Texas 2025 - 89th Regular

Texas Senate Bill SB1014 Compare Versions

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

Old	New	Differences
1	1	89R3231 RDR-F
2	2	By: Sparks S.B. No. 1014
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6	6
7	7	A BILL TO BE ENTITLED
8	8	AN ACT
9	9	relating to certain health care services contract arrangements
10	10	entered into by insurers and health care providers.
11	11	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
12	12	SECTION 1. Subchapter A, Chapter 1301, Insurance Code, is
13	13	amended by adding Section 1301.0065 to read as follows:
14	14	Sec. 1301.0065. VALUE-BASED AND CAPITATED PAYMENT
15	15	ARRANGEMENTS WITH PRIMARY CARE PHYSICIANS OR PRIMARY CARE PHYSICIAN
16	16	GROUPS NOT PROHIBITED. (a) In this section:
17	17	(1) "Primary care physician" means a specialist in
18	18	family medicine, general internal medicine, or general pediatrics
19	19	who provides definitive care to the undifferentiated patient at the
20	20	point of first contact and takes continuing responsibility for
21	21	providing the patient's comprehensive care, which may include
22	22	chronic, preventive, and acute care.
23	23	(2) "Primary care physician group" means an entity
24	24	through which two or more primary care physicians deliver health
25	25	care to the public through the practice of medicine on a regular
26	26	basis and that is:
27	27	(A) owned and operated by two or more physicians;
28	28	or
29	29	(B) a freestanding clinic, center, or office of a
30	30	nonprofit health organization certified by the Texas Medical Board
31	31	under Section 162.001(b), Occupations Code, that complies with the
32	32	requirements of Chapter 162, Occupations Code.
33	33	(b) A preferred provider benefit plan or an exclusive
34	34	provider benefit plan may provide or arrange for health care
35	35	services with a primary care physician or primary care physician
36	36	group through a contract for compensation under:
37	37	(1) a fee-for-service arrangement;
38	38	(2) a risk-sharing arrangement;
39	39	(3) a capitation arrangement under which a fixed
40	40	predetermined payment is made in exchange for the provision of, or
41	41	for the arrangement to provide and the guaranty of the provision of,
42	42	a contractually defined set of covered services to covered persons
43	43	for a specified period without regard to the quantity of services
44	44	actually provided; or
45	45	(4) any combination of arrangements described by
46	46	Subdivisions (1) through (3).
47	47	(c) A primary care physician or primary care physician group
48	48	that enters into a contract described by Subsection (b) is not
49	49	considered to be engaging in the business of insurance.
50	50	(d) A primary care physician or primary care physician group
51	51	is not required to enter into a payment arrangement under this
52	52	section, and an insurer may not discriminate against a physician or
53	53	physician group that elects not to participate in an arrangement
54	54	under this section, including by:
55	55	(1) reducing the fee schedule of a physician or
56	56	physician group because the physician or physician group does not
57	57	participate in the insurer's value-based or capitated payment
58	58	arrangement or other payment arrangement provided under this
59	59	section; or
60	60	(2) requiring a physician or physician group to
61	61	participate in the insurer's value-based or capitated payment
62	62	arrangement or other payment arrangement provided under this
63	63	section as a condition of participation in the insurer's provider
64	64	network.
65	65	(e) A primary care physician or primary care physician group
66	66	may file a complaint with the department if the physician or
67	67	physician group believes the physician or physician group has been
68	68	discriminated against in violation of Subsection (d).
69	69	(f) A contract allowing for a value-based or capitated
70	70	payment arrangement or other payment arrangement provided under
71	71	this section:
72	72	(1) may not create a disincentive to the provision of
73	73	medically necessary health care services and may not interfere with
74	74	the physician's independent medical judgment on which services are
75	75	medically appropriate or medically necessary;
76	76	(2) must specify:
77	77	(A) in writing if compensation is being paid
78	78	based on satisfaction of performance measures and, if so,
79	79	specifically provide:
80	80	(i) the performance measures;
81	81	(ii) the source of the measures;
82	82	(iii) the method and time period for
83	83	calculating whether the performance measures have been satisfied;
84	84	(iv) access to financial and
85	85	performance-based information used to determine whether the
86	86	physician met those measures; and
87	87	(v) the method by which the physician may
88	88	request reconsideration;
89	89	(B) that the attribution process will assign a
90	90	patient to:
91	91	(i) first the patient's established
92	92	physician, as determined by a prior annual exam or other office
93	93	visits; and
94	94	(ii) if no established physician
95	95	relationship exists, then a physician chosen by the patient;
96	96	(C) if payment involves capitation, whether a
97	97	bridge rate, such as a discounted fee for service, will remain in
98	98	effect for a certain period until sufficient data has been
99	99	generated regarding utilization to allow an insurer to make an
100	100	informed decision regarding fully capitated rates;
101	101	(D) whether the capitated rate, if any, will
102	102	provide for a stop-loss threshold or a guaranteed minimum level of
103	103	payment per month, and whether the physician will obtain stop-loss
104	104	coverage; and
105	105	(E) whether payment will take into account
106	106	patients who are added to or eliminated from the attributed
107	107	population during the course of a measurement period;
108	108	(3) if payment involves capitation, must provide for
109	109	the opportunity to renegotiate in good faith a revised capitation
110	110	rate, or reimburse on a fee-for-service basis under a contractual
111	111	fee schedule until a revised capitation rate is agreed to if there
112	112	is a material increase in the scope of services provided by the
113	113	physician or a material change by the payer in the benefit
114	114	structure; and
115	115	(4) must state:
116	116	(A) whether catastrophic events are excluded
117	117	from the final cost calculation for an attributed population when
118	118	compared to the cost target for the measurement period, if
119	119	applicable; and
120	120	(B) if payment involves shared savings, whether
121	121	the entire savings is shared when the minimum savings rate is
122	122	reached, or whether only the amount in excess of the minimum savings
123	123	rate is shared.
124	124	(g) This section does not authorize a preferred provider
125	125	benefit plan or an exclusive provider benefit plan to provide or
126	126	arrange for health care services with a primary care physician or
127	127	primary care physician group through a contract for compensation
128	128	under a global capitation arrangement.
129	129	(h) The parties to a contract under Subsection (b) are the
130	130	primary care physician or primary care physician group and the
131	131	preferred provider benefit plan or exclusive provider benefit plan.
132	132	A party to a contract under Subsection (b) may not subcontract.
133	133	SECTION 2. This Act takes effect immediately if it receives
134	134	a vote of two-thirds of all the members elected to each house, as
135	135	provided by Section 39, Article III, Texas Constitution. If this
136	136	Act does not receive the vote necessary for immediate effect, this
137	137	Act takes effect September 1, 2025.