87R18910 SMT-F
By: Frank H.B. No. 4051
Substitute the following for H.B. No. 4051:
By: Oliverson C.S.H.B. No. 4051
A BILL TO BE ENTITLED
AN ACT
relating to the method of payment for certain health care and
certain contract provisions affecting health care reimbursement
rates.
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. DIRECT PAYMENT OF PHYSICIAN OR HEALTH CARE PROVIDER
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 States.
(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. PAYMENT IN LIEU OF CLAIM FOR BENEFITS; OTHER
DIRECT PAYMENTS. (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 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 by Subsection (a) or
from a patient without a health benefit plan 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 by
adding Subdivision (5-a) to read as follows:
(5-a) "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 health care services at a
lower rate; or
(ii) a contracting entity from contracting
with another provider to provide health care services at a higher
rate;
(B) requires or grants an option to require:
(i) a provider to accept a lower rate for
health care services if the provider agrees with another
contracting entity to accept a lower rate for the services; or
(ii) a contracting entity to pay a higher
rate for health care services if the entity agrees with another
provider to pay a higher rate for the services;
(C) requires or grants an option to require
termination or renegotiation of an existing provider network
contract if:
(i) a provider agrees with another
contracting entity to accept a lower rate for providing health care
services; or
(ii) a contracting entity agrees with a
provider to pay a higher rate for health care services; or
(D) requires:
(i) a provider to disclose the provider's
contractual reimbursement rates with other contracting entities;
or
(ii) a contracting entity to disclose the
contracting entity's contractual reimbursement rates with other
providers.
SECTION 3. Section 1458.101, Insurance Code, is amended by
adding Subsection (g) to read as follows:
(g) A contracting entity may 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 retains a most favored nation
clause.
SECTION 4. This Act takes effect September 1, 2021.