TX
Texas House Bill HB4051

Texas 2021 - 87th Regular

Texas House Bill HB4051 Compare Versions

OldNewDifferences
1-87R18910 SMT-F
21 By: Frank H.B. No. 4051
3- Substitute the following for H.B. No. 4051:
4- By: Oliverson C.S.H.B. No. 4051
52
63
74 A BILL TO BE ENTITLED
85 AN ACT
9- relating to the method of payment for certain health care and
10- certain contract provisions affecting health care reimbursement
11- rates.
6+ relating to method of payment for certain medical care and contract
7+ arrangements.
128 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
139 SECTION 1. Chapter 1204, Insurance Code, is amended by
1410 adding Subchapter G to read as follows:
15- SUBCHAPTER G. DIRECT PAYMENT OF PHYSICIAN OR HEALTH CARE PROVIDER
11+ SUBCHAPTER G. AUTHORIZED PAYMENT BY ENROLLEES IN LIEU OF CLAIM FOR
12+ BENEFITS
1613 Sec. 1204.301. DEFINITIONS. In this subchapter:
1714 (1) "Enrollee" means an individual who is enrolled in
1815 a health care plan or entitled to coverage under a health benefit
1916 plan.
2017 (2) "Health benefit plan" means an individual, group,
2118 blanket, or franchise insurance policy, a group hospital service
2219 contract, or a group subscriber contract or evidence of coverage
2320 issued by a health maintenance organization, that provides benefits
2421 for health care services.
2522 (3) "Health care provider" means a person who provides
2623 health care services under a license, certificate, registration, or
2724 other similar evidence of regulation issued by this or another
28- state of the United States.
25+ state of the United State.
2926 (4) "Health care service" means a service to diagnose,
3027 prevent, alleviate, cure, or heal a human illness or injury that is
3128 provided to a covered person by a physician or other health care
3229 provider.
3330 (5) "Physician" means an individual licensed to
3431 practice medicine in this or another state of the United States.
3532 Sec. 1204.302. APPLICABILITY TO CERTAIN PLANS. In addition
3633 to the health benefit plans described by Section 1204.301,
3734 notwithstanding any other law, this subchapter applies to:
3835 (1) a basic coverage plan under Chapter 1551;
3936 (2) a basic plan under Chapter 1575;
4037 (3) a primary care coverage plan under Chapter 1579;
4138 and
4239 (4) a plan providing basic coverage under Chapter
4340 1601.
44- Sec. 1204.303. PAYMENT IN LIEU OF CLAIM FOR BENEFITS; OTHER
45- DIRECT PAYMENTS. (a) A physician or health care provider may not
46- be prohibited from accepting directly from an enrollee full payment
41+ Sec. 1204.303. AUTHORIZED PAYMENT IN LIEU OF CLAIM FOR
42+ BENEFITS. (a) A physician or health care provider may not be
43+ prohibited from accepting directly from an enrollee full payment
4744 for a health care service in lieu of submitting a claim to the
4845 enrollee's health benefit plan.
49- (b) Notwithstanding Section 552.003 or any other law, the
50- charge for a health care service for which a physician or health
51- care provider accepts a payment as described by Subsection (a) or
52- from a patient without a health benefit plan may not exceed the
53- lowest contract rate for the health care service allowable under
54- any health benefit plan with respect to which the physician or
55- health care provider is a contracted, preferred, or participating
56- provider.
57- SECTION 2. Section 1458.001, Insurance Code, is amended by
58- adding Subdivision (5-a) to read as follows:
59- (5-a) "Most favored nation clause" means a provision
46+ (b) Notwithstanding Insurance Code Section 552.003 or any
47+ other law, the charge for a health care service for which a
48+ physician or health care provider accepts a payment as described
49+ Subsection (a) may not exceed the lowest contract rate for the
50+ health care service allowable under any health benefit plan with
51+ respect to which the physician or health care provider is a
52+ contracted, preferred, or participating provider.
53+ SECTION 2. Section 1458.001 , Insurance Code, is amended to
54+ read as follows:
55+ Sec. 1458.001. GENERAL DEFINITIONS. In this chapter:
56+ (1) "Affiliate" means a person who, directly or
57+ indirectly through one or more intermediaries, controls, is
58+ controlled by, or is under common control with another person.
59+ (2) "Contracting entity" means a person who:
60+ (A) enters into a direct contract with a provider
61+ for the delivery of health care services to covered individuals;
62+ and
63+ (B) in the ordinary course of business
64+ establishes a provider network or networks for access by another
65+ party.
66+ (3) "Covered individual" means an individual who is
67+ covered under a health benefit plan.
68+ (4) "Express authority" means a provider's consent
69+ that is obtained through separate signature lines for each line of
70+ business.
71+ (5) "Health care services" means services provided for
72+ the diagnosis, prevention, treatment, or cure of a health
73+ condition, illness, injury, or disease.
74+ (5-1) "Most favored nation clause" means a provision
6075 in a provider network contract that:
6176 (A) Prohibits or grants an option to prohibit:
6277 (i) a provider from contracting with
6378 another contracting entity to provide healthcare services at a
64- lower rate; or
79+ lower price; or
6580 (ii) a contracting entity from contracting
6681 with another provider to provide healthcare services at a higher
67- rate;
82+ price;
6883 (B) Requires or grants an option to require:
69- (i) a provider to accept a lower rate for
70- health care services if the provider agrees with another
71- contracting entity to accept a lower rate for the services; or
72- (ii) a contracting entity to pay a higher
73- rate for health care services if the entity agrees with another
74- provider to pay a higher rate for the services;
84+ (i) a provider to accept a lower payment in
85+ the event the provider agrees to provide healthcare services to
86+ another contracting entity at a lower price; or
87+ (ii) a contracting entity to pay at a higher
88+ rate in the event the contracting entity agrees to pay another
89+ provider at a higher rate;
7590 (C) Requires or grants an option to require
7691 termination or renegotiation of an existing provider network
7792 contract if:
78- (i) a provider agrees with another
79- contracting entity to accept a lower rate for providing health care
80- services; or
81- (ii) a contracting entity agrees with a
82- provider to pay a higher rate for health care services; or
83- (D) requires:
84- (i) a provider to disclose the provider's
85- contractual reimbursement rates with other contracting entities;
86- or
87- (ii) a contracting entity to disclose the
88- contracting entity's contractual reimbursement rates with other
89- providers.
90- SECTION 3. Section 1458.101, Insurance Code, is amended by
91- adding Subsection (g) to read as follows:
92- (g) A contracting entity may not:
93+ (i) a provider agrees to provide healthcare
94+ services to another contracting entity at a lower price; or
95+ (ii) a contracting entity agrees to pay
96+ another provider at a higher rate;
97+ (D) Requires a provider to disclose the
98+ provider's contractual reimbursement rates with other contracting
99+ entities or a contracting entity to disclose the contracting
100+ entity's contractual reimbursement rates with other providers.
101+ (6) "Person" has the meaning assigned by Section
102+ 823.002.
103+ (7)(A) "Provider" means:
104+ (i) an advanced practice nurse;
105+ (ii) an optometrist;
106+ (iii) a therapeutic optometrist;
107+ (iv) a physician;
108+ (v) a physician assistant;
109+ (vi) a professional association composed
110+ solely of physicians, optometrists, or therapeutic optometrists;
111+ (vii) a single legal entity authorized to
112+ practice medicine owned by two or more physicians;
113+ (viii) a nonprofit health corporation
114+ certified by the Texas Medical Board under Chapter 162, Occupations
115+ Code;
116+ (ix) a partnership composed solely of
117+ physicians, optometrists, or therapeutic optometrists;
118+ (x) a physician-hospital organization that
119+ acts exclusively as an administrator for a provider to facilitate
120+ the provider's participation in health care contracts; or
121+ (xi) an institution that is licensed under
122+ Chapter 241, Health and Safety Code.
123+ (B) "Provider" does not include a
124+ physician-hospital organization that leases or rents the
125+ physician-hospital organization's network to another party.
126+ (8) "Provider network contract" means a contract
127+ between a contracting entity and a provider for the delivery of, and
128+ payment for, health care services to a covered individual.
129+ SECTION 3. Section 1458.101, Insurance Code is amended to
130+ read as follows:
131+ Sec. 1458.101. CONTRACT REQUIREMENTS. (a) In this section,
132+ the following are each considered a single separate line of
133+ business:
134+ (1) preferred provider benefit plans covering
135+ individuals and groups;
136+ (2) exclusive provider benefit plans covering
137+ individuals and groups;
138+ (3) health maintenance organization plans covering
139+ individuals and groups;
140+ (4) Medicare Advantage or similar plans issued in
141+ connection with a contract with the Centers for Medicare and
142+ Medicaid Services;
143+ (5) Medicaid managed care; and
144+ (6) the state child health plan established under
145+ Chapter 62, Health and Safety Code, or the comparable plan under
146+ Chapter 63, Health and Safety Code.
147+ (b) A contracting entity may not sell, lease, or otherwise
148+ transfer information regarding the payment or reimbursement terms
149+ of the provider network contract without the express authority of
150+ and prior adequate notification to the provider. The prior
151+ adequate notification may be provided in the written format
152+ specified by a provider network contract subject to this chapter.
153+ (c) A contracting entity may not provide a person access to
154+ health care services or contractual discounts under a provider
155+ network contract unless the provider network contract specifically
156+ states that the contracting entity may contract with a person to
157+ provide access to the contracting entity's rights and
158+ responsibilities under the provider network contract.
159+ (d) The provider network contract must require that on the
160+ request of the provider, the contracting entity will provide
161+ information necessary to determine whether a particular person has
162+ been authorized to access the provider's health care services and
163+ contractual discounts.
164+ (e) To be enforceable against a provider, a provider network
165+ contract, including the lines of business described by Subsections
166+ (a) and (f), must also specify or reference a separate fee schedule
167+ for each such line of business. The separate fee schedule may
168+ describe specific services or procedures that the provider will
169+ deliver along with a corresponding payment, may describe a
170+ methodology for calculating payment based on a published fee
171+ schedule, or may describe payment in any other reasonable manner
172+ that specifies a definite payment for services. The fee
173+ information may be provided by any reasonable method, including
174+ electronically.
175+ (f) The commissioner may, by rule, add additional lines of
176+ business for which express authority is required.
177+ (g) A contracting entity shall not:
93178 (1) Offer to a provider a provider network contract
94179 that includes a most favored nation clause;
95180 (2) Enter into a provider network contract that
96181 includes a most favored nation clause; or
97182 (3) Amend or renew an existing provider network
98183 contract previously entered into with a provider so that the
99- contract as amended or renewed adds or retains a most favored nation
100- clause.
184+ contract as amended or renewed adds or continues to include a most
185+ favored nation clause.
186+ The change in law made by this Act to Chapter 552, Insurance
187+ Code, does not apply to an offense committed before the effective
188+ date of this Act. An offense committed before the effective date of
189+ this Act is governed by the law as it existed on the date the offense
190+ was committed, and the former law is continued in effect for that
191+ purpose. For purposes of this section, an offense was committed
192+ before the effective date of this Act if any element of the offense
193+ occurred before that date.
101194 SECTION 4. This Act takes effect September 1, 2021.