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A BILL TO BE ENTITLED
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AN ACT
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relating to prohibited conduct of a health benefit plan issuer in |
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relation to affiliated and nonaffiliated providers. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle F, Title 8, Insurance Code, is amended |
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by adding Chapter 1462 to read as follows: |
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CHAPTER 1462. AFFILIATED PROVIDERS |
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Sec. 1462.001. DEFINITIONS. In this chapter: |
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(1) "Affiliated provider" means a health care provider |
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that directly, or indirectly through one or more intermediaries, |
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controls, is controlled by, or is under common control with a health |
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benefit plan issuer. |
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(2) "Nonaffiliated provider" means a health care |
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provider that does not directly, or indirectly through one or more |
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intermediaries, control and is not controlled by or under common |
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control with a health benefit plan issuer. |
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Sec. 1462.002. APPLICABILITY OF CHAPTER. (a) This chapter |
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applies only to a health benefit plan that provides benefits for |
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medical or surgical expenses incurred as a result of a health |
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condition, accident, or sickness, including an individual, group, |
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blanket, or franchise insurance policy or insurance agreement, a |
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group hospital service contract, or an individual or group evidence |
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of coverage or similar coverage document that is offered by: |
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(1) an insurance company; |
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(2) a group hospital service corporation operating |
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under Chapter 842; |
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(3) a health maintenance organization operating under |
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Chapter 843; |
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(4) an approved nonprofit health corporation that |
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holds a certificate of authority under Chapter 844; |
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(5) a multiple employer welfare arrangement that holds |
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a certificate of authority under Chapter 846; |
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(6) a stipulated premium company operating under |
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Chapter 884; |
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(7) a fraternal benefit society operating under |
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Chapter 885; |
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(8) a Lloyd's plan operating under Chapter 941; or |
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(9) an exchange operating under Chapter 942. |
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(b) Notwithstanding any other law, this chapter applies to: |
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(1) a small employer health benefit plan subject to |
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Chapter 1501, including coverage provided through a health group |
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cooperative under Subchapter B of that chapter; |
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(2) a standard health benefit plan issued under |
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Chapter 1507; |
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(3) health benefits provided by or through a church |
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benefits board under Subchapter I, Chapter 22, Business |
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Organizations Code; |
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(4) group health coverage made available by a school |
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district in accordance with Section 22.004, Education Code; |
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(5) a regional or local health care program operated |
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under Section 75.104, Health and Safety Code; and |
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(6) a self-funded health benefit plan sponsored by a |
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professional employer organization under Chapter 91, Labor Code. |
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Sec. 1462.003. EXCEPTION TO APPLICABILITY OF CHAPTER. This |
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chapter does not apply to an issuer, provider, or administrator of |
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health benefits under: |
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(1) the state Medicaid program, including the Medicaid |
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managed care program operated under Chapter 533, Government Code; |
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(2) the child health plan program under Chapter 62, |
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Health and Safety Code; |
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(3) a basic coverage plan under Chapter 1551; |
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(4) a basic plan under Chapter 1575; |
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(5) a coverage plan under Chapter 1579; |
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(6) a plan providing basic coverage under Chapter |
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1601; or |
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(7) a workers' compensation insurance policy or other |
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form of providing medical benefits under Title 5, Labor Code. |
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Sec. 1462.004. REIMBURSEMENT OF AFFILIATED AND |
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NONAFFILIATED PROVIDERS. (a) A health benefit plan issuer may not |
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offer a higher reimbursement rate to a health care practitioner who |
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is a member of a nonaffiliated provider based on a condition that |
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the practitioner agrees to join an affiliated provider. |
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(b) A health benefit plan issuer may not pay an affiliated |
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provider a reimbursement amount that is more than the amount the |
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issuer pays a nonaffiliated provider for the same health care |
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service. |
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Sec. 1462.005. PROHIBITION ON CERTAIN COMMUNICATIONS. A |
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health benefit plan issuer may not encourage or direct a patient to |
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use the issuer's affiliated provider through any oral or written |
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communication, including: |
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(1) online messaging regarding the provider; or |
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(2) patient- or prospective patient-specific |
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advertising, marketing, or promotion of the provider. |
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Sec. 1462.006. PROHIBITION ON CERTAIN REFERRALS AND |
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SOLICITATIONS. (a) A health benefit plan issuer may not require a |
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patient to use the issuer's affiliated provider for the patient to |
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receive the maximum benefit for the service under the patient's |
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health benefit plan. |
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(b) A health benefit plan issuer may not offer or implement |
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a health benefit plan that requires or induces a patient to use the |
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issuer's affiliated provider, including by providing for reduced |
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cost-sharing if the patient uses the affiliated provider. |
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(c) A health benefit plan issuer may not solicit a patient |
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or prescriber to transfer a patient's prescription to the issuer's |
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affiliated provider. |
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SECTION 2. Chapter 1462, Insurance Code, as added by this |
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Act, applies only to a health benefit plan delivered, issued for |
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delivery, or renewed on or after January 1, 2024. |
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SECTION 3. This Act takes effect September 1, 2023. |