Texas 2025 - 89th Regular

Texas House Bill HB1959 Compare Versions

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

Old	New	Differences
1	1	89R7882 DNC-F
2	2	By: Frank H.B. No. 1959
3	3
4	4
5	5
6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to certain practices of health benefit plan issuers to
10	10	encourage the use of certain physicians and health care providers
11	11	and rank physicians.
12	12	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
13	13	SECTION 1. Subchapter I, Chapter 843, Insurance Code, is
14	14	amended by adding Section 843.322 to read as follows:
15	15	Sec. 843.322. INCENTIVES TO USE CERTAIN PHYSICIANS OR
16	16	PROVIDERS. (a) A health maintenance organization may provide
17	17	incentives for enrollees to use certain physicians or providers
18	18	through modified deductibles, copayments, coinsurance, or other
19	19	cost-sharing provisions.
20	20	(b) A health maintenance organization that encourages an
21	21	enrollee to obtain a health care service from a particular
22	22	physician or provider, including offering incentives to encourage
23	23	enrollees to use specific physicians or providers, or that
24	24	introduces or modifies a tiered network plan or assigns physicians
25	25	or providers into tiers, has a fiduciary duty to the enrollee or
26	26	group contract holder to engage in that conduct only for the primary
27	27	benefit of the enrollee or group contract holder.
28	28	SECTION 2. Section 1301.0045(a), Insurance Code, is amended
29	29	to read as follows:
30	30	(a) Except as provided by Sections [Section] 1301.0046 and
31	31	1301.0047, this chapter may not be construed to limit the level of
32	32	reimbursement or the level of coverage, including deductibles,
33	33	copayments, coinsurance, or other cost-sharing provisions, that
34	34	are applicable to preferred providers or, for plans other than
35	35	exclusive provider benefit plans, nonpreferred providers.
36	36	SECTION 3. Subchapter A, Chapter 1301, Insurance Code, is
37	37	amended by adding Section 1301.0047 to read as follows:
38	38	Sec. 1301.0047. INCENTIVES TO USE CERTAIN PHYSICIANS OR
39	39	HEALTH CARE PROVIDERS. (a) An insurer may provide incentives for
40	40	insureds to use certain physicians or health care providers through
41	41	modified deductibles, copayments, coinsurance, or other
42	42	cost-sharing provisions.
43	43	(b) An insurer that encourages an insured to obtain a health
44	44	care service from a particular physician or health care provider,
45	45	including offering incentives to encourage insureds to use specific
46	46	physicians or providers, or that introduces or modifies a tiered
47	47	network plan or assigns physicians or providers into tiers, has a
48	48	fiduciary duty to the insured or policyholder to engage in that
49	49	conduct only for the primary benefit of the insured or
50	50	policyholder.
51	51	SECTION 4. Section 1460.003, Insurance Code, is amended by
52	52	amending Subsection (a) and adding Subsection (a-1) to read as
53	53	follows:
54	54	(a) A health benefit plan issuer, including a subsidiary or
55	55	affiliate, may not rank physicians or[,] classify physicians into
56	56	tiers based on performance[, or publish physician-specific
57	57	information that includes rankings, tiers, ratings, or other
58	58	comparisons of a physician's performance against standards,
59	59	measures, or other physicians,] unless:
60	60	(1) the standards used by the health benefit plan
61	61	issuer to rank or classify are propagated or developed by an
62	62	organization designated by the commissioner through rules adopted
63	63	under Section 1460.005;
64	64	(2) the ranking, comparison, or evaluation:
65	65	(A) is disclosed to each affected physician at
66	66	least 45 days before the date the ranking, comparison, or
67	67	evaluation is released, published, or distributed to enrollees by
68	68	the health benefit plan issuer; and
69	69	(B) identifies which products or networks
70	70	offered by the health benefit plan issuer the ranking, comparison,
71	71	or evaluation will be used for; and
72	72	(3) each affected physician is given an easy-to-use
73	73	process to identify discrepancies between the standards and the
74	74	ranking, comparison, or evaluation as propagated by the health
75	75	benefit plan issuer [the standards used by the health benefit plan
76	76	issuer conform to nationally recognized standards and guidelines as
77	77	required by rules adopted under Section 1460.005;
78	78	[(2) the standards and measurements to be used by the
79	79	health benefit plan issuer are disclosed to each affected physician
80	80	before any evaluation period used by the health benefit plan
81	81	issuer; and
82	82	[(3) each affected physician is afforded, before any
83	83	publication or other public dissemination, an opportunity to
84	84	dispute the ranking or classification through a process that, at a
85	85	minimum, includes due process protections that conform to the
86	86	following protections:
87	87	[(A) the health benefit plan issuer provides at
88	88	least 45 days' written notice to the physician of the proposed
89	89	rating, ranking, tiering, or comparison, including the
90	90	methodologies, data, and all other information utilized by the
91	91	health benefit plan issuer in its rating, tiering, ranking, or
92	92	comparison decision;
93	93	[(B) in addition to any written fair
94	94	reconsideration process, the health benefit plan issuer, upon a
95	95	request for review that is made within 30 days of receiving the
96	96	notice under Paragraph (A), provides a fair reconsideration
97	97	proceeding, at the physician's option:
98	98	[(i) by teleconference, at an agreed upon
99	99	time; or
100	100	[(ii) in person, at an agreed upon time or
101	101	between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday;
102	102	[(C) the physician has the right to provide
103	103	information at a requested fair reconsideration proceeding for
104	104	determination by a decision-maker, have a representative
105	105	participate in the fair reconsideration proceeding, and submit a
106	106	written statement at the conclusion of the fair reconsideration
107	107	proceeding; and
108	108	[(D) the health benefit plan issuer provides a
109	109	written communication of the outcome of a fair reconsideration
110	110	proceeding prior to any publication or dissemination of the rating,
111	111	ranking, tiering, or comparison. The written communication must
112	112	include the specific reasons for the final decision].
113	113	(a-1) If a physician submits information to a health benefit
114	114	plan issuer under Subsection (a)(3) sufficient to establish a
115	115	discrepancy, the health benefit plan issuer must remedy the
116	116	discrepancy by the later of:
117	117	(1) publication; or
118	118	(2) the 30th day after the date the health benefit plan
119	119	issuer receives the information.
120	120	SECTION 5. Section 1460.005(c), Insurance Code, is amended
121	121	to read as follows:
122	122	(c) In adopting rules under this section, the commissioner
123	123	may only designate [shall consider the standards, guidelines, and
124	124	measures prescribed by nationally recognized] organizations that
125	125	meet the following requirements:
126	126	(1) the prescribing organization is bona fide and
127	127	unbiased toward or against any medical provider;
128	128	(2) the standards to be used in rankings, comparisons,
129	129	or evaluations:
130	130	(A) are nationally recognized, or based on
131	131	expert-provider consensus or leading clinical evidence-based
132	132	scholarship;
133	133	(B) have a publicly transparent methodology; and
134	134	(C) if based on clinical outcomes, are
135	135	risk-adjusted; and
136	136	(3) the prescribing organization has an easy-to-use
137	137	process by which a medical provider may report data, evidentiary,
138	138	factual, or mathematical errors for prompt investigation and, if
139	139	appropriate, correction [establish or promote guidelines and
140	140	performance measures emphasizing quality of health care, including
141	141	the National Quality Forum and the AQA Alliance. If neither the
142	142	National Quality Forum nor the AQA Alliance has established
143	143	standards or guidelines regarding an issue, the commissioner shall
144	144	consider the standards, guidelines, and measures prescribed by the
145	145	National Committee on Quality Assurance and other similar national
146	146	organizations. If neither the National Quality Forum, nor the AQA
147	147	Alliance, nor other national organizations have established
148	148	standards or guidelines regarding an issue, the commissioner shall
149	149	consider standards, guidelines, and measures based on other bona
150	150	fide nationally recognized guidelines, expert-based physician
151	151	consensus quality standards, or leading objective clinical
152	152	evidence and scholarship].
153	153	SECTION 6. This Act takes effect September 1, 2025.