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A BILL TO BE ENTITLED
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AN ACT
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relating to establishment of a shared savings program for health |
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maintenance organizations and preferred provider benefit plans. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subtitle C, Title 8, Insurance Code, is amended |
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by adding Chapter 1276 to read as follows: |
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CHAPTER 1276. SHARED SAVINGS PROGRAM |
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SUBCHAPTER A. GENERAL PROVISIONS |
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Sec. 1276.001. DEFINITIONS. In this chapter: |
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(1) "Direct pay provider" means a health care provider |
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of any health care service or supply that will accept direct payment |
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for a health care service or supply from a patient instead of |
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processing a claim for payment for the service or supply through the |
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patient's health care plan or preferred provider benefit plan. |
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(2) "Health care provider" means a health care |
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practitioner or health care facility that provides health care |
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services or supplies under a license, certificate, registration, or |
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similar authorization issued by this state. |
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(3) "Program" means a shared savings program |
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established under this chapter. |
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Sec. 1276.002. APPLICABILITY OF CHAPTER. This chapter |
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applies only to medically necessary nonemergency health care |
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services or supplies covered under: |
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(1) a health care plan provided by a health |
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maintenance organization operating under Chapter 843; or |
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(2) a preferred provider benefit plan provided under |
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Chapter 1301. |
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Sec. 1276.003. RULES. The commissioner may adopt rules |
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necessary to implement this chapter. |
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SUBCHAPTER B. PROGRAM REQUIREMENTS |
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Sec. 1276.051. PROGRAM REQUIRED. (a) A health maintenance |
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organization or insurer to which this chapter applies shall |
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establish a shared savings program in accordance with this chapter. |
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(b) A health maintenance organization or insurer shall |
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provide written notice to its enrollees or insureds of the program. |
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(c) An insurer may not require a different procedure for an |
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insured to claim a shared savings incentive payment under this |
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chapter than the procedures established by the insurer under |
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Section 1301.140. |
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Sec. 1276.052. AVERAGE CONTRACTED RATE DISCLOSURE. (a) As |
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part of the program, a health maintenance organization or insurer |
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shall establish a publicly available Internet website for any |
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person to view the average contracted rate paid by the health |
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maintenance organization or insurer under a health care plan or |
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preferred provider benefit plan to a health care provider in the |
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plan's provider network for a particular health care service or |
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supply in the preceding 12 months. The health maintenance |
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organization or insurer shall update the average contracted rate at |
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least once per month. |
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(b) As part of the program, a health maintenance |
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organization or insurer shall establish and operate a toll-free |
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telephone number for an enrollee or insured to request disclosure |
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of the average contracted rate paid under the enrollee's health |
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care plan or the insured's preferred provider benefit plan to a |
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health care provider in the plan's provider network for a |
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particular health care service or supply in the preceding 12 |
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months. |
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(c) An insurer may use a system described by Subsection (a) |
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or (b) for the purposes of Section 1301.140. |
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(d) A health maintenance organization or insurer shall |
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disclose to the enrollee or insured the rate the enrollee or insured |
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requested under Subsection (b). |
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Sec. 1276.053. PARTICIPATION USING DIRECT PAY PROVIDER. |
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(a) For purposes of enrollee or insured eligibility for a shared |
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savings incentive payment under Section 1276.054, a health care |
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provider may be considered a direct pay provider if the health care |
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provider: |
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(1) publishes the final price that the provider would |
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accept for a health care service or supply eligible under a program |
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for each of the 100 most common nonemergency health care services or |
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supplies offered by the provider and that reflects the enrollee's |
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or insured's final out-of-pocket cost for the service or supply; or |
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(2) provides an enrollee or insured on request a |
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direct pay price with a written estimate of the final charge for a |
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proposed health care service or supply eligible under the |
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enrollee's or insured's program that includes prices for all |
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services or supplies associated with the proposed service or supply |
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and that reflects the enrollee's or insured's final out-of-pocket |
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cost associated with the proposed service or supply. |
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(b) A facility to which Chapter 324, Health and Safety Code, |
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applies that provides an estimate of the facility's charges for a |
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proposed service in accordance with Section 324.101(d), Health and |
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Safety Code, satisfies Subsection (a)(2) with respect to that |
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service. |
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(c) An enrollee or insured may request a direct pay price |
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described by Subsection (a)(2) from any health care provider, |
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regardless of whether the provider has published the information |
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described by Subsection (a)(1), and the enrollee's or insured's |
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decision to obtain a health care service or supply from that |
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provider does not affect the enrollee's or insured's eligibility |
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for a shared savings incentive payment under the enrollee's or |
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insured's program. |
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(d) A direct pay provider may provide assistance to an |
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enrollee or insured in filing paperwork or providing proof of care |
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or medical necessity in connection with the enrollee's or insured's |
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claim for reimbursement or a shared savings incentive payment under |
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this chapter. |
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Sec. 1276.054. SHARED SAVINGS INCENTIVE PAYMENT. (a) An |
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enrollee or insured who elects and receives a medically necessary |
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and covered health care service or supply from a direct pay provider |
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and pays an actual price less than the rate disclosed by the |
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enrollee's health maintenance organization or the insured's insurer |
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under Section 1276.052 is eligible for a shared savings incentive |
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payment under the enrollee's or insured's program. |
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(b) Except as provided by Subsection (c), a health |
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maintenance organization or insurer shall pay to an eligible |
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enrollee or insured a shared savings incentive payment equal to 50 |
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percent of the difference between the disclosed rate and the actual |
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price paid to the direct pay provider, minus any applicable |
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deductible, copayment, or coinsurance. |
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(c) A health maintenance organization or insurer is not |
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required to pay an enrollee or insured a shared savings incentive |
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payment under Subsection (b) if: |
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(1) the amount of the shared savings incentive payment |
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would be less than $50; or |
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(2) both: |
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(A) the enrollee's or insured's total shared |
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savings incentive payments for the plan year exceed the greater of: |
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(i) $20,000; or |
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(ii) the enrollee's or insured's |
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deductibles and out-of-pocket maximum; and |
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(B) the health maintenance organization or |
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insurer has provided written notice to the enrollee or insured that |
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the enrollee or insured is not eligible for a shared savings |
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incentive payment for the remainder of the plan year. |
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(d) A health maintenance organization or insurer shall pay |
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an enrollee or insured under Subsection (b) not later than the 30th |
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day after the date on which the enrollee or insured submits a |
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program claim. |
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(e) A health maintenance organization or insurer may pay a |
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shared savings incentive payment through a cash payment or other |
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incentive or combination of incentives, including: |
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(1) a gift card; |
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(2) a deposit into a health reimbursement arrangement |
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or savings account; |
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(3) a premium reduction or rebate; and |
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(4) a cost-sharing reduction. |
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Sec. 1276.055. COST SHARING UNDER PROGRAM FOR PREFERRED |
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PROVIDER BENEFIT PLAN. (a) This section applies only to a |
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medically necessary health care service or supply that: |
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(1) is covered under a preferred provider benefit |
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plan; and |
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(2) an insured receives from a direct pay provider for |
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an amount that is less than the average contracted rate disclosed by |
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the insured's insurer under Section 1276.052. |
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(b) An insurer shall comply with the requirements of Section |
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1301.140 to ensure that cost-sharing amounts paid by an insured for |
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a service or supply described by Subsection (a) are counted toward |
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the insured's in-network cost-sharing limits. |
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Sec. 1276.056. ACCOUNTING AND ADMINISTRATION FOR HEALTH |
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MAINTENANCE ORGANIZATION OR INSURER. (a) If required by the |
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federal government, a health maintenance organization or insurer |
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that pays total shared savings incentive payments in excess of $600 |
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to an enrollee or insured during a calendar year shall issue to the |
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enrollee or insured an Internal Revenue Service Form 1099 not later |
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than January 31 of the following year. |
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(b) A health maintenance organization or insurer that pays |
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shared savings incentive payments under this chapter may apply to |
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the United States Department of Health and Human Services to |
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include the payments as incurred claims under 45 C.F.R. Section |
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158.221(b)(8). |
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Sec. 1276.057. LIABILITY FOR UNFORESEEN CHARGE OVER |
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ESTIMATE. If the final charge for the health care service or supply |
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described by Section 1276.055(a) is an amount greater than the |
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amount estimated under Section 1276.053 due to unforeseen |
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circumstances, the enrollee or insured is liable for the difference |
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only if: |
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(1) before the enrollee or insured is billed, the |
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enrollee or insured agrees in writing to pay the additional amount; |
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and |
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(2) before receiving the service or supply, the |
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enrollee or insured receives written notice that the enrollee or |
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insured may be liable for charges resulting from unforeseen |
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circumstances. |
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SECTION 2. Chapter 1276, Insurance Code, as added by this |
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Act, applies only to a health care plan or insurance policy |
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delivered, issued for delivery, or renewed on or after January 1, |
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2026. |
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SECTION 3. This Act takes effect September 1, 2025. |
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* * * * * |