Texas 2025 - 89th Regular

Texas House Bill HB2254 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		89R3231 RDR-F
2	2		By: Hull H.B. No. 2254
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4	6
5	7		A BILL TO BE ENTITLED
6	8		AN ACT
7	9		relating to certain health care services contract arrangements
8	10		entered into by insurers and health care providers.
9	11		BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
10	12		SECTION 1. Subchapter A, Chapter 1301, Insurance Code, is
11	13		amended by adding Section 1301.0065 to read as follows:
12	14		Sec. 1301.0065. VALUE-BASED AND CAPITATED PAYMENT
13	15		ARRANGEMENTS WITH PRIMARY CARE PHYSICIANS OR PRIMARY CARE PHYSICIAN
14	16		GROUPS NOT PROHIBITED. (a) In this section:
15	17		(1) "Primary care physician" means a specialist in
16	18		family medicine, general internal medicine, or general pediatrics
17	19		who provides definitive care to the undifferentiated patient at the
18	20		point of first contact and takes continuing responsibility for
19	21		providing the patient's comprehensive care, which may include
20	22		chronic, preventive, and acute care.
21	23		(2) "Primary care physician group" means an entity
22	24		through which two or more primary care physicians deliver health
23	25		care to the public through the practice of medicine on a regular
24	26		basis and that is:
25	27		(A) owned and operated by two or more physicians;
26	28		or
27	29		(B) a freestanding clinic, center, or office of a
28	30		nonprofit health organization certified by the Texas Medical Board
29	31		under Section 162.001(b), Occupations Code, that complies with the
30	32		requirements of Chapter 162, Occupations Code.
31	33		(b) A preferred provider benefit plan or an exclusive
32	34		provider benefit plan may provide or arrange for health care
33	35		services with a primary care physician or primary care physician
34	36		group through a contract for compensation under:
35	37		(1) a fee-for-service arrangement;
36	38		(2) a risk-sharing arrangement;
37	39		(3) a capitation arrangement under which a fixed
38	40		predetermined payment is made in exchange for the provision of, or
39	41		for the arrangement to provide and the guaranty of the provision of,
40	42		a contractually defined set of covered services to covered persons
41	43		for a specified period without regard to the quantity of services
42	44		actually provided; or
43	45		(4) any combination of arrangements described by
44	46		Subdivisions (1) through (3).
45	47		(c) A primary care physician or primary care physician group
46	48		that enters into a contract described by Subsection (b) is not
47	49		considered to be engaging in the business of insurance.
48	50		(d) A primary care physician or primary care physician group
49	51		is not required to enter into a payment arrangement under this
50	52		section, and an insurer may not discriminate against a physician or
51	53		physician group that elects not to participate in an arrangement
52	54		under this section, including by:
53	55		(1) reducing the fee schedule of a physician or
54	56		physician group because the physician or physician group does not
55	57		participate in the insurer's value-based or capitated payment
56	58		arrangement or other payment arrangement provided under this
57	59		section; or
58	60		(2) requiring a physician or physician group to
59	61		participate in the insurer's value-based or capitated payment
60	62		arrangement or other payment arrangement provided under this
61	63		section as a condition of participation in the insurer's provider
62	64		network.
63	65		(e) A primary care physician or primary care physician group
64	66		may file a complaint with the department if the physician or
65	67		physician group believes the physician or physician group has been
66	68		discriminated against in violation of Subsection (d).
67	69		(f) A contract allowing for a value-based or capitated
68	70		payment arrangement or other payment arrangement provided under
69	71		this section:
70	72		(1) may not create a disincentive to the provision of
71	73		medically necessary health care services and may not interfere with
72	74		the physician's independent medical judgment on which services are
73	75		medically appropriate or medically necessary;
74	76		(2) must specify:
75	77		(A) in writing if compensation is being paid
76	78		based on satisfaction of performance measures and, if so,
77	79		specifically provide:
78	80		(i) the performance measures;
79	81		(ii) the source of the measures;
80	82		(iii) the method and time period for
81	83		calculating whether the performance measures have been satisfied;
82	84		(iv) access to financial and
83	85		performance-based information used to determine whether the
84	86		physician met those measures; and
85	87		(v) the method by which the physician may
86	88		request reconsideration;
87	89		(B) that the attribution process will assign a
88	90		patient to:
89	91		(i) first the patient's established
90	92		physician, as determined by a prior annual exam or other office
91	93		visits; and
92	94		(ii) if no established physician
93	95		relationship exists, then a physician chosen by the patient;
94	96		(C) if payment involves capitation, whether a
95	97		bridge rate, such as a discounted fee for service, will remain in
96	98		effect for a certain period until sufficient data has been
97	99		generated regarding utilization to allow an insurer to make an
98	100		informed decision regarding fully capitated rates;
99	101		(D) whether the capitated rate, if any, will
100	102		provide for a stop-loss threshold or a guaranteed minimum level of
101	103		payment per month, and whether the physician will obtain stop-loss
102	104		coverage; and
103	105		(E) whether payment will take into account
104	106		patients who are added to or eliminated from the attributed
105	107		population during the course of a measurement period;
106	108		(3) if payment involves capitation, must provide for
107	109		the opportunity to renegotiate in good faith a revised capitation
108	110		rate, or reimburse on a fee-for-service basis under a contractual
109	111		fee schedule until a revised capitation rate is agreed to if there
110	112		is a material increase in the scope of services provided by the
111	113		physician or a material change by the payer in the benefit
112	114		structure; and
113	115		(4) must state:
114	116		(A) whether catastrophic events are excluded
115	117		from the final cost calculation for an attributed population when
116	118		compared to the cost target for the measurement period, if
117	119		applicable; and
118	120		(B) if payment involves shared savings, whether
119	121		the entire savings is shared when the minimum savings rate is
120	122		reached, or whether only the amount in excess of the minimum savings
121	123		rate is shared.
122	124		(g) This section does not authorize a preferred provider
123	125		benefit plan or an exclusive provider benefit plan to provide or
124	126		arrange for health care services with a primary care physician or
125	127		primary care physician group through a contract for compensation
126	128		under a global capitation arrangement.
127	129		(h) The parties to a contract under Subsection (b) are the
128	130		primary care physician or primary care physician group and the
129	131		preferred provider benefit plan or exclusive provider benefit plan.
130	132		A party to a contract under Subsection (b) may not subcontract.
131	133		SECTION 2. This Act takes effect immediately if it receives
132	134		a vote of two-thirds of all the members elected to each house, as
133	135		provided by Section 39, Article III, Texas Constitution. If this
134	136		Act does not receive the vote necessary for immediate effect, this
135	137		Act takes effect September 1, 2025.