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A BILL TO BE ENTITLED
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AN ACT
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relating to the relationship between a physician or health care |
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provider and a health maintenance organization or insurer. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 101.055(a), Insurance Code, is amended |
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to read as follows: |
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(a) Section 101.051(b)(7) does not apply to: |
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(1) a program otherwise authorized by law that is |
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established: |
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(A) by a political subdivision of this state; |
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(B) by a state agency; or |
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(C) under Chapter 791, Government Code; [or] |
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(2) a multiple employer welfare arrangement that is |
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fully insured as defined by 29 U.S.C. Section 1144(b)(6); or |
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(3) a self-funded employee welfare benefit plan that |
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accesses a value-based risk sharing contract arrangement entered |
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into by an authorized health insurer or health maintenance |
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organization and a health care provider or group of health care |
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providers. |
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SECTION 2. Subchapter I, Chapter 843, Insurance Code, is |
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amended by adding Section 843.322 to read as follows: |
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Sec. 843.322. INCENTIVES TO USE CERTAIN PHYSICIANS OR |
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PROVIDERS. A health maintenance organization may provide |
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incentives for enrollees to use certain physicians or providers |
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through modified deductibles, copayments, coinsurance, or other |
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cost-sharing provisions. |
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SECTION 3. Section 1301.0045(a), Insurance Code, is amended |
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to read as follows: |
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(a) Except as provided by Sections [Section] 1301.0046 and |
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1301.0047, this chapter may not be construed to limit the level of |
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reimbursement or the level of coverage, including deductibles, |
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copayments, coinsurance, or other cost-sharing provisions, that |
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are applicable to preferred providers or, for plans other than |
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exclusive provider benefit plans, nonpreferred providers. |
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SECTION 4. Subchapter A, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.0047 to read as follows: |
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Sec. 1301.0047. INCENTIVES TO USE CERTAIN PHYSICIANS OR |
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HEALTH CARE PROVIDERS. An insurer may provide incentives for |
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insureds to use certain physicians or health care providers through |
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modified deductibles, copayments, coinsurance, or other |
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cost-sharing provisions. |
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SECTION 5. Subchapter A, Chapter 1301, Insurance Code, is |
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amended by adding Section 1301.0065 to read as follows: |
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Sec. 1301.0065. COMPENSATION OF PHYSICIANS OR PROVIDERS |
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UNDER HEALTH CARE SERVICES ARRANGEMENTS. (a) A preferred provider |
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benefit plan may provide or arrange for health care services with a |
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physician or health care provider through a contract or |
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subcontract for compensation under: |
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(1) a fee-for-service arrangement; |
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(2) a risk-sharing arrangement; or |
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(3) a capitation arrangement under which a fixed |
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predetermined payment is made in exchange for the provision of, or |
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for the arrangement to provide and the guaranty of the provision of, |
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a defined set of covered services to covered persons for a |
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specified period without regard to the quantity of services |
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actually provided. |
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(b) A physician or health care provider that enters into a |
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contract or subcontract described by Subsection (a) is not |
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considered to be engaging in the business of insurance. |
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SECTION 6. This Act takes effect September 1, 2023. |