Texas 2025 - 89th Regular

Texas House Bill HB1225 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	89R3370 SCL-D
2	2	By: Gates H.B. No. 1225
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7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to the establishment of a bundled-pricing program to
10	10	reduce certain health care costs in the state employees group
11	11	benefits program.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Chapter 1551, Insurance Code, is amended by
14	14	adding Subchapter K to read as follows:
15	15	SUBCHAPTER K. BUNDLED-PRICING PROGRAM
16	16	Sec. 1551.501. DEFINITIONS. In this subchapter:
17	17	(1) "Facility-based provider" has the meaning
18	18	assigned by Section 1551.229.
19	19	(2) "Program" means the bundled-pricing program
20	20	developed under this subchapter.
21	21	Sec. 1551.502. BUNDLED-PRICING PROGRAM. (a) The board of
22	22	trustees shall develop a cost-positive bundled-pricing program for
23	23	health benefit plans provided under the group benefits program.
24	24	(b) The program must be designed to reduce health care costs
25	25	in the group benefits program by contracting with a health care
26	26	facility, physician, or health care provider at a consolidated rate
27	27	for an inpatient or outpatient surgery procedure that is a covered
28	28	health care or medical service under a health benefit plan provided
29	29	under the group benefits program.
30	30	(c) A consolidated rate described by Subsection (b) must
31	31	include all fees related to the covered surgery procedure,
32	32	including fees for a health care facility, physician, health care
33	33	provider, laboratory, anesthesia, perioperative service,
34	34	prescription drug, or pharmacy service.
35	35	(d) The board of trustees shall contract with a third-party
36	36	administrator to administer the program. The program administrator
37	37	may be independent from the administrator of a health benefit plan
38	38	under the group benefits program.
39	39	Sec. 1551.503. PARTICIPATION; COST-SHARING OBLIGATION.
40	40	(a) A participant may have only an inpatient or outpatient surgery
41	41	procedure under the program.
42	42	(b) Except as provided by Subsection (c), the board of
43	43	trustees or a participating health care facility, physician, or
44	44	health care provider may not require a participant to pay a
45	45	deductible, copayment, coinsurance, or other cost-sharing
46	46	obligation for a covered surgery procedure provided under the
47	47	program.
48	48	(c) The board of trustees may require a participant in the
49	49	state consumer-directed health plan established under Section
50	50	1551.452 to meet the participant's deductible before the plan pays
51	51	for a covered surgery procedure provided under the program.
52	52	Sec. 1551.504. PROVIDER PARTICIPATION. (a) A health care
53	53	facility, physician, or health care provider is not required to
54	54	participate in the program. To participate, a health care
55	55	facility, physician, or health care provider must voluntarily and
56	56	expressly agree in writing to participate.
57	57	(b) A health care facility may not directly or indirectly:
58	58	(1) coerce a facility-based provider or physician to
59	59	participate in the program or accept a lower rate for an inpatient
60	60	or outpatient surgery procedure;
61	61	(2) condition a physician's staff membership or
62	62	privileges on the physician's participation in the program;
63	63	(3) consider a physician's participation or lack of
64	64	participation in the program in credentialing the physician;
65	65	(4) offer preferential scheduling to a participating
66	66	physician as compared to a physician who elects not to participate;
67	67	or
68	68	(5) terminate or otherwise penalize a physician or
69	69	health care provider for an election to not participate in the
70	70	program.
71	71	(c) The board of trustees, a health benefit plan, an
72	72	administrator of a health benefit plan provided under the group
73	73	program, or a health benefit plan issuer may not directly or
74	74	indirectly:
75	75	(1) coerce a health care facility, physician, or
76	76	health care provider to participate in the program;
77	77	(2) condition any plan participation on participation
78	78	in the program; or
79	79	(3) terminate or otherwise penalize a health care
80	80	facility, physician, or health care provider for electing not to
81	81	participate in the program.
82	82	Sec. 1551.505. PROCEDURE APPROVAL. (a) Before scheduling
83	83	a procedure under the program, a participating health care
84	84	facility, physician, or health care provider must apply for
85	85	approval from the program administrator in the form and manner
86	86	prescribed by the board of trustees.
87	87	(b) The approval application must include the consolidated
88	88	rate for the procedure and any other information determined
89	89	necessary by the program administrator.
90	90	(c) In determining whether to approve a procedure under this
91	91	section, the program administrator shall:
92	92	(1) ensure that the quality of care is comparable to
93	93	the care provided by a network provider for a health benefit plan
94	94	under the group benefits program;
95	95	(2) ensure that the procedure's cost is lower than the
96	96	procedure's cost if performed outside of the program; and
97	97	(3) if there is not a quality differential and
98	98	multiple health care facilities, physicians, or health care
99	99	providers apply to perform the same procedure for a participant,
100	100	consider the procedure's consolidated rate and the time the
101	101	procedure will be performed as the most important factors.
102	102	Sec. 1551.506. PAYMENT. (a) The board of trustees shall
103	103	ensure that a participating health care facility, physician, or
104	104	health care provider receives payment for a covered surgery
105	105	procedure not later than the 30th day after the date the program
106	106	administrator receives a claim for the procedure that includes, at
107	107	a minimum, each current procedural terminology code associated with
108	108	the bundled procedure and each ICD-10 code associated with the
109	109	patient.
110	110	(b) The program must include the methods by which payments
111	111	are allocated among a participating health care facility,
112	112	physician, or health care provider. If the consolidated bundled
113	113	payment is to be paid to an entity for further distribution to other
114	114	participating health care facilities, physicians, or health care
115	115	providers, the entity receiving the consolidated payment must be a
116	116	physician-led organization and have contracting authority on
117	117	behalf of the other participating facilities, physicians, and
118	118	providers.
119	119	(c) A participating health care facility, physician, or
120	120	health care provider may submit a request for payment to the
121	121	administrator for unanticipated services required to be provided
122	122	while performing a procedure under the program. The request must
123	123	include information on the reason the services were required.
124	124	Sec. 1551.507. BUNDLED-PRICING DISCLOSURE. (a) A
125	125	participating health care facility, physician, or health care
126	126	provider shall provide a written disclosure to a participant or the
127	127	participant's representative of the consolidated rate for a
128	128	procedure provided under the program before scheduling the
129	129	procedure.
130	130	(b) A health care facility, physician, or health care
131	131	provider that participates in the program may disclose a
132	132	consolidated rate for an inpatient or outpatient surgery procedure
133	133	on the facility's, physician's, or provider's Internet website and
134	134	marketing materials.
135	135	Sec. 1551.508. PUBLICATION OF INFORMATION. The board of
136	136	trustees shall publish information on the program, including a list
137	137	of participating health care facilities, physicians, and health
138	138	care providers and the consolidated rates offered by each
139	139	participating facility, physician, and provider, on the Employees
140	140	Retirement System of Texas website.
141	141	Sec. 1551.509. UNAUTHORIZED PRACTICE OF MEDICINE
142	142	PROHIBITED. This subchapter may not be construed to authorize:
143	143	(1) a lay person or entity to supervise or otherwise
144	144	control the practice of medicine as prohibited under Subtitle B,
145	145	Title 3, Occupations Code;
146	146	(2) a person or entity to engage in the unauthorized
147	147	practice of medicine in this state;
148	148	(3) a person or entity to misrepresent that the person
149	149	or entity is entitled to practice medicine; or
150	150	(4) a violation of Section 155.001, 155.003, 157.001,
151	151	164.052, or 165.156, Occupations Code.
152	152	Sec. 1551.510. RULEMAKING. The board of trustees may adopt
153	153	rules as necessary to implement this subchapter.
154	154	SECTION 2. This Act takes effect September 1, 2025.