Texas 2023 - 88th Regular

Texas House Bill HB1073 Compare Versions

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Version 2 (New)

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1	1	88R23302 CJD-F
2	2	By: Hull H.B. No. 1073
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to certain health care services contract arrangements
8	8	entered into by insurers and health care providers.
9	9	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	10	SECTION 1. Subchapter A, Chapter 1301, Insurance Code, is
11	11	amended by adding Section 1301.0065 to read as follows:
12	12	Sec. 1301.0065. VALUE-BASED AND CAPITATED PAYMENT
13	13	ARRANGEMENTS WITH PRIMARY CARE PHYSICIANS OR PRIMARY CARE PHYSICIAN
14	14	GROUPS NOT PROHIBITED. (a) In this section:
15	15	(1) "Primary care physician" means a specialist in
16	16	family medicine, general internal medicine, or general pediatrics
17	17	who provides definitive care to the undifferentiated patient at the
18	18	point of first contact and takes continuing responsibility for
19	19	providing the patient's comprehensive care, which may include
20	20	chronic, preventive, and acute care.
21	21	(2) "Primary care physician group" means an entity
22	22	through which two or more primary care physicians deliver health
23	23	care to the public through the practice of medicine on a regular
24	24	basis and that is:
25	25	(A) owned and operated by two or more physicians;
26	26	or
27	27	(B) a freestanding clinic, center, or office of a
28	28	nonprofit health organization certified by the Texas Medical Board
29	29	under Section 162.001(b), Occupations Code, that complies with the
30	30	requirements of Chapter 162, Occupations Code.
31	31	(b) A preferred provider benefit plan or an exclusive
32	32	provider benefit plan may provide or arrange for health care
33	33	services with a primary care physician or primary care physician
34	34	group through a contract for compensation under:
35	35	(1) a fee-for-service arrangement;
36	36	(2) a risk-sharing arrangement;
37	37	(3) a capitation arrangement under which a fixed
38	38	predetermined payment is made in exchange for the provision of, or
39	39	for the arrangement to provide and the guaranty of the provision of,
40	40	a contractually defined set of covered services to covered persons
41	41	for a specified period without regard to the quantity of services
42	42	actually provided; or
43	43	(4) any combination of arrangements described by
44	44	Subdivisions (1) through (3).
45	45	(c) A primary care physician or primary care physician group
46	46	that enters into a contract described by Subsection (b) is not
47	47	considered to be engaging in the business of insurance.
48	48	(d) A primary care physician or primary care physician group
49	49	is not required to enter into a payment arrangement under this
50	50	section, and an insurer may not discriminate against a physician or
51	51	physician group that elects not to participate in an arrangement
52	52	under this section, including by:
53	53	(1) reducing the fee schedule of a physician or
54	54	physician group because the physician or physician group does not
55	55	participate in the insurer's value-based or capitated payment
56	56	arrangement or other payment arrangement provided under this
57	57	section; or
58	58	(2) requiring a physician or physician group to
59	59	participate in the insurer's value-based or capitated payment
60	60	arrangement or other payment arrangement provided under this
61	61	section as a condition of participation in the insurer's provider
62	62	network.
63	63	(e) A primary care physician or primary care physician group
64	64	may file a complaint with the department if the physician or
65	65	physician group believes the physician or physician group has been
66	66	discriminated against in violation of Subsection (d).
67	67	(f) A contract allowing for a value-based or capitated
68	68	payment arrangement or other payment arrangement provided under
69	69	this section:
70	70	(1) may not create a disincentive to the provision of
71	71	medically necessary health care services and may not interfere with
72	72	the physician's independent medical judgment on which services are
73	73	medically appropriate or medically necessary;
74	74	(2) must specify:
75	75	(A) in writing if compensation is being paid
76	76	based on satisfaction of performance measures and, if so,
77	77	specifically provide:
78	78	(i) the performance measures;
79	79	(ii) the source of the measures;
80	80	(iii) the method and time period for
81	81	calculating whether the performance measures have been satisfied;
82	82	(iv) access to financial and
83	83	performance-based information used to determine whether the
84	84	physician met those measures; and
85	85	(v) the method by which the physician may
86	86	request reconsideration;
87	87	(B) that the attribution process will assign a
88	88	patient to:
89	89	(i) first the patient's established
90	90	physician, as determined by a prior annual exam or other office
91	91	visits; and
92	92	(ii) if no established physician
93	93	relationship exists, then a physician chosen by the patient;
94	94	(C) if payment involves capitation, whether a
95	95	bridge rate, such as a discounted fee for service, will remain in
96	96	effect for a certain period until sufficient data has been
97	97	generated regarding utilization to allow an insurer to make an
98	98	informed decision regarding fully capitated rates;
99	99	(D) whether the capitated rate, if any, will
100	100	provide for a stop-loss threshold or a guaranteed minimum level of
101	101	payment per month, and whether the physician will obtain stop-loss
102	102	coverage; and
103	103	(E) whether payment will take into account
104	104	patients who are added to or eliminated from the attributed
105	105	population during the course of a measurement period;
106	106	(3) if payment involves capitation, must provide for
107	107	the opportunity to renegotiate in good faith a revised capitation
108	108	rate, or reimburse on a fee-for-service basis under a contractual
109	109	fee schedule until a revised capitation rate is agreed to if there
110	110	is a material increase in the scope of services provided by the
111	111	physician or a material change by the payer in the benefit
112	112	structure; and
113	113	(4) must state:
114	114	(A) whether catastrophic events are excluded
115	115	from the final cost calculation for an attributed population when
116	116	compared to the cost target for the measurement period, if
117	117	applicable; and
118	118	(B) if payment involves shared savings, whether
119	119	the entire savings is shared when the minimum savings rate is
120	120	reached, or whether only the amount in excess of the minimum savings
121	121	rate is shared.
122	122	(g) This section does not authorize a preferred provider
123	123	benefit plan or an exclusive provider benefit plan to provide or
124	124	arrange for health care services with a primary care physician or
125	125	primary care physician group through a contract for compensation
126	126	under a global capitation arrangement.
127	127	(h) The parties to a contract under Subsection (b) are the
128	128	primary care physician or primary care physician group and the
129	129	preferred provider benefit plan or exclusive provider benefit plan.
130	130	A party to a contract under Subsection (b) may not subcontract.
131	131	SECTION 2. This Act takes effect immediately if it receives
132	132	a vote of two-thirds of all the members elected to each house, as
133	133	provided by Section 39, Article III, Texas Constitution. If this
134	134	Act does not receive the vote necessary for immediate effect, this
135	135	Act takes effect September 1, 2023.