By: Frank H.B. No. 4051
A BILL TO BE ENTITLED
AN ACT
relating to method of payment for certain medical care and contract
arrangements.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Chapter 1204, Insurance Code, is amended by
adding Subchapter G to read as follows:
SUBCHAPTER G. AUTHORIZED PAYMENT BY ENROLLEES IN LIEU OF CLAIM FOR
BENEFITS
Sec. 1204.301. DEFINITIONS. In this subchapter:
(1) "Enrollee" means an individual who is enrolled in
a health care plan or entitled to coverage under a health benefit
plan.
(2) "Health benefit plan" means an individual, group,
blanket, or franchise insurance policy, a group hospital service
contract, or a group subscriber contract or evidence of coverage
issued by a health maintenance organization, that provides benefits
for health care services.
(3) "Health care provider" means a person who provides
health care services under a license, certificate, registration, or
other similar evidence of regulation issued by this or another
state of the United State.
(4) "Health care service" means a service to diagnose,
prevent, alleviate, cure, or heal a human illness or injury that is
provided to a covered person by a physician or other health care
provider.
(5) "Physician" means an individual licensed to
practice medicine in this or another state of the United States.
Sec. 1204.302. APPLICABILITY TO CERTAIN PLANS. In addition
to the health benefit plans described by Section 1204.301,
notwithstanding any other law, this subchapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579;
and
(4) a plan providing basic coverage under Chapter
1601.
Sec. 1204.303. AUTHORIZED PAYMENT IN LIEU OF CLAIM FOR
BENEFITS. (a) A physician or health care provider may not be
prohibited from accepting directly from an enrollee full payment
for a health care service in lieu of submitting a claim to the
enrollee's health benefit plan.
(b) Notwithstanding Insurance Code Section 552.003 or any
other law, the charge for a health care service for which a
physician or health care provider accepts a payment as described
Subsection (a) may not exceed the lowest contract rate for the
health care service allowable under any health benefit plan with
respect to which the physician or health care provider is a
contracted, preferred, or participating provider.
SECTION 2. Section 1458.001 , Insurance Code, is amended to
read as follows:
Sec. 1458.001. GENERAL DEFINITIONS. In this chapter:
(1) "Affiliate" means a person who, directly or
indirectly through one or more intermediaries, controls, is
controlled by, or is under common control with another person.
(2) "Contracting entity" means a person who:
(A) enters into a direct contract with a provider
for the delivery of health care services to covered individuals;
and
(B) in the ordinary course of business
establishes a provider network or networks for access by another
party.
(3) "Covered individual" means an individual who is
covered under a health benefit plan.
(4) "Express authority" means a provider's consent
that is obtained through separate signature lines for each line of
business.
(5) "Health care services" means services provided for
the diagnosis, prevention, treatment, or cure of a health
condition, illness, injury, or disease.
(5-1) "Most favored nation clause" means a provision
in a provider network contract that:
(A) Prohibits or grants an option to prohibit:
(i) a provider from contracting with
another contracting entity to provide healthcare services at a
lower price; or
(ii) a contracting entity from contracting
with another provider to provide healthcare services at a higher
price;
(B) Requires or grants an option to require:
(i) a provider to accept a lower payment in
the event the provider agrees to provide healthcare services to
another contracting entity at a lower price; or
(ii) a contracting entity to pay at a higher
rate in the event the contracting entity agrees to pay another
provider at a higher rate;
(C) Requires or grants an option to require
termination or renegotiation of an existing provider network
contract if:
(i) a provider agrees to provide healthcare
services to another contracting entity at a lower price; or
(ii) a contracting entity agrees to pay
another provider at a higher rate;
(D) Requires a provider to disclose the
provider's contractual reimbursement rates with other contracting
entities or a contracting entity to disclose the contracting
entity's contractual reimbursement rates with other providers.
(6) "Person" has the meaning assigned by Section
823.002.
(7)(A) "Provider" means:
(i) an advanced practice nurse;
(ii) an optometrist;
(iii) a therapeutic optometrist;
(iv) a physician;
(v) a physician assistant;
(vi) a professional association composed
solely of physicians, optometrists, or therapeutic optometrists;
(vii) a single legal entity authorized to
practice medicine owned by two or more physicians;
(viii) a nonprofit health corporation
certified by the Texas Medical Board under Chapter 162, Occupations
Code;
(ix) a partnership composed solely of
physicians, optometrists, or therapeutic optometrists;
(x) a physician-hospital organization that
acts exclusively as an administrator for a provider to facilitate
the provider's participation in health care contracts; or
(xi) an institution that is licensed under
Chapter 241, Health and Safety Code.
(B) "Provider" does not include a
physician-hospital organization that leases or rents the
physician-hospital organization's network to another party.
(8) "Provider network contract" means a contract
between a contracting entity and a provider for the delivery of, and
payment for, health care services to a covered individual.
SECTION 3. Section 1458.101, Insurance Code is amended to
read as follows:
Sec. 1458.101. CONTRACT REQUIREMENTS. (a) In this section,
the following are each considered a single separate line of
business:
(1) preferred provider benefit plans covering
individuals and groups;
(2) exclusive provider benefit plans covering
individuals and groups;
(3) health maintenance organization plans covering
individuals and groups;
(4) Medicare Advantage or similar plans issued in
connection with a contract with the Centers for Medicare and
Medicaid Services;
(5) Medicaid managed care; and
(6) the state child health plan established under
Chapter 62, Health and Safety Code, or the comparable plan under
Chapter 63, Health and Safety Code.
(b) A contracting entity may not sell, lease, or otherwise
transfer information regarding the payment or reimbursement terms
of the provider network contract without the express authority of
and prior adequate notification to the provider. The prior
adequate notification may be provided in the written format
specified by a provider network contract subject to this chapter.
(c) A contracting entity may not provide a person access to
health care services or contractual discounts under a provider
network contract unless the provider network contract specifically
states that the contracting entity may contract with a person to
provide access to the contracting entity's rights and
responsibilities under the provider network contract.
(d) The provider network contract must require that on the
request of the provider, the contracting entity will provide
information necessary to determine whether a particular person has
been authorized to access the provider's health care services and
contractual discounts.
(e) To be enforceable against a provider, a provider network
contract, including the lines of business described by Subsections
(a) and (f), must also specify or reference a separate fee schedule
for each such line of business. The separate fee schedule may
describe specific services or procedures that the provider will
deliver along with a corresponding payment, may describe a
methodology for calculating payment based on a published fee
schedule, or may describe payment in any other reasonable manner
that specifies a definite payment for services. The fee
information may be provided by any reasonable method, including
electronically.
(f) The commissioner may, by rule, add additional lines of
business for which express authority is required.
(g) A contracting entity shall not:
(1) Offer to a provider a provider network contract
that includes a most favored nation clause;
(2) Enter into a provider network contract that
includes a most favored nation clause; or
(3) Amend or renew an existing provider network
contract previously entered into with a provider so that the
contract as amended or renewed adds or continues to include a most
favored nation clause.
The change in law made by this Act to Chapter 552, Insurance
Code, does not apply to an offense committed before the effective
date of this Act. An offense committed before the effective date of
this Act is governed by the law as it existed on the date the offense
was committed, and the former law is continued in effect for that
purpose. For purposes of this section, an offense was committed
before the effective date of this Act if any element of the offense
occurred before that date.
SECTION 4. This Act takes effect September 1, 2021.