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A BILL TO BE ENTITLED
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AN ACT
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relating to method of payment for certain medical care and contract |
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arrangements. |
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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. AUTHORIZED PAYMENT BY ENROLLEES IN LIEU OF CLAIM FOR |
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BENEFITS |
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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 State. |
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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. AUTHORIZED PAYMENT IN LIEU OF CLAIM FOR |
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BENEFITS. (a) A physician or health care provider may not be |
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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 Insurance Code Section 552.003 or any |
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other law, the charge for a health care service for which a |
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physician or health care provider accepts a payment as described |
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Subsection (a) may not exceed the lowest contract rate for the |
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health care service allowable under any health benefit plan with |
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respect to which the physician or health care provider is a |
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contracted, preferred, or participating provider. |
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SECTION 2. Section 1458.001 , Insurance Code, is amended to |
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read as follows: |
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Sec. 1458.001. GENERAL DEFINITIONS. In this chapter: |
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(1) "Affiliate" means a person who, directly or |
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indirectly through one or more intermediaries, controls, is |
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controlled by, or is under common control with another person. |
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(2) "Contracting entity" means a person who: |
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(A) enters into a direct contract with a provider |
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for the delivery of health care services to covered individuals; |
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and |
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(B) in the ordinary course of business |
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establishes a provider network or networks for access by another |
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party. |
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(3) "Covered individual" means an individual who is |
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covered under a health benefit plan. |
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(4) "Express authority" means a provider's consent |
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that is obtained through separate signature lines for each line of |
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business. |
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(5) "Health care services" means services provided for |
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the diagnosis, prevention, treatment, or cure of a health |
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condition, illness, injury, or disease. |
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(5-1) "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 healthcare services at a |
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lower price; or |
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(ii) a contracting entity from contracting |
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with another provider to provide healthcare services at a higher |
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price; |
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(B) Requires or grants an option to require: |
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(i) a provider to accept a lower payment in |
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the event the provider agrees to provide healthcare services to |
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another contracting entity at a lower price; or |
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(ii) a contracting entity to pay at a higher |
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rate in the event the contracting entity agrees to pay another |
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provider at a higher rate; |
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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 to provide healthcare |
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services to another contracting entity at a lower price; or |
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(ii) a contracting entity agrees to pay |
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another provider at a higher rate; |
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(D) Requires a provider to disclose the |
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provider's contractual reimbursement rates with other contracting |
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entities or a contracting entity to disclose the contracting |
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entity's contractual reimbursement rates with other providers. |
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(6) "Person" has the meaning assigned by Section |
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823.002. |
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(7)(A) "Provider" means: |
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(i) an advanced practice nurse; |
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(ii) an optometrist; |
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(iii) a therapeutic optometrist; |
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(iv) a physician; |
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(v) a physician assistant; |
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(vi) a professional association composed |
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solely of physicians, optometrists, or therapeutic optometrists; |
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(vii) a single legal entity authorized to |
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practice medicine owned by two or more physicians; |
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(viii) a nonprofit health corporation |
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certified by the Texas Medical Board under Chapter 162, Occupations |
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Code; |
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(ix) a partnership composed solely of |
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physicians, optometrists, or therapeutic optometrists; |
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(x) a physician-hospital organization that |
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acts exclusively as an administrator for a provider to facilitate |
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the provider's participation in health care contracts; or |
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(xi) an institution that is licensed under |
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Chapter 241, Health and Safety Code. |
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(B) "Provider" does not include a |
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physician-hospital organization that leases or rents the |
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physician-hospital organization's network to another party. |
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(8) "Provider network contract" means a contract |
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between a contracting entity and a provider for the delivery of, and |
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payment for, health care services to a covered individual. |
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SECTION 3. Section 1458.101, Insurance Code is amended to |
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read as follows: |
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Sec. 1458.101. CONTRACT REQUIREMENTS. (a) In this section, |
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the following are each considered a single separate line of |
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business: |
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(1) preferred provider benefit plans covering |
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individuals and groups; |
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(2) exclusive provider benefit plans covering |
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individuals and groups; |
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(3) health maintenance organization plans covering |
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individuals and groups; |
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(4) Medicare Advantage or similar plans issued in |
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connection with a contract with the Centers for Medicare and |
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Medicaid Services; |
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(5) Medicaid managed care; and |
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(6) the state child health plan established under |
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Chapter 62, Health and Safety Code, or the comparable plan under |
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Chapter 63, Health and Safety Code. |
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(b) A contracting entity may not sell, lease, or otherwise |
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transfer information regarding the payment or reimbursement terms |
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of the provider network contract without the express authority of |
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and prior adequate notification to the provider. The prior |
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adequate notification may be provided in the written format |
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specified by a provider network contract subject to this chapter. |
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(c) A contracting entity may not provide a person access to |
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health care services or contractual discounts under a provider |
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network contract unless the provider network contract specifically |
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states that the contracting entity may contract with a person to |
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provide access to the contracting entity's rights and |
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responsibilities under the provider network contract. |
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(d) The provider network contract must require that on the |
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request of the provider, the contracting entity will provide |
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information necessary to determine whether a particular person has |
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been authorized to access the provider's health care services and |
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contractual discounts. |
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(e) To be enforceable against a provider, a provider network |
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contract, including the lines of business described by Subsections |
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(a) and (f), must also specify or reference a separate fee schedule |
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for each such line of business. The separate fee schedule may |
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describe specific services or procedures that the provider will |
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deliver along with a corresponding payment, may describe a |
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methodology for calculating payment based on a published fee |
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schedule, or may describe payment in any other reasonable manner |
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that specifies a definite payment for services. The fee |
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information may be provided by any reasonable method, including |
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electronically. |
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(f) The commissioner may, by rule, add additional lines of |
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business for which express authority is required. |
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(g) A contracting entity shall 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 continues to include a most |
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favored nation clause. |
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The change in law made by this Act to Chapter 552, Insurance |
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Code, does not apply to an offense committed before the effective |
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date of this Act. An offense committed before the effective date of |
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this Act is governed by the law as it existed on the date the offense |
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was committed, and the former law is continued in effect for that |
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purpose. For purposes of this section, an offense was committed |
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before the effective date of this Act if any element of the offense |
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occurred before that date. |
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SECTION 4. This Act takes effect September 1, 2021. |