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(i) a provider to disclose the provider's |
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contractual reimbursement rates with other contracting entities; |
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or |
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(ii) a contracting entity to disclose the |
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contracting entity's contractual reimbursement rates with other |
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providers. |
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SECTION 3. Section 1458.101, Insurance Code, is amended by |
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adding Subsection (g) to read as follows: |
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(g) A contracting entity may not: |
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(1) offer to a provider a provider network contract |
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that includes a most favored nation clause; |
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(2) enter into a provider network contract that |
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includes a most favored nation clause; or |
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(3) amend or renew an existing provider network |
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contract previously entered into with a provider so that the |
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contract as amended or renewed adds or retains a most favored nation |
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clause. |
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SECTION 4. This Act takes effect September 1, 2021. |